2002 Optima Award Winner – The Safety Program: Sunset for Sundowning

Adapted from the submission by Bortz Health Care of Traverse City, Traverse City, Michigan; written by Debra Hagerty, BS, BSN, MSN, SW, Director of Nurses
If you were to ask any professional about the phenomenon of geriatric sundowning-a burst of energy some residents experience at sundown-most could define and describe it without hesitation. It occurs in every nursing home across the country and can create serious resident-care challenges for staff.

Some of the consequences of this burst of energy are risks of wandering, falls and aggressive outbursts, all of which could cause serious injury. Our ongoing safety analysis revealed that a high number of such incidents involving our cognitively impaired residents occurred between 6:30 and 8:00 p.m. As a result of this data analysis, our continuous quality improvement team (CQIT) set forth to analyze and prevent this trend from continuing.


Initially, we evaluated all incidents occurring within this time period. Commonalities were identified and care plans modified for several residents, but it was clear that a large group of residents involved were experiencing a type of sundowners’ phenomenon, characterized by:

  • getting up unassisted
  • wandering into the wrong room
  • showing increased confusion with elevated agitation
  • exhibiting increasingly repetitive actions or speaking patterns
  • engaging in combative behaviors

The CQIT reviewed the incidents and the times of their occurrence and concluded that these residents could be sundowning. The team developed a program designed to occupy the attention of these particularly fragile residents at their most vulnerable time of the evening. The program was named, affectionately, “The Safety Program.”

All departments were invited to participate in developing program guidelines. Social services assisted with managing behaviors, an experience that provided insight for all staff into management techniques that would promote residents’ dignity and provide them with meaningful life activities. The restorative department provided physical exercise and activities appropriate to the residents’ physical and functional abilities. The activity department was consulted regarding activities and equipment that might be beneficial for cog-nitively impaired individuals.

Figure 1. Incidents during 1st quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m.
Figure 2. Incidents during 2nd quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m.
Figure 3. Incidents during 3rd quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m.
Figure 4. Incidents during 4th quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m.
Figure 5. Incidents during 1st quarters of 2000 and 2002 that occurred between 6:30 and 8:00 p.m.

The goals of The Safety Program were:

  • to reduce incidents and accidents involving a fragile geriatric population during a recognized high-risk, high-incident time period;
  • to provide appropriate therapeutic activities to enhance residents’ quality of life;
  • to incorporate Edenization into our safety programming; and
  • to recognize the need for budgetary compliance. This program had to be implemented without additional cost to the nursing department or the facility.

Resident Criteria

Based on review of the incidents, the following criteria were developed to identify those residents who would be appropriate for this type of programming:

  • residents with cognitive impairments
  • residents with high safety risks, particularly falls and elopement
  • residents with serious behavioral issues
  • residents who were experiencing recognizable sundowning symptoms

The Safety Program Activities

The Safety Program incorporates a variety of games and activities designed to stimulate and entertain the selected residents during this high-risk daily period, under direct supervision of our qualified staff. Some examples of these activities include ball toss, reading out loud, reminiscing and/or validation, coloring, tactile stimulation and music.

Program Leadership

We chose a competency-evaluated nursing assistant (CENA) as the hands-on leader, under the supervision of a licensed nurse.
Qualifications of the person for directing the program included:

  • qualified in personal care
  • able to respond to an emergency
  • able to direct simple activities
  • available from 6:30 to 8:00 p.m.

The target date for implementation was January 1, 2001. Before that, extensive training and collaboration involving CENAs and shift nursing took place. Staff were comfortable with the activities/programming planned and were encouraged to make suggestions as issues arose.

This project was not without struggles, though. Change is difficult for people. The CENAs felt this was an additional duty. Some staff wanted to skip the program altogether on nights when staffing availability was challenged. It took a while for the staff to become vested in the benefits of the program, but they eventually came to realize its importance in providing environmentally safe solutions for residents who are sundowning, cog-nitively impaired or otherwise at high risk. Once vested, the staff showed intense pride in The Safety Program’s accident prevention record.

Our safety team has continued monitoring all new admissions, as well as any resident who experiences a significant change in condition or status. Recommendations from any of our team members regarding residents who might need The Safety Program are taken very seriously. Residents are assessed by the restorative nurse and the unit managers for potential placement.

Table. Results by quarter.
Program Evaluation

Our initial findings for the first three months were outstanding: We had a total of 18 incidents between the hours of 6:30 and 8:00 p.m. during that period-a significant decrease from the 26 incidents of the previous quarter. And the results have continued to improve.

In year-to-year comparisons, we found that between the first quarter of 2000 and the first quarter of 2001, two fewer incidents occurred-a decrease of 10% (Figure 1). The second quarter of 2001 showed a steep drop in incidents from the second quarter of 2000: 41% (Figure 2). Third quarter 2001 had a 49% decrease in incidents compared to a year earlier (Figure 3), and fourth quarter comparisons of 2000 and 2001 showed a decrease of 58% (Figure 4).

Comparing the first quarter of 2000 with that of 2002 disclosed a 61% drop in the number of incidents (Figure 5).

To further investigate the program’s effectiveness, we compared the raw numbers of incidents quarter by quarter, year by year (Table). Figure 6 summarizes the program’s results over a two-and-a-quarter-year period.

Resident satisfaction surveys have indicated positive responses from families and residents. We attained 100% overall resident satisfaction with our facility programming during the last quarter of 2001. Examples of comments include:

  • “My husband really enjoyed all of the activities and appreciated being included in them on a regular basis.”
  • “My family and I enjoyed being involved in this part of his care, as well.”
  • “The residents are safe, warm, happy and looked after every minute.”
  • “My family feels safe leaving our loved one here.”
  • “In this day and age of always cutting back on services provided, this facility seems to manage to keep the services provided at a high level, which is very unique.”
Figure 6. Number of incidents by quarter occurring between 6:30 and 8:00 p.m. for 2000, 2001 and 2002*.
Our continuing quality improvement efforts and our incorporation of the Eden principles, as well as input from our staff members, have influenced the programming since its inception. Activities have been modified consistently throughout to meet the individualized needs of an everchanging resident population. We have provided an increase in tactile stim-ulation activities, group activities, pet therapy and other activities appropriate for the cognitively impaired resident. Our Safety Program has increased the quality of life for our at-risk population by decreasing the number of incidents, maintaining and improving residents’ functional levels, and enabling residents at risk to participate in activities especially formatted for them. This program has benefitted the staff and residents with meaningful and improved relationships, increased safety awareness, increased resident satisfaction and significant decreases in the number of incidents, as well as a decrease in the seriousness of incidents that do occur between the hours of 6:30 and 8:00 p.m. Program benefits have surpassed our expectations. NH
Program Staff

  • Mark Crane, RN, MSA, NHA,Administrator
  • Debra Hagerty, BS, BSN, MSN, SW, Director of Nurses
  • Shelly Davis, LPN, Restorative Nurse
  • Denise Arlt, RN, Unit Manager
  • Diane Simpson, RN, Unit Manager
  • Stuart Smith, RN, BSN, Unit Manager
  • Rosemary Russell, RN, In-service Coordinator
  • Amy Huis, BA, Activity Director
  • Our Dedicated Floor Staff
To comment on this article, e-mail hagerty0902@nursinghomesmagazine.com.

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