- Email: [email protected]
Sleep promotion in the intensive care unit—A survey of nurses’ interventions
Intensive and Critical Care Nursing (2011) 27, 138—142
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
Sleep promotion in the intensive care unit—–A survey of nurses’ interventions Kirsten M. Eliassen a,∗, Laila A. Hopstock b a
Department of Cardiology, Division of Cardiothoracic and Respiratory Medicine, University Hospital of Northern Norway, Tromsø, Norway b Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway Accepted 4 March 2011
KEYWORDS Sleep; Sleep deprivation; Intensive care units; Nursing
Summary Sleep deprivation is common amongst patients in intensive care units (ICU) and can lead to physiological and psychological dysfunctions that affect the healing process and increase morbidity and mortality. A focus on the effects of the ICU environment on patient sleep quality has lead to strategies for improvements in patient care. The aim of this smallscale study was to investigate the perceptions of the sleep-promoting interventions that ICU nurses believe they provide. A review of the literature identified four main approaches, i.e., noise reduction, light reduction, patient comfort improvement and clustering of patient care activities, to allow uninterrupted time for adequate sleep. A questionnaire was created to collect information on the nurses’ interventions to promote night- and daytime patient sleep in accordance with the literature findings. A total of 25 ICU nurses working in an ICU with medical and surgical patients at the University Hospital of Northern Norway completed the email-administered web-based questionnaire. The ICU nurses reported an overall interest and awareness in sleep-promoting interventions utilising all four approaches, but the challenge of caring for critically ill patients with demands of frequent assessment and nursing may influence which interventions are prioritised. © 2011 Elsevier Ltd. All rights reserved.
Introduction Sleep deprivation has been identified as a challenge for patients in the intensive care unit (ICU) for four decades (McFadden and Giblin, 1971) and has been well documented
∗ Corresponding author at: Department of Heart Disease, Division of Cardiothoracic and Respiratory Medicine, University Hospital of Northern Norway, N-9038 Tromsø, Norway. Tel.: +47 07766; fax: +47 77669320. E-mail address: [email protected] (K.M. Eliassen).
in review articles (Bijwadia and Ejaz, 2009; Parthasarathy and Tobin, 2004; Redeker, 2000). Sleep deprivation may lead to a variety of physiological and psychological dysfunctions (Friese, 2008) that affect the healing process and increase morbidity and mortality amongst ICU patients (Krachman et al., 1995). Factors contributing to sleep deprivation are multifactorial; however, the most important contributor to sleep deprivation is the ICU environment (Krachman et al., 1995). Environmental stimuli such as noise, lighting and frequent patient care activities are prevalent in the ICU during day and night (Honkus, 2003) and will, together with suboptimal nursing care, hinder patient sleep. These well-
0964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2011.03.001
Sleep promotion in the intensive care unit—–A survey of nurses’ interventions known threats to patient sleep quality have led to strategies for improvements in patient care (Friese, 2008). It is of interest to know whether interventions to improve sleep quality are implemented by nurses. The aim of this small-scale study was to investigate the perceptions of the sleep-promoting interventions that ICU nurses believe they provide.
