- Email: [email protected]
Common meanings of good and bad sleep in a healthy population sample
Sleep Health 2 (2016) 253–259
Contents lists available at ScienceDirect
Sleep Health Journal of the National Sleep Foundation journal homepage: sleephealthjournal.org
Common meanings of good and bad sleep in a healthy population sample Suzanne S. Dickerson, DNS, RN a,⁎, Karen J. Klingman, PhD, RN b, Carla R. Jungquist, PhD, RN, FNP-BC c a b c
BioBehavioral Health and Clinical Science, University at Buffalo, School of Nursing, 301E Wende Hall, 3435 Main Street, Buffalo, NY 14214 Upstate Medical University, College of Nursing, 750 East Adams Street, Syracuse, NY 13210 University at Buffalo, School of Nursing, 314 Wende Hall, 3435 Main Street, Buffalo, NY 14214
a r t i c l e
i n f o
Article history: Received 13 November 2015 Received in revised form 20 June 2016 Accepted 23 June 2016 Keywords: Meaning of sleep Qualitative Public health Sleep hygiene Healthy adults
a b s t r a c t Objectives: The study's purpose was to understand the common meanings and shared practices related to good and bad sleep from narratives of a sample of healthy participants. Design: Interpretive phenomenology was the approach to analyze narratives of the participants' everyday experiences with sleep. Participants were interviewed and asked to describe typical good and bad nights' sleep, what contributes to their sleep experience, and the importance of sleep in their lives. Team interpretations of narratives identified common themes by consensus. Setting: Medium sized city in New York State (upper west region). Participants: A sample of 30 healthy participants were from a parent study (n = 300) on testing the sleep questions from the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention. Measurements/analysis: Interpretations of good and bad sleep. Results: Participants described similar experiences of good and bad sleep often directly related to their ability to schedule time to sleep, fall asleep, and maintain sleep. Worrying about life stresses and interruptions prevented participants from falling asleep and staying asleep. Yet, based on current life priorities (socializers, family work focused, and optimum health seekers), they had differing values related to seeking sleep opportunities and strategizing to overcome challenges. Conclusions: The participants' priorities reflected the context of their main concerns and stresses in life that influenced the importance given to promoting sleep opportunities. Public health messages tailored to life priorities could be developed to promote healthy sleep practices. © 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Introduction Sleep is a normal physiologic need for people that has been objectively studied in terms of sleep length, stages, continuity, rhythms, disturbances, and quality. 1–4 However, for the average person, sleep is ubiquitous, something that is part of life and only thought about when lack of sleep results in trouble or ill health, which ultimately results in apathy toward sleep health. More recently, sleep research outcomes have focused on length of sleep, whereby short-sleep (b5 hours) and long-sleep (N9 hours) are associated with development of cardiovascular, depression, and obesity risks. 5 To gain insight into the average persons sleep practices that affect their health and
⁎ Corresponding author. E-mail address: [email protected] (S.S. Dickerson).
wellness, what is needed is to understand the common meanings and shared practices of sleep in the context of daily life experiences. In the US and worldwide, health organizations have identified sleep problems as detrimental to general health and well-being. The Institute of Medicine6 declared poor sleep as a major public health problem, the World Health Organization categorized obstructive sleep apnea as a major preventable chronic respiratory disease, 7 and the Centers for Disease Control and Prevention (CDC) 8 report that 7–19% of Americans state they never get sufficient sleep. Furthermore, the US Department of Health and Human Services 9 incorporated sleep into its Healthy People 2020 agenda for improving national health by increasing hours of sleep in adults to 7 or more hours in 70.8% of the population, for individuals with sleep apnea symptoms to seek evaluation (28%), and to decrease the rate of car crashes involving drowsy driving to 2.1 per 100 million miles traveled. More recently, the American Academy of Sleep Medicine and
http://dx.doi.org/10.1016/j.sleh.2016.06.004 2352-7218/© 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
254
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
Sleep Research Society in a joint consensus statement recommended 7 to 9 hours of sleep to promote optimum health in a healthy adult.10 While organizations have determined the need, it is unknown what average healthy persons think about their sleep. If we can understand the meaning and value of sleep in peoples' lives that influences sleep practices, we can obtain insight into potential interventions to promote healthy sleep. Normal sleep has been studied from a neurological and molecular perspective.1 Nonetheless, there are only a few qualitative papers related to sleep experiences in healthy people. One early study, Askerstend et al. 11 reported on the subjective meaning of sleep from a longitudinal design that followed eight subjects sleeping in a lab at a variety of schedules measured by polysomnography to predict sleep quality measures. They found that perceived sleep quality was closely related to the subjects' ability to fall asleep quickly and stay asleep (sleep continuity) and awaken close to the acrophase or time of peak activity. The study was an in-lab study and lacked experiential context of sleep. A more recent study, Harvey et al. 12 compared the subjective meaning of sleep quality between individuals with and without insomnia using a “speak freely” interview approach to ask participants to describe good and poor sleep quality, and found that tiredness on awakening and the number of awakenings during the night were the most important variables regarding sleep quality. These studies reported comparisons of subjective and objective sleep; however, they did not provide context of daily lived experiences that may influence the meaning and importance of sleep. In another study, Coveney 13 described the subjective sleep experiences and sleep practices of shift workers, and students, realizing that the social context influenced how they managed sleep in their lives. This context was influential in understanding the meaning of their attitudes toward sleep. More recently, Buysse 14 introduced a conceptual model of sleep health in order to clearly establish a meaning of the term Sleep Health. Five dimensions of sleep were identified as relevant including: sleep duration, sleep continuity or efficiency, timing, alertness/sleepiness, and satisfaction/quality (subjective assessment of good or poor sleep). The subjective dimension of satisfaction/quality clearly places good sleep in the context of the individual and society that could be explicated with qualitative research approaches. Sleep Health is then appreciated in the context of individual, social, and environmental demands from the perspective of the participants' situational meanings. Thus, an investigation of healthy individuals is warranted to add contextual insights to understanding sleep health. Thus, the purpose of this study was to understand the common meanings and shared practices of good and bad sleep. The parent study provided the text data from the rich narrative descriptions of good and bad sleep. The goal of the parent study was to validate and refine the sleep questions from the Behavioral Risk Factor Surveillance System (BRFSS) from the CDC.15 Methodology An interpretive phenomenological approach was used to guide the study of the everyday experiences of sleep in the narratives of a sample of healthy people.16,17 In this method, the researchers uncover the everyday common meanings of an individual's life with the goal of discovering the meaning embedded in the text. The purpose of this analysis is not to predict but to understand the contextual meaning of a situation. The researchers' interpretations reveal what is important to the individual, his/her issues, concerns, and understandings of his/her world. 18 Human experiences are historical and temporal, based on language and cultural practices. 19 Recurring themes or common knowledge identified by interpretive studies embody the practical knowledge or wisdom that is familiar to the individuals in their lives. By reflecting on the experiences of individuals,
the investigator identifies the issues and problems as they are best understood in that particular context. Thus, we are able to describe the experience of everyday living and sleeping. Participants and methods Thirty participants randomly sampled from the parent study (n = 300) 15 were interviewed. The original pool of n = 300 participants were English-speaking community-dwelling adults aged 18 and older who did not use continuous positive airway pressure (CPAP) or oxygen while sleeping. Potential participants had previously consented to be contacted for interviews as part of the parent study. A random number generator was used to yield 30 numbers between 1 and 300. The target number of participants for the parent study interviews was preset to 30 so that participant characteristics (such as shown in Table 1) would be representative of the parent sample by virtue of the central limit theorem. Participants were contacted in numerical order. If participants were unreachable or declined to be interviewed, a block of five additional random numbers was generated. Contacts were made until thirty agreed to be interviewed. Only three potential participants declined (giving lack of time as a reason), thus, only one additional random number block was generated. When participants agreed to be interviewed, they chose from several time slots for their interviews; they were encouraged to be in a private location where they could talk freely by phone during the interview. Twenty-nine participants who agreed to be interviewed completed their interviews at the appointed times; one appointment was missed, then rescheduled and completed. Ultimately, thirty participants were interviewed about their everyday sleep experiences. See Table 2 for the interview guide. These narratives provided rich descriptions of everyday sleep experiences that provided the data for text analysis. Interview procedure The interviewer (first author), an expert in the interpretive phenomenology method, developed the open-ended questions for the interview based on the methodology. Questions were reviewed and approved by the research team. For the parent study, the investigator was initially blinded to all participants' data (age, gender, Table 1 Participant characteristics (n = 30) Variable
Mean (SD)
Range
Age BMI Sleep hours to feel rested (BRFSS #1) Average hours of sleep (BRFSS #2) Epworth sleepiness scale Actigraphy measures: Total sleep time (hours) Sleep efficiency (%) Sleep latency (minutes) Wake after sleep onset (minutes) Gender Racea Comorbiditiesb
38.8 (14.9) 25.8 (5.2) 7.8 (3.3) 7.0 (1.1) 5.8 (4.9)
19–71 18–37 5–24 4–8 0–21
6.8 (.9) 82.0 (5.8) 17.0 (11.7) 48.9 (15.1) Male/Female W/AA/Asian Heart attack Irregular rhythm Metabolic syndrome Asthma Depression Anxiety
4.6–8.2 71–91 0–47 24–68 8/22 28/1/1 3 1 2 3 4 4
Notes a. Race and ethnicity self-identified. W = white. AA = black or African American. HL = Hispanic or Latino. b. Comorbidities based on self-report medical history.
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259 Table 2 Interview Guide Thank you for agreeing to speak to me today about your sleep. There are no right or wrong answers, we learn from all your comments. 1. Can you please describe for me what is a typical good night sleep for you? a. Please explain in detail how do you know or feel that is was good? b. What contributed to your good night sleep? c. How often does this happen and for how long does it last. 2. Can you please describe for me a typical poor night sleep? a. Please explain in detail how do you know or feel that it was poor? b. What contributes to your poor sleep? c. How often does it occur and how long does it last? 3. Is there anything else you want us to know about determining good or poor sleep?
questionnaire responses and sleep study results) except name and phone number. Based on first name, the interviewer may have begun each session with a preconceived notion regarding participants' gender, thus blinding to gender was not absolute. The participants were familiar with the research team and easily dialogued with the interviewer by the phone interviews, which lasted approximately 30 minutes. Interviews were digitally recorded and transcribed for analysis. Both team members listened to the interview to verify the transcript accuracy and inserted emphasis to clarify meanings (i.e. Laughter indicated humor or capitalization to emphasize strong feelings.) In the parent study, the goal of the interview was to obtain common language to represent their sleep experiences that was used to validate and update the BRFSS questions. The text data narratives provided detailed stories of everyday sleep that were used for this interpretive analysis. Analysis Text data in this study were interpreted by a modified interpretive process described below. 16,20 The transcripts were downloaded in NVIVO for analysis. The research team consisted of the principal investigator, an expert in interpretive phenomenology, and a doctoral student trained in qualitative research techniques. First, each member of the research team examined each narrative text as a whole. Next, each researcher wrote an interpretive summary of the text that described the possible common meanings of the texts with excerpts from the text to support the interpretation. These summaries were the basis of the discussion of similarities and differences at weekly meetings with a goal to reach consensus on emerging themes. The analysis involved moving from the whole text to parts of the text in circular fashion known as the hermeneutic circle. When there were discrepancies, further clarification of interpretations was reached by returning to the original text to ensure keeping close to the meaning of the participants and not inserting pre-existing theories. Each previous text was reread again to compare themes across all texts to develop the relational themes that linked meanings across texts in a circular process. Then, all texts were reread to further uncover common meanings and clarify relational themes. During the analysis meetings the participants' background meanings and priorities emerged in the interpretations of the meaning of good and bad sleep. The researchers created matrixes of the relational themes present in each participant's narrative, to gain an understanding of the contextual similarities and differences between participants' stories. This step in the analysis clarified how the participants' experiences reflected their priorities in their life situations. Finally, the principal investigator produced a final interpretive summary report, which represented the current understanding of good and bad sleep and used quotes that allowed for validation by the reader. The multiple levels of interpretation served to expose conflicts and inconsistencies in the analysis and served to eliminate unsubstantiated
255
meanings. Although there is no single correct interpretation, continuous examination of the whole and the parts of the text with constant reference to the text ensured that interpretations were grounded and focused.16 When the interpretations are visible, clear and redundant with each new text, the findings are considered saturated.20 Overall similarities and differences were determined, noting that the narratives reflected life experiences and current life challenges. Results Characteristics of sample The thirty participants were generally healthy, with few comorbidities and a small percentage of smokers. Data from the parent study was measured approximately 6–12 months from the interviews. Sleep characteristics were comprised of subjective questions regarding usual hours of sleep (BRFSS questions no. 1 and 2), and daytime sleepiness (Epworth Sleepiness Scale). Objective measures from actigraphy included: sleep latency, wake after sleep onset, total sleep time, and sleep efficiency (see Table 1). Thematic findings There are two general themes that described the meaning and experiences of sleep for the healthy participants. Theme One: Agreeing on the meaning of good and bad sleep The participants' everyday sleep experiences were embedded within the stories of their ordinary lives, which involved a variety of good and bad sleep. Interestingly, they often described their good night sleep as when bad sleep did not occur. When they slept well, they quickly entered a sleep state, had several hours of uninterrupted sleep, and did not wake up during the night, or if they awoke they fell back to sleep quickly. In the morning they woke up refreshed often not needing an alarm clock. The participants predominantly discussed that a lack of interruptions from the environment or worry about their own life situations contributed to good sleep. Many of the participants stated that good sleep meant to sleep without interruptions, eg, “where I don't wake up continuously during the night.” “It's good when I'm not tossing and turning at night,” and “my child not waking up in the middle of the night coming into the bedroom.” Participants described good sleep outcomes as: waking up feeling rested with energy to face the day's tasks, having a positive attitude, improved mood, and general health. For example, one participant said, “When I get enough sleep? Everything runs smooth. I don't think that I require as much sugar or caffeine or things like that.” Another said “I feel good about myself…about life in general. My frame of mind is much better,” and another said “[sleep] is one of the main things that I use to make sure I don't get sick.” Another participant related: A good night's sleep helps you function through the day, and it affects your mood definitely. I know at least personally if I don't get a good night's sleep I'm more tired, maybe a little bit crankier. Most participants described factors that contributed to good sleep such as: having the time or opportunity to sleep, being free of stress such as having a calm day, being tired from the day (activities), and having a comfortable environments to sleep in including bed comfort, white noise, darkness and lack of interruptions. Participants described bad sleep as not being able to initiate and maintain sleep at night. They described having trouble falling asleep because of stress, being awoken by interruptions from a variety of reasons, and once awake they could not fall back to sleep. Most
256
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
participants attested to the role of stress in keeping them awake such as life events similar to job loss or other worries, which kept them awake. One participant stated: “sometimes if I'm stressed out or upset about something, I cannot sleep.” Participants also described situations that contributed to their bad sleep including interruptions from noises, children, or stormy weather, or experiences of musculoskeletal pain, too much caffeine or alcohol, and exercising too close to sleep time. One participant summed up her bad sleep: Well, I guess when it's not a good night's sleep I feel cold and restless and I have a hard time falling asleep, and sometimes I think that's associated with caffeine too late in the day. Participants complained that after a night of bad sleep, they awoke feeling groggy, cranky and in bad mood or attitude, with a lack of concentration, poor memory, and feeling not well. Participants' statements about bad sleep were clear and emphatic, for example: When I have a poor night's sleep I don't feel good at all. I mean, I'm miserable, and I'm very on edge, I feel grumpy. I'm edgy. I'm irritable…very anxious. I'm not able to process thoughts and problems…. I get really crotchety. My brain starts to wander from consciousness, When I don't get sleep sometimes, it feels like you have a hangover where your stomach is a little sick and you get a headache. Theme Two: Living with situational life contexts and priorities Participants' narratives all described their everyday life experiences and challenges that affected their sleep patterns and practices. These social and environmental contexts affected their ability, or desire, to make sleep a priority, or not, in their lives. All participants' narratives of sleep included stories of their current lives where sleep was only part of the whole story. They had responsibilities in their lives that included family, friends, work, and their own health and well-being. In addition, in the participants' stories, sleep opportunities and interruptions differed in relation to situational life priorities. Participants' narratives revealed three different perspectives related to their situational life contexts and priorities: Socializers, Family-focused Workers, and Optimum Health Seekers. Socializers Participants who prioritized their social life described their life in terms of going out late at night with friends and not leaving enough time to sleep. They clearly described the influence of lack of sleep on their mood, interpersonal relationships, and need to be productive at work or school in spite of prioritizing their social life. For example, one participant described why he limited the amount of time spent sleeping: Just me being how social I am, I mean, I work during the day, and it's hard to see my friends going to school and everything, so we'll get together at nighttime and see each other and lose track of time. Another participant who discussed the importance of her social life re-counted that “with school and taking 19 credits, I don't feel like I have enough time at all.” Their ability to focus improved with good sleep. Some of the participants who were at college described studying late and then taking long naps over the weekend or term breaks. This group valued social media as a way to maintain their social connections and often reported using their smart phone or computer at night to interact with others. They often talked about using