Literature review We searched MEDLINE, CINAHL and the British Nursing Index with the following combination of MeSH-headings: ‘‘sleep’’ OR ‘‘sleep deprivation’’ AND ‘‘intensive care units’’ OR ‘‘intensive care’’ OR ‘‘critical care’’ OR ‘‘critical illness.’’ The search was limited to the English language and yielded 184, 58 and 12 hits, respectively; each study was reviewed to determine the relevance to critical care nursing. Four recent review studies (Fontana and Pittiglio, 2010; Friese, 2008; Patel et al., 2008; Tembo and Parker, 2009) and three earlier overview articles (Evans and French, 1995; Honkus, 2003; Parker, 1995) suggesting strategies to improve sleep in the ICU were examined. We chose to exclude pharmacologic interventions from this study. Four main approaches were identified: noise reduction, light reduction, improvement of patient comfort and clustering of patient care activities to allow uninterrupted time for adequate sleep (Evans and French, 1995; Fontana and Pittiglio, 2010; Friese, 2008; Honkus, 2003; Parker, 1995; Patel et al., 2008; Tembo and Parker, 2009). Noise reduction can be achieved by liberalising monitor and ventilator alarm settings (Friese, 2008), minimise conversations near the patient bedside (Fontana and Pittiglio, 2010), and by offering the patient earplugs (Evans and French, 1995; Friese, 2008; Patel et al., 2008). Light reduction can be achieved by dimming the light (Evans and French, 1995; Fontana and Pittiglio, 2010; Honkus, 2003; Patel et al., 2008) and offering the patient an eye mask (blindfolds) (Friese, 2008). Improvements in patient comfort include interventions such as adjustments to achieve optimal patient—ventilator synchrony, adequate pain relief (Friese, 2008; Patel et al., 2008), control of patient position and bed adjustments (Honkus, 2003; Parker, 1995), relaxation techniques such as massage or mouth care (Honkus, 2003; Parker, 1995; Patel et al., 2008), and communicating to the patient when it is time to sleep (Evans and French, 1995). Patient care activities can be coordinated and clustered (Fontana and Pittiglio, 2010; Friese, 2008; Parker, 1995; Tembo and Parker, 2009) to allow uninterrupted sleep. Normal sleep architecture is divided to non-rapid eye movement (NREM) sleep (consisting of stage 1, stage 2 and stage N, formerly known as stage 3/4) and rapid eye movement (REM) sleep (Patel et al., 2008). ICU patients suffer from both quantitative and qualitative sleep deprivation (Hardin, 2009). Some ICU patients sleep as little as 1.7 hours per day and experience predominantly light stage 1 sleep and decreased or absent stages 2, 3/4 and REM sleep (Freedman et al., 2001). A full cycle through the different stages of sleep normally requires 90—110 minutes (Gabor et al., 2001). Patient sleep time is often overestimated by nurses, and a minimum of two hours of uninterrupted sleep is preferable (Honkus, 2003) for daytime and nighttime sleep periods.
139
Methods Participants and setting The study was conducted in an ICU with medical and surgical patients at the University Hospital of Northern Norway. To be included in the study, the respondents had to be registered nurses with continuing education as critical care nurses and with permanent positions in the ICU. A total of 49 nurses fulfilled the inclusion criteria.
Data collection and analysis The head nurse of the ICU department provided a hospital e-mail address list of nurses fulfilling the inclusion criteria. A web-based anonymous questionnaire (in Norwegian) was administered by e-mail via the QuestBack program (SaaS, QuestBack, Oslo, Norway). The nurses could choose to participate by clicking a link to the online questionnaire. To improve the response rate, a short orientation was administered by the head nurse at a staff meeting, where the nurses were requested to check their e-mail inbox for a questionnaire on patient sleep. After 10 days, a reminder was sent by e-mail. Due to in house regulation for the use of the Questback programme, the questionnaire was only available on the web for 18 days and then closed. Descriptive statistics were calculated with the QuestBack program. Results are presented as numbers and percentages.