caffeine to keep awake after a short night sleep and spoke to using alcohol, which affected their sleep, for some alcohol use helped them fall asleep. The socializers commented that their lack of sleep often increased their susceptibility to colds and viruses. The socializers prioritized social and work-related functions as most important. They valued their social life more than their quality of sleep. Interruptions were related to late night studying, sleeping environment or bed partners, and stress keeping them awake. For example, one participant commented that there are not enough hours in the day: In order to have work and have the social life, sometimes in order to go out at night, since most stuff happens at night, and if there was a couple of hours to sleep, it would balance social and sleep. Another older man discussed the importance of a socializing in his life: If I had a relationship with another woman in my life, I'd be a lot calmer and I would sleep better…when I don't talk to her on a regular basis it makes my personal life and sleep poor. My wife died nine years ago, and it is hard but don't get single when you are old.
Family-focused workers Another group of participants prioritized their lives with family and/or work commitments and had different descriptions of their stressful lives and sleep needs. They often did not have enough time to sleep with too much to do, rigorous work schedules, and/or small children who would interrupt their sleep. Family-focused workers described their everyday experiences in short and to the point statements that emphasized the priority being on work and family versus good sleep. They also had less discussion and recognition of the physical effects of sleep deprivation (clumsy, forgetful, and lethargic). Life stresses plagued their minds as they tried to catch up and turn off their worries at night. Participants described pain and muscle tension, the beginning of “stomach burn” [gastro-esophageal reflux], and symptoms of depression related to stress. They would awaken at night, worrying about unresolved work issues and family issues resulting in less sleep, greater fatigue, and more caffeine use. Weekends served as a time to catch up on sleep for some, but they rarely had time for naps. The sleep environment was noisy (children or bed partner snoring) interrupting their sleep. Sleep was needed but not a priority. For instance, one participant described how nighttime is the only time to accomplish chores: Generally I would say my sleep is not usually a priority for me, mostly because of having two small children and the business that I'm running. So sleep tends to get put on the side burner trying to get stuff done at night when the kids are sleeping. The family-focused workers prioritized work and family and paid less attention to the effects of short sleep. Their life stresses kept them from obtaining optimal sleep, which increased risk for loss of productivity and potential for occupational injuries. Yet, sleep was not a major concern versus work and family priorities; for example, one participant described the reasons for not getting proper sleep as: Just circumstance for me. I mean, I have five kids, so, I mean, I have a two-year-old that likes to stay up sometimes till one in the morning, and she's still going. Trying to get her to go down, and it pretty much depends on my situation around me whether or not I get proper sleep, you know? Another parent stated, “We have young kids, and we're always on the go. There's always something scheduled, even on the weekends.” And, another described work/commute obligations as taking priority:
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
“I work twelve-hour days and I drive about an hour to work one way.” Interruptions of mental worry or a young family kept them awake. Some health issues began to keep them awake (tension and worry). Optimum health seekers Another group had a different perspective and awareness of their sleep and activity patterns that related to optimizing their health and benefit toward their weight. The optimum health seekers were attuned to the effect of poor sleep on their health. This group described clear timing and routines for sleep, valuing sleeping through the night and waking well-rested. They recognized their good mood and motivations and clearer thinking with a good night sleep. As one participant stated: It's just essential. It's stress relief. It's—I don't know beyond huge. I mean, yeah, it's very important that I get enough sleep. I mean it affects my whole day. It effects your whole lifestyle. The optimum health seekers recognized the value of exercise and eating well, as well as the role of sleep deprivation in causing cravings for comfort food of carbs, sugar and caffeine. If they were not sleeping well, they described themselves as having less energy and ambition. They had descriptions of the role of their physical and mental health in sleep with their health affecting night time awakenings. For example one woman said: Sleep is such a priority for me, I make sure that I stop whatever I′m doing. For instance, if I know that I′m going to be getting up early, then I go to bed early. I′m just probably too obsessed about that, but it's—I just need to sleep so I make sure that I have time for it. That's why it's so frustrating right now, because it's not really my fault. It's the hormones [from menopause], not me, that's causing the problem. The optimum health seekers knew of the outcomes of poor sleep such as troubles with concentration, anxiety, and mood. They also recognized the role of environmental interruptions of bed partners, pets, environmental noises as well as the effect of alcohol and caffeine on their sleep quality. Overall, they valued sleep for optimal health, especially if health issues began to compound sleep issues, and some used sleep aids. The optimum health seekers learned the value of sleep in optimizing health and prioritizing their time to account for adequate sleep time. One said, “It is probably the most important... next to nutrition and exercise, it's the top three important health issues to me.” Another stated, “Sleep is very important to me, and I suffer from migraines so I'm very careful with my sleep,” and another added, “it's like breathing the air.” They recognized patterns related to their sleep such as the effect of eating too late or drinking alcohol or caffeine, seasonal differences in activity and getting outside to exercise. In addition, they recognized the influence of sleep on their health and mental well-being. They also knew of more strategies to improve sleep such as sleep environment and comfort. Discussion This study of the meaning of good and bad sleep explicates priority-related situational contexts for understanding differences in issues with sleep continuity, opportunity, and prioritizing sleep in this group of participants. The idea of good sleep being related to sleep continuity was also found in the Akerstedt et al 11 study. Furthermore, in the current study, participants described the deleterious effects of poor sleep on the person's ability to function (mentally and emotionally) and be productive during the day. Participants all described life stresses as central to a bad night's
257
sleep. For participants, poor sleep lead to lost productivity and increased potential for injury. Participants' life situational contexts, such as emphasis on work demands and social life (family focused workers and socializers), informed the valuing of a good night's sleep that minimized obtaining sleep opportunities and subsequent sleep management practices, similar to Coveney. 13 Some sleep management practices included use of caffeine to stay awake and alcohol to de-stress. In addition, for family-focused workers, the dynamic interactions among the family members influence sleep opportunities. Likewise, Meltzer et al21 emphasized that the importance of sleep is best understood from the family context. Life stresses interfered with the ability to fall asleep as their mind raced with thoughts at bedtime and the children often interrupted their sleep. Future research could further examine family, social, and environmental contexts on sleep practices among a broader age range and ask more questions about life situations or developmental tasks such as in young families. The optimum health seekers prioritized and valued sleep, and they took advantage of sleep opportunities, and used their knowledge of sleep hygiene to attempt to improve sleep and manage stress. This perspective was more cognizant of the influence sleep health. The optimum health seekers prioritized sleep in their lives no matter what age. Theory development This work provides understanding and insight in the situational context and background of the participants' lives that influenced their sleep management practices (see Fig. 1). This situational contextual model adds to the understanding of Buysse's conceptual model of sleep health 14 by providing potential background perspectives to the sleep dimension process. The subjective sleep quality/ satisfaction is an assessment of sleep that is based on the individual's life situations and perspectives related to environmental and social contexts and backgrounds, upon which everyday experiences of sleep are situated and prioritized. The participant's life situation and priorities may place sleep health as only part of their lifeworld, where sleep opportunities are not maximized. The participants' current priority may change over time as the situations change as described by a few of the older participants. For some, sleep practices involve only obtaining the minimal amount of sleep to maintain alertness. Furthermore, in these narratives, bad sleep results in poorer mood, lack of concentration, and inability to function. These sleep management practices potentially affect health outcomes such as increased severity/frequency of cardiovascular, metabolic, and mental health diseases and injuries due to lack of alertness or focus. Future research could examine contextual priorities in other populations to further understand and give insight into potential influences on sleep health as well as a way to guide interventions to promote sleep health. Practice and policy implications The impact of sleep hygiene to promote public health has been discussed by Irish et al.22 in a review of empirical evidence on recommendations regarding stress management, exercise, and caffeine intake on sleep health. They propose that the effect of individual sleep hygiene programs on sleep is untested. Furthermore they concur with the current study's interpretations of the complex and contextual interplay among individuals' behaviors that should be considered when developing personalized strategies toward maximizing sleep opportunities. Future research needs to consider the impact of these differences on sleep promotion programs. In today's world of increasing technologies that allow a 24/7 time awake-ness, understanding the values that influence sleep practices are useful in educating the public about the importance of sleep to
258
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
Fig. 1. Common experiences and shared practices of good and bad sleep.
maintain health and safety. While public health messages could focus on risk identification for poor outcomes with bad sleep, alternatively the messages could relate to the positive impact of good sleep on mental and physical health that could be integrated in personalized sleep promotion interventions. Good sleep is taken for granted, but the lack of sleep has consequences. In clinical practices, health care providers could explore an individual's life priorities to determine if health promoting practices such as sleep hygiene and stress management may facilitate patients' sleep health. Motivational interviewing could be a potential intervention that would focus on the individual's priorities and health. Public health message programs could be developed to target the familyfocused workers and socializers who need to be aware of the health risks of sleep deprivation and potential occupational injury as well as the impact of good sleep on health and wellness. For optimum health seekers, educational guides on sleep hygiene may be more readily accepted and self -management could be reinforced. In this study, the previous surveys may have added to the participants' awareness of the effect of sleep in their lives and, therefore, they may more readily accept recommendations for sleep hygiene practices. Thus, clinicians asking a simple question like “are you having problems with your sleep?” might begin the conversation. Limitations Qualitative approaches promote understanding of the meaning of everyday experiences in the context of the individuals' experiences. However, this approach limits generalizability to populations in general. In addition, there were more white females than male participants that influenced the interpretation. In addition, no participants were above the age of 70, limiting the elders' perspective. In addition, we did not specifically ask about the influence of work, partners and children on sleep that emerged as important dimensions of findings, thus, we do not have data from all participants about those aspects. Nonetheless, 30 participants' rich narratives on their current lives, and what was important to them, provided text data to qualitatively analyze the related themes. The approach to recruit by random selection from the parent study group promoted varied responses. The participants' understanding of sleep issues may have been influenced by the questionnaires regarding insomnia, general depression, anxiety, fatigue, physical function, and sleep disturbance that they had completed in the parent study, although many had completed the survey a year earlier. Disclosure The authors have no conflicts of interest.
Acknowledgment This manuscript was supported by Cooperative Agreement Numbers U48DP001910 and U48DP001910-05S1 from The CDC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. References 1. Monti JM, Monti D. Human sleep: an overview. In: Verster JC, Pandi-Permual SR, Streiner DL, editors. Sleep and quality of life in clinical medicine. Towowa, NJ: Humana Press; 2008. p. 29–36. 2. Landis CA. Physiological and behavioral aspects of sleep. In: Redeker NS, GPM, editors. Sleep disorders and sleep promotion in nursing practice. New York, NY: Springer publishing company; 2011. p. 1–18. 3. Redeker NS. Developmental aspects of normal sleep. In: Redeker NS, GPM, editors. Sleep disorders and sleep promotion in nursing practice. New York, NY: Springer Publishing Company; 2011. p. 19–32. 4. Minarik PA. Gender and sleep. In: Redeker NS, GPM, editors. Sleep disorders and sleep promotion in nursing practice. New York, NY: Springer publishing company; 2011. p. 33–42. 5. Kim C-W, Chang Y, Zhao D, Cainzos-Achirica M, Ryu S, Jung H-S, et al. Sleep duration, sleep quality, and markers of subclinical arterial disease in healthy men and women. Arteriosclerosis, Thrombosis, and Vascular Biology; 2015. 6. Institute of Medicine. Sleep disorders and sleep deprivation: an unmet public health problem. Washington, DC: National Academies Press; 2006 [available from http://www.ncbi.nlm.nih.gov/books/NBK19958/]. 7. World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach; 2007. 8. Centers for Disease Control and Prevention. Sleep and sleep disorders: data and statistics; 2014 [cited 2014 September 16. Available from: http://www.cdc.gov/ sleep/data_statistics.htm]. 9. U.S. Department of Health and Human Services. 2020 topics & objectives: sleep health; 2014 [[cited 2014 September 17]. Available from: http://www. healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=38]. 10. Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of sleep medicine and Sleep Research Society. Sleep. 2015; 38(6):843–844. 11. Akerstedt T, Hume K, Minors D, Waterhouse J. The meaning of good sleep: a longitudinal study of polysomnography and subjective sleep quality. J Sleep Res. 1994; 3(3):152–158. 12. Harvey AG, Stinson K, Whitaker KL, Moskovitz D, Virk H. The subjective meaning of sleep quality: a comparison of individuals with and without insomnia. Sleep. 2008;31(3):383–393. 13. Coveney CM. Managing sleep and wakefulness in a 24-hour world. Sociol Health Illn. 2014;36(1):123–136. 14. Buysse DJ. Sleep health: can We define it? Does it matter? Sleep. 2014;37(1): 9–17. 15. Jungquist CR, Mund J, Aquilina AT, Klingman K, Pender J, Ochs-Balcom H, et al. Validation of the BRFSS sleep questions. J Clin Sleep Med. 2015. 16. Diekelmann N, Ironside P. Hermeneutics. In: Fitzpatrick J, editor. Encyclopedia of nursing research. New York: Springer; 1998. p. 243–245. 17. Heidegger M. In: Macquarrie J, Robinson E, editors. Being and time. Bloomington, IN: Indiana University Press; 1962. 18. Plager KA. Hermeneutic phenomenology: a methodology for family health adn health promotion study in nursing. In: Benner P, editor. Interpretive phenomenology: embodiment, caring and ethics in health and illness. Thousand Oaks: Sage Publications; 1994. p. 65–83.
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259 19. Benner P. Quality of life: a phenomenological perspective on explanation, prediction, and understanding in nursing science. ANS Adv Nurs Sci. 1985;8(1):1–14. 20. Benner P. The tradition and skill of interpretive phenomenology in studying health, illness and caring practices. In: Benner P, editor. Interpretive phenomenology. Thousand Oaks: Sage; 1994.
259
21. Meltzer LJ, Montgomery-Downs HE. Sleep in the family. Pediatr Clin North Am. 2011;58(3):765–774. 22. Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The role of sleep hygiene in promoting public health: a review of empirical evidence. Sleep Med Rev. 2015;22: 23–36.
Contents lists available at ScienceDirect
Sleep Health Journal of the National Sleep Foundation journal homepage: sleephealthjournal.org
Common meanings of good and bad sleep in a healthy population sample Suzanne S. Dickerson, DNS, RN a,⁎, Karen J. Klingman, PhD, RN b, Carla R. Jungquist, PhD, RN, FNP-BC c a b c
BioBehavioral Health and Clinical Science, University at Buffalo, School of Nursing, 301E Wende Hall, 3435 Main Street, Buffalo, NY 14214 Upstate Medical University, College of Nursing, 750 East Adams Street, Syracuse, NY 13210 University at Buffalo, School of Nursing, 314 Wende Hall, 3435 Main Street, Buffalo, NY 14214
a r t i c l e
i n f o
Article history: Received 13 November 2015 Received in revised form 20 June 2016 Accepted 23 June 2016 Keywords: Meaning of sleep Qualitative Public health Sleep hygiene Healthy adults
a b s t r a c t Objectives: The study's purpose was to understand the common meanings and shared practices related to good and bad sleep from narratives of a sample of healthy participants. Design: Interpretive phenomenology was the approach to analyze narratives of the participants' everyday experiences with sleep. Participants were interviewed and asked to describe typical good and bad nights' sleep, what contributes to their sleep experience, and the importance of sleep in their lives. Team interpretations of narratives identified common themes by consensus. Setting: Medium sized city in New York State (upper west region). Participants: A sample of 30 healthy participants were from a parent study (n = 300) on testing the sleep questions from the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention. Measurements/analysis: Interpretations of good and bad sleep. Results: Participants described similar experiences of good and bad sleep often directly related to their ability to schedule time to sleep, fall asleep, and maintain sleep. Worrying about life stresses and interruptions prevented participants from falling asleep and staying asleep. Yet, based on current life priorities (socializers, family work focused, and optimum health seekers), they had differing values related to seeking sleep opportunities and strategizing to overcome challenges. Conclusions: The participants' priorities reflected the context of their main concerns and stresses in life that influenced the importance given to promoting sleep opportunities. Public health messages tailored to life priorities could be developed to promote healthy sleep practices. © 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Introduction Sleep is a normal physiologic need for people that has been objectively studied in terms of sleep length, stages, continuity, rhythms, disturbances, and quality. 1–4 However, for the average person, sleep is ubiquitous, something that is part of life and only thought about when lack of sleep results in trouble or ill health, which ultimately results in apathy toward sleep health. More recently, sleep research outcomes have focused on length of sleep, whereby short-sleep (b5 hours) and long-sleep (N9 hours) are associated with development of cardiovascular, depression, and obesity risks. 5 To gain insight into the average persons sleep practices that affect their health and
⁎ Corresponding author. E-mail address: [email protected] (S.S. Dickerson).
wellness, what is needed is to understand the common meanings and shared practices of sleep in the context of daily life experiences. In the US and worldwide, health organizations have identified sleep problems as detrimental to general health and well-being. The Institute of Medicine6 declared poor sleep as a major public health problem, the World Health Organization categorized obstructive sleep apnea as a major preventable chronic respiratory disease, 7 and the Centers for Disease Control and Prevention (CDC) 8 report that 7–19% of Americans state they never get sufficient sleep. Furthermore, the US Department of Health and Human Services 9 incorporated sleep into its Healthy People 2020 agenda for improving national health by increasing hours of sleep in adults to 7 or more hours in 70.8% of the population, for individuals with sleep apnea symptoms to seek evaluation (28%), and to decrease the rate of car crashes involving drowsy driving to 2.1 per 100 million miles traveled. More recently, the American Academy of Sleep Medicine and
http://dx.doi.org/10.1016/j.sleh.2016.06.004 2352-7218/© 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
254
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
Sleep Research Society in a joint consensus statement recommended 7 to 9 hours of sleep to promote optimum health in a healthy adult.10 While organizations have determined the need, it is unknown what average healthy persons think about their sleep. If we can understand the meaning and value of sleep in peoples' lives that influences sleep practices, we can obtain insight into potential interventions to promote healthy sleep. Normal sleep has been studied from a neurological and molecular perspective.1 Nonetheless, there are only a few qualitative papers related to sleep experiences in healthy people. One early study, Askerstend et al. 11 reported on the subjective meaning of sleep from a longitudinal design that followed eight subjects sleeping in a lab at a variety of schedules measured by polysomnography to predict sleep quality measures. They found that perceived sleep quality was closely related to the subjects' ability to fall asleep quickly and stay asleep (sleep continuity) and awaken close to the acrophase or time of peak activity. The study was an in-lab study and lacked experiential context of sleep. A more recent study, Harvey et al. 12 compared the subjective meaning of sleep quality between individuals with and without insomnia using a “speak freely” interview approach to ask participants to describe good and poor sleep quality, and found that tiredness on awakening and the number of awakenings during the night were the most important variables regarding sleep quality. These studies reported comparisons of subjective and objective sleep; however, they did not provide context of daily lived experiences that may influence the meaning and importance of sleep. In another study, Coveney 13 described the subjective sleep experiences and sleep practices of shift workers, and students, realizing that the social context influenced how they managed sleep in their lives. This context was influential in understanding the meaning of their attitudes toward sleep. More recently, Buysse 14 introduced a conceptual model of sleep health in order to clearly establish a meaning of the term Sleep Health. Five dimensions of sleep were identified as relevant including: sleep duration, sleep continuity or efficiency, timing, alertness/sleepiness, and satisfaction/quality (subjective assessment of good or poor sleep). The subjective dimension of satisfaction/quality clearly places good sleep in the context of the individual and society that could be explicated with qualitative research approaches. Sleep Health is then appreciated in the context of individual, social, and environmental demands from the perspective of the participants' situational meanings. Thus, an investigation of healthy individuals is warranted to add contextual insights to understanding sleep health. Thus, the purpose of this study was to understand the common meanings and shared practices of good and bad sleep. The parent study provided the text data from the rich narrative descriptions of good and bad sleep. The goal of the parent study was to validate and refine the sleep questions from the Behavioral Risk Factor Surveillance System (BRFSS) from the CDC.15 Methodology An interpretive phenomenological approach was used to guide the study of the everyday experiences of sleep in the narratives of a sample of healthy people.16,17 In this method, the researchers uncover the everyday common meanings of an individual's life with the goal of discovering the meaning embedded in the text. The purpose of this analysis is not to predict but to understand the contextual meaning of a situation. The researchers' interpretations reveal what is important to the individual, his/her issues, concerns, and understandings of his/her world. 18 Human experiences are historical and temporal, based on language and cultural practices. 19 Recurring themes or common knowledge identified by interpretive studies embody the practical knowledge or wisdom that is familiar to the individuals in their lives. By reflecting on the experiences of individuals,
the investigator identifies the issues and problems as they are best understood in that particular context. Thus, we are able to describe the experience of everyday living and sleeping. Participants and methods Thirty participants randomly sampled from the parent study (n = 300) 15 were interviewed. The original pool of n = 300 participants were English-speaking community-dwelling adults aged 18 and older who did not use continuous positive airway pressure (CPAP) or oxygen while sleeping. Potential participants had previously consented to be contacted for interviews as part of the parent study. A random number generator was used to yield 30 numbers between 1 and 300. The target number of participants for the parent study interviews was preset to 30 so that participant characteristics (such as shown in Table 1) would be representative of the parent sample by virtue of the central limit theorem. Participants were contacted in numerical order. If participants were unreachable or declined to be interviewed, a block of five additional random numbers was generated. Contacts were made until thirty agreed to be interviewed. Only three potential participants declined (giving lack of time as a reason), thus, only one additional random number block was generated. When participants agreed to be interviewed, they chose from several time slots for their interviews; they were encouraged to be in a private location where they could talk freely by phone during the interview. Twenty-nine participants who agreed to be interviewed completed their interviews at the appointed times; one appointment was missed, then rescheduled and completed. Ultimately, thirty participants were interviewed about their everyday sleep experiences. See Table 2 for the interview guide. These narratives provided rich descriptions of everyday sleep experiences that provided the data for text analysis. Interview procedure The interviewer (first author), an expert in the interpretive phenomenology method, developed the open-ended questions for the interview based on the methodology. Questions were reviewed and approved by the research team. For the parent study, the investigator was initially blinded to all participants' data (age, gender, Table 1 Participant characteristics (n = 30) Variable
Mean (SD)
Range
Age BMI Sleep hours to feel rested (BRFSS #1) Average hours of sleep (BRFSS #2) Epworth sleepiness scale Actigraphy measures: Total sleep time (hours) Sleep efficiency (%) Sleep latency (minutes) Wake after sleep onset (minutes) Gender Racea Comorbiditiesb
38.8 (14.9) 25.8 (5.2) 7.8 (3.3) 7.0 (1.1) 5.8 (4.9)
19–71 18–37 5–24 4–8 0–21
6.8 (.9) 82.0 (5.8) 17.0 (11.7) 48.9 (15.1) Male/Female W/AA/Asian Heart attack Irregular rhythm Metabolic syndrome Asthma Depression Anxiety
4.6–8.2 71–91 0–47 24–68 8/22 28/1/1 3 1 2 3 4 4
Notes a. Race and ethnicity self-identified. W = white. AA = black or African American. HL = Hispanic or Latino. b. Comorbidities based on self-report medical history.
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259 Table 2 Interview Guide Thank you for agreeing to speak to me today about your sleep. There are no right or wrong answers, we learn from all your comments. 1. Can you please describe for me what is a typical good night sleep for you? a. Please explain in detail how do you know or feel that is was good? b. What contributed to your good night sleep? c. How often does this happen and for how long does it last. 2. Can you please describe for me a typical poor night sleep? a. Please explain in detail how do you know or feel that it was poor? b. What contributes to your poor sleep? c. How often does it occur and how long does it last? 3. Is there anything else you want us to know about determining good or poor sleep?
questionnaire responses and sleep study results) except name and phone number. Based on first name, the interviewer may have begun each session with a preconceived notion regarding participants' gender, thus blinding to gender was not absolute. The participants were familiar with the research team and easily dialogued with the interviewer by the phone interviews, which lasted approximately 30 minutes. Interviews were digitally recorded and transcribed for analysis. Both team members listened to the interview to verify the transcript accuracy and inserted emphasis to clarify meanings (i.e. Laughter indicated humor or capitalization to emphasize strong feelings.) In the parent study, the goal of the interview was to obtain common language to represent their sleep experiences that was used to validate and update the BRFSS questions. The text data narratives provided detailed stories of everyday sleep that were used for this interpretive analysis. Analysis Text data in this study were interpreted by a modified interpretive process described below. 16,20 The transcripts were downloaded in NVIVO for analysis. The research team consisted of the principal investigator, an expert in interpretive phenomenology, and a doctoral student trained in qualitative research techniques. First, each member of the research team examined each narrative text as a whole. Next, each researcher wrote an interpretive summary of the text that described the possible common meanings of the texts with excerpts from the text to support the interpretation. These summaries were the basis of the discussion of similarities and differences at weekly meetings with a goal to reach consensus on emerging themes. The analysis involved moving from the whole text to parts of the text in circular fashion known as the hermeneutic circle. When there were discrepancies, further clarification of interpretations was reached by returning to the original text to ensure keeping close to the meaning of the participants and not inserting pre-existing theories. Each previous text was reread again to compare themes across all texts to develop the relational themes that linked meanings across texts in a circular process. Then, all texts were reread to further uncover common meanings and clarify relational themes. During the analysis meetings the participants' background meanings and priorities emerged in the interpretations of the meaning of good and bad sleep. The researchers created matrixes of the relational themes present in each participant's narrative, to gain an understanding of the contextual similarities and differences between participants' stories. This step in the analysis clarified how the participants' experiences reflected their priorities in their life situations. Finally, the principal investigator produced a final interpretive summary report, which represented the current understanding of good and bad sleep and used quotes that allowed for validation by the reader. The multiple levels of interpretation served to expose conflicts and inconsistencies in the analysis and served to eliminate unsubstantiated
255
meanings. Although there is no single correct interpretation, continuous examination of the whole and the parts of the text with constant reference to the text ensured that interpretations were grounded and focused.16 When the interpretations are visible, clear and redundant with each new text, the findings are considered saturated.20 Overall similarities and differences were determined, noting that the narratives reflected life experiences and current life challenges. Results Characteristics of sample The thirty participants were generally healthy, with few comorbidities and a small percentage of smokers. Data from the parent study was measured approximately 6–12 months from the interviews. Sleep characteristics were comprised of subjective questions regarding usual hours of sleep (BRFSS questions no. 1 and 2), and daytime sleepiness (Epworth Sleepiness Scale). Objective measures from actigraphy included: sleep latency, wake after sleep onset, total sleep time, and sleep efficiency (see Table 1). Thematic findings There are two general themes that described the meaning and experiences of sleep for the healthy participants. Theme One: Agreeing on the meaning of good and bad sleep The participants' everyday sleep experiences were embedded within the stories of their ordinary lives, which involved a variety of good and bad sleep. Interestingly, they often described their good night sleep as when bad sleep did not occur. When they slept well, they quickly entered a sleep state, had several hours of uninterrupted sleep, and did not wake up during the night, or if they awoke they fell back to sleep quickly. In the morning they woke up refreshed often not needing an alarm clock. The participants predominantly discussed that a lack of interruptions from the environment or worry about their own life situations contributed to good sleep. Many of the participants stated that good sleep meant to sleep without interruptions, eg, “where I don't wake up continuously during the night.” “It's good when I'm not tossing and turning at night,” and “my child not waking up in the middle of the night coming into the bedroom.” Participants described good sleep outcomes as: waking up feeling rested with energy to face the day's tasks, having a positive attitude, improved mood, and general health. For example, one participant said, “When I get enough sleep? Everything runs smooth. I don't think that I require as much sugar or caffeine or things like that.” Another said “I feel good about myself…about life in general. My frame of mind is much better,” and another said “[sleep] is one of the main things that I use to make sure I don't get sick.” Another participant related: A good night's sleep helps you function through the day, and it affects your mood definitely. I know at least personally if I don't get a good night's sleep I'm more tired, maybe a little bit crankier. Most participants described factors that contributed to good sleep such as: having the time or opportunity to sleep, being free of stress such as having a calm day, being tired from the day (activities), and having a comfortable environments to sleep in including bed comfort, white noise, darkness and lack of interruptions. Participants described bad sleep as not being able to initiate and maintain sleep at night. They described having trouble falling asleep because of stress, being awoken by interruptions from a variety of reasons, and once awake they could not fall back to sleep. Most
256
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
participants attested to the role of stress in keeping them awake such as life events similar to job loss or other worries, which kept them awake. One participant stated: “sometimes if I'm stressed out or upset about something, I cannot sleep.” Participants also described situations that contributed to their bad sleep including interruptions from noises, children, or stormy weather, or experiences of musculoskeletal pain, too much caffeine or alcohol, and exercising too close to sleep time. One participant summed up her bad sleep: Well, I guess when it's not a good night's sleep I feel cold and restless and I have a hard time falling asleep, and sometimes I think that's associated with caffeine too late in the day. Participants complained that after a night of bad sleep, they awoke feeling groggy, cranky and in bad mood or attitude, with a lack of concentration, poor memory, and feeling not well. Participants' statements about bad sleep were clear and emphatic, for example: When I have a poor night's sleep I don't feel good at all. I mean, I'm miserable, and I'm very on edge, I feel grumpy. I'm edgy. I'm irritable…very anxious. I'm not able to process thoughts and problems…. I get really crotchety. My brain starts to wander from consciousness, When I don't get sleep sometimes, it feels like you have a hangover where your stomach is a little sick and you get a headache. Theme Two: Living with situational life contexts and priorities Participants' narratives all described their everyday life experiences and challenges that affected their sleep patterns and practices. These social and environmental contexts affected their ability, or desire, to make sleep a priority, or not, in their lives. All participants' narratives of sleep included stories of their current lives where sleep was only part of the whole story. They had responsibilities in their lives that included family, friends, work, and their own health and well-being. In addition, in the participants' stories, sleep opportunities and interruptions differed in relation to situational life priorities. Participants' narratives revealed three different perspectives related to their situational life contexts and priorities: Socializers, Family-focused Workers, and Optimum Health Seekers. Socializers Participants who prioritized their social life described their life in terms of going out late at night with friends and not leaving enough time to sleep. They clearly described the influence of lack of sleep on their mood, interpersonal relationships, and need to be productive at work or school in spite of prioritizing their social life. For example, one participant described why he limited the amount of time spent sleeping: Just me being how social I am, I mean, I work during the day, and it's hard to see my friends going to school and everything, so we'll get together at nighttime and see each other and lose track of time. Another participant who discussed the importance of her social life re-counted that “with school and taking 19 credits, I don't feel like I have enough time at all.” Their ability to focus improved with good sleep. Some of the participants who were at college described studying late and then taking long naps over the weekend or term breaks. This group valued social media as a way to maintain their social connections and often reported using their smart phone or computer at night to interact with others. They often talked about using
caffeine to keep awake after a short night sleep and spoke to using alcohol, which affected their sleep, for some alcohol use helped them fall asleep. The socializers commented that their lack of sleep often increased their susceptibility to colds and viruses. The socializers prioritized social and work-related functions as most important. They valued their social life more than their quality of sleep. Interruptions were related to late night studying, sleeping environment or bed partners, and stress keeping them awake. For example, one participant commented that there are not enough hours in the day: In order to have work and have the social life, sometimes in order to go out at night, since most stuff happens at night, and if there was a couple of hours to sleep, it would balance social and sleep. Another older man discussed the importance of a socializing in his life: If I had a relationship with another woman in my life, I'd be a lot calmer and I would sleep better…when I don't talk to her on a regular basis it makes my personal life and sleep poor. My wife died nine years ago, and it is hard but don't get single when you are old.
Family-focused workers Another group of participants prioritized their lives with family and/or work commitments and had different descriptions of their stressful lives and sleep needs. They often did not have enough time to sleep with too much to do, rigorous work schedules, and/or small children who would interrupt their sleep. Family-focused workers described their everyday experiences in short and to the point statements that emphasized the priority being on work and family versus good sleep. They also had less discussion and recognition of the physical effects of sleep deprivation (clumsy, forgetful, and lethargic). Life stresses plagued their minds as they tried to catch up and turn off their worries at night. Participants described pain and muscle tension, the beginning of “stomach burn” [gastro-esophageal reflux], and symptoms of depression related to stress. They would awaken at night, worrying about unresolved work issues and family issues resulting in less sleep, greater fatigue, and more caffeine use. Weekends served as a time to catch up on sleep for some, but they rarely had time for naps. The sleep environment was noisy (children or bed partner snoring) interrupting their sleep. Sleep was needed but not a priority. For instance, one participant described how nighttime is the only time to accomplish chores: Generally I would say my sleep is not usually a priority for me, mostly because of having two small children and the business that I'm running. So sleep tends to get put on the side burner trying to get stuff done at night when the kids are sleeping. The family-focused workers prioritized work and family and paid less attention to the effects of short sleep. Their life stresses kept them from obtaining optimal sleep, which increased risk for loss of productivity and potential for occupational injuries. Yet, sleep was not a major concern versus work and family priorities; for example, one participant described the reasons for not getting proper sleep as: Just circumstance for me. I mean, I have five kids, so, I mean, I have a two-year-old that likes to stay up sometimes till one in the morning, and she's still going. Trying to get her to go down, and it pretty much depends on my situation around me whether or not I get proper sleep, you know? Another parent stated, “We have young kids, and we're always on the go. There's always something scheduled, even on the weekends.” And, another described work/commute obligations as taking priority:
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
“I work twelve-hour days and I drive about an hour to work one way.” Interruptions of mental worry or a young family kept them awake. Some health issues began to keep them awake (tension and worry). Optimum health seekers Another group had a different perspective and awareness of their sleep and activity patterns that related to optimizing their health and benefit toward their weight. The optimum health seekers were attuned to the effect of poor sleep on their health. This group described clear timing and routines for sleep, valuing sleeping through the night and waking well-rested. They recognized their good mood and motivations and clearer thinking with a good night sleep. As one participant stated: It's just essential. It's stress relief. It's—I don't know beyond huge. I mean, yeah, it's very important that I get enough sleep. I mean it affects my whole day. It effects your whole lifestyle. The optimum health seekers recognized the value of exercise and eating well, as well as the role of sleep deprivation in causing cravings for comfort food of carbs, sugar and caffeine. If they were not sleeping well, they described themselves as having less energy and ambition. They had descriptions of the role of their physical and mental health in sleep with their health affecting night time awakenings. For example one woman said: Sleep is such a priority for me, I make sure that I stop whatever I′m doing. For instance, if I know that I′m going to be getting up early, then I go to bed early. I′m just probably too obsessed about that, but it's—I just need to sleep so I make sure that I have time for it. That's why it's so frustrating right now, because it's not really my fault. It's the hormones [from menopause], not me, that's causing the problem. The optimum health seekers knew of the outcomes of poor sleep such as troubles with concentration, anxiety, and mood. They also recognized the role of environmental interruptions of bed partners, pets, environmental noises as well as the effect of alcohol and caffeine on their sleep quality. Overall, they valued sleep for optimal health, especially if health issues began to compound sleep issues, and some used sleep aids. The optimum health seekers learned the value of sleep in optimizing health and prioritizing their time to account for adequate sleep time. One said, “It is probably the most important... next to nutrition and exercise, it's the top three important health issues to me.” Another stated, “Sleep is very important to me, and I suffer from migraines so I'm very careful with my sleep,” and another added, “it's like breathing the air.” They recognized patterns related to their sleep such as the effect of eating too late or drinking alcohol or caffeine, seasonal differences in activity and getting outside to exercise. In addition, they recognized the influence of sleep on their health and mental well-being. They also knew of more strategies to improve sleep such as sleep environment and comfort. Discussion This study of the meaning of good and bad sleep explicates priority-related situational contexts for understanding differences in issues with sleep continuity, opportunity, and prioritizing sleep in this group of participants. The idea of good sleep being related to sleep continuity was also found in the Akerstedt et al 11 study. Furthermore, in the current study, participants described the deleterious effects of poor sleep on the person's ability to function (mentally and emotionally) and be productive during the day. Participants all described life stresses as central to a bad night's
257
sleep. For participants, poor sleep lead to lost productivity and increased potential for injury. Participants' life situational contexts, such as emphasis on work demands and social life (family focused workers and socializers), informed the valuing of a good night's sleep that minimized obtaining sleep opportunities and subsequent sleep management practices, similar to Coveney. 13 Some sleep management practices included use of caffeine to stay awake and alcohol to de-stress. In addition, for family-focused workers, the dynamic interactions among the family members influence sleep opportunities. Likewise, Meltzer et al21 emphasized that the importance of sleep is best understood from the family context. Life stresses interfered with the ability to fall asleep as their mind raced with thoughts at bedtime and the children often interrupted their sleep. Future research could further examine family, social, and environmental contexts on sleep practices among a broader age range and ask more questions about life situations or developmental tasks such as in young families. The optimum health seekers prioritized and valued sleep, and they took advantage of sleep opportunities, and used their knowledge of sleep hygiene to attempt to improve sleep and manage stress. This perspective was more cognizant of the influence sleep health. The optimum health seekers prioritized sleep in their lives no matter what age. Theory development This work provides understanding and insight in the situational context and background of the participants' lives that influenced their sleep management practices (see Fig. 1). This situational contextual model adds to the understanding of Buysse's conceptual model of sleep health 14 by providing potential background perspectives to the sleep dimension process. The subjective sleep quality/ satisfaction is an assessment of sleep that is based on the individual's life situations and perspectives related to environmental and social contexts and backgrounds, upon which everyday experiences of sleep are situated and prioritized. The participant's life situation and priorities may place sleep health as only part of their lifeworld, where sleep opportunities are not maximized. The participants' current priority may change over time as the situations change as described by a few of the older participants. For some, sleep practices involve only obtaining the minimal amount of sleep to maintain alertness. Furthermore, in these narratives, bad sleep results in poorer mood, lack of concentration, and inability to function. These sleep management practices potentially affect health outcomes such as increased severity/frequency of cardiovascular, metabolic, and mental health diseases and injuries due to lack of alertness or focus. Future research could examine contextual priorities in other populations to further understand and give insight into potential influences on sleep health as well as a way to guide interventions to promote sleep health. Practice and policy implications The impact of sleep hygiene to promote public health has been discussed by Irish et al.22 in a review of empirical evidence on recommendations regarding stress management, exercise, and caffeine intake on sleep health. They propose that the effect of individual sleep hygiene programs on sleep is untested. Furthermore they concur with the current study's interpretations of the complex and contextual interplay among individuals' behaviors that should be considered when developing personalized strategies toward maximizing sleep opportunities. Future research needs to consider the impact of these differences on sleep promotion programs. In today's world of increasing technologies that allow a 24/7 time awake-ness, understanding the values that influence sleep practices are useful in educating the public about the importance of sleep to
258
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259
Fig. 1. Common experiences and shared practices of good and bad sleep.
maintain health and safety. While public health messages could focus on risk identification for poor outcomes with bad sleep, alternatively the messages could relate to the positive impact of good sleep on mental and physical health that could be integrated in personalized sleep promotion interventions. Good sleep is taken for granted, but the lack of sleep has consequences. In clinical practices, health care providers could explore an individual's life priorities to determine if health promoting practices such as sleep hygiene and stress management may facilitate patients' sleep health. Motivational interviewing could be a potential intervention that would focus on the individual's priorities and health. Public health message programs could be developed to target the familyfocused workers and socializers who need to be aware of the health risks of sleep deprivation and potential occupational injury as well as the impact of good sleep on health and wellness. For optimum health seekers, educational guides on sleep hygiene may be more readily accepted and self -management could be reinforced. In this study, the previous surveys may have added to the participants' awareness of the effect of sleep in their lives and, therefore, they may more readily accept recommendations for sleep hygiene practices. Thus, clinicians asking a simple question like “are you having problems with your sleep?” might begin the conversation. Limitations Qualitative approaches promote understanding of the meaning of everyday experiences in the context of the individuals' experiences. However, this approach limits generalizability to populations in general. In addition, there were more white females than male participants that influenced the interpretation. In addition, no participants were above the age of 70, limiting the elders' perspective. In addition, we did not specifically ask about the influence of work, partners and children on sleep that emerged as important dimensions of findings, thus, we do not have data from all participants about those aspects. Nonetheless, 30 participants' rich narratives on their current lives, and what was important to them, provided text data to qualitatively analyze the related themes. The approach to recruit by random selection from the parent study group promoted varied responses. The participants' understanding of sleep issues may have been influenced by the questionnaires regarding insomnia, general depression, anxiety, fatigue, physical function, and sleep disturbance that they had completed in the parent study, although many had completed the survey a year earlier. Disclosure The authors have no conflicts of interest.
Acknowledgment This manuscript was supported by Cooperative Agreement Numbers U48DP001910 and U48DP001910-05S1 from The CDC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. References 1. Monti JM, Monti D. Human sleep: an overview. In: Verster JC, Pandi-Permual SR, Streiner DL, editors. Sleep and quality of life in clinical medicine. Towowa, NJ: Humana Press; 2008. p. 29–36. 2. Landis CA. Physiological and behavioral aspects of sleep. In: Redeker NS, GPM, editors. Sleep disorders and sleep promotion in nursing practice. New York, NY: Springer publishing company; 2011. p. 1–18. 3. Redeker NS. Developmental aspects of normal sleep. In: Redeker NS, GPM, editors. Sleep disorders and sleep promotion in nursing practice. New York, NY: Springer Publishing Company; 2011. p. 19–32. 4. Minarik PA. Gender and sleep. In: Redeker NS, GPM, editors. Sleep disorders and sleep promotion in nursing practice. New York, NY: Springer publishing company; 2011. p. 33–42. 5. Kim C-W, Chang Y, Zhao D, Cainzos-Achirica M, Ryu S, Jung H-S, et al. Sleep duration, sleep quality, and markers of subclinical arterial disease in healthy men and women. Arteriosclerosis, Thrombosis, and Vascular Biology; 2015. 6. Institute of Medicine. Sleep disorders and sleep deprivation: an unmet public health problem. Washington, DC: National Academies Press; 2006 [available from http://www.ncbi.nlm.nih.gov/books/NBK19958/]. 7. World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach; 2007. 8. Centers for Disease Control and Prevention. Sleep and sleep disorders: data and statistics; 2014 [cited 2014 September 16. Available from: http://www.cdc.gov/ sleep/data_statistics.htm]. 9. U.S. Department of Health and Human Services. 2020 topics & objectives: sleep health; 2014 [[cited 2014 September 17]. Available from: http://www. healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=38]. 10. Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of sleep medicine and Sleep Research Society. Sleep. 2015; 38(6):843–844. 11. Akerstedt T, Hume K, Minors D, Waterhouse J. The meaning of good sleep: a longitudinal study of polysomnography and subjective sleep quality. J Sleep Res. 1994; 3(3):152–158. 12. Harvey AG, Stinson K, Whitaker KL, Moskovitz D, Virk H. The subjective meaning of sleep quality: a comparison of individuals with and without insomnia. Sleep. 2008;31(3):383–393. 13. Coveney CM. Managing sleep and wakefulness in a 24-hour world. Sociol Health Illn. 2014;36(1):123–136. 14. Buysse DJ. Sleep health: can We define it? Does it matter? Sleep. 2014;37(1): 9–17. 15. Jungquist CR, Mund J, Aquilina AT, Klingman K, Pender J, Ochs-Balcom H, et al. Validation of the BRFSS sleep questions. J Clin Sleep Med. 2015. 16. Diekelmann N, Ironside P. Hermeneutics. In: Fitzpatrick J, editor. Encyclopedia of nursing research. New York: Springer; 1998. p. 243–245. 17. Heidegger M. In: Macquarrie J, Robinson E, editors. Being and time. Bloomington, IN: Indiana University Press; 1962. 18. Plager KA. Hermeneutic phenomenology: a methodology for family health adn health promotion study in nursing. In: Benner P, editor. Interpretive phenomenology: embodiment, caring and ethics in health and illness. Thousand Oaks: Sage Publications; 1994. p. 65–83.
S.S. Dickerson et al. / Sleep Health 2 (2016) 253–259 19. Benner P. Quality of life: a phenomenological perspective on explanation, prediction, and understanding in nursing science. ANS Adv Nurs Sci. 1985;8(1):1–14. 20. Benner P. The tradition and skill of interpretive phenomenology in studying health, illness and caring practices. In: Benner P, editor. Interpretive phenomenology. Thousand Oaks: Sage; 1994.
259
21. Meltzer LJ, Montgomery-Downs HE. Sleep in the family. Pediatr Clin North Am. 2011;58(3):765–774. 22. Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The role of sleep hygiene in promoting public health: a review of empirical evidence. Sleep Med Rev. 2015;22: 23–36.