Instrument The questionnaire was designed to collect information from the respondents with regard to the interventions they believe to provide to promote night- and daytime patient sleep, as presented in the literature review. The first part of the questionnaire contained six questions on nursing interventions such as reduction of noise and light and improvements related to patient comfort. Closed-ended questions were used, as the respondent was expected to choose one or more options from a list of answers. Each question also had an answer option called ‘‘other,’’ where the respondent could fill in comments. The next part of the questionnaire contained closed-ended questions on whether the nurse informed the patient when it was time to sleep (‘‘yes often’’/‘‘no seldom’’) or scheduled patient sleep time during daytime (‘‘yes often’’/‘‘no seldom’’). At the end, two questions were posed, with the following answer options: ‘‘Your patient has slept little last night, how long will you let him sleep on this dayshift?’’ (‘‘one hour’’, ‘‘two hours’’ or ‘‘until he wakes up by himself’’) and ‘‘Which patient care interventions will make you wake up a patient who is sleeping during the daytime and slept little last night?’’ (‘‘central venous catheter care’’, ‘‘physiotherapy’’, ‘‘X-ray’’, ‘‘doctor’s rounds’’, ‘‘administration of antibiotics’’, ‘‘visit by relatives’’ and ‘‘blood gas control’’). To check for representativeness, the respondents were asked questions related to years of work experience in an ICU and whether the respondent had more night shifts than day or afternoon shifts. To test the instrument, a small pilot study was undertaken with two intensive
140
K.M. Eliassen, L.A. Hopstock
Table 1 Nurses’ self reported use of patient sleep promoting interventions in the intensive care unit during nightshifts and dayshifts (N = 25). Values are n (percentages). Sleep promoting interventions
Nighttime n (%)
Noise reduction Reduce alarm levels on monitor 13 (52) Reduce alarm levels on ventilator 15 (60) Avoid bedside staff conversations 22 (88) Offer earplugs 18 (72) Lighting practices Turn off small lamps 19 (76) Turn off ceiling lamps 25 (100) Pulling down window shades 17 (68) Offer eye masks 0 (0) Patient comfort Bed adjustments/patient position 24 (96) Patient—ventilator synchrony 18 (72) Adequate pain relief 23 (92) Massage, mouth care 14 (56)
Daytime n (%) 10 11 21 12
(40) (44) (84) (48)
17 (68) 15 (60) 9 (36) 1 (4) 24 17 22 8
(96) (68) (88) (32)
care nurses at another ICU in the same hospital. As they found no difficulties in completing the questionnaire, only minor corrections were made.
Ethical considerations The respondents received written information about participation in the study being voluntary and anonymous and were informed that the investigators would have no access to identifiable data. Research on anonymous data does not fall within the Norwegian legislation of health research (The Health Research Act, 2008) and is therefore not considered by The Regional Board of Research Ethics. The participants’ completion and return of the questionnaire was considered to represent consent. Approval to perform the study was obtained by the head of the ICU Department.
Results Respondents A total of 25 (51%) of the nurses answered the questionnaire. Amongst the respondents, 10 (40%) had more night shifts than day or afternoon shifts. Five (20%) respondents had up to four years of work experience in an ICU; six (24%) had five to nine years of experience and 14 (56%) had worked 10 years or more in an ICU. All respondents answered all the questions in the questionnaire.
ventions described as answers to the open-ended question regarding nighttime sleep were lowering of the voice and asking other staff members to do the same and adjusting time intervals between non-invasive blood-pressure measurements. For daytime sleep, the respondents reported that they shielded the patient from the activities in the unit by pulling the curtains and placing a ‘‘the patient is sleeping’’ note on the curtains or the door. One nurse reportedly offered the use of an eye mask during the daytime, whilst none offered the use of an eye mask during nighttime. One respondent commented that some procedures required light. One respondent commented that offering eye masks on a regular basis could be the solution to work difficulties related to light reduction.
Patient comfort Patient comfort interventions during night- and daytime are presented in Table 1. Patient comfort strategies were commonly used to promote both night- and daytime sleep, except for massage and mouth care, which were considered less important to promote daytime sleep. Other interventions reported in answers to the open-ended question regarding nighttime sleep were performing foot- or hand massage, holding the patient’s hand, sitting within visual distance if the patient was anxious, or offering television, radio or music if the patient desired such entertainment before sleeping. For day-sleep, massage in connection to caring routines was also reported. One respondent reported engaging in all such efforts during all shifts. All respondents reported that they informed the patient when it was time to sleep.
Patient care activities A total of 18 respondents (72%) reported that they planned a sleep period for the patient during daytime. Uninterrupted sleep during daytime after a night with little sleep was reported to last for ‘‘one hour’’ (eight respondents, 32%), ‘‘two hours’’ (14, 56%) or ‘‘until he wakes up by himself’’ (three, 12%). Patient care interventions that would require the nurse to wake a patient sleeping during the daytime who had slept little the night before were reported as ‘‘physiotherapy’’ (two, 8%), ‘‘X-ray’’ (six, 24%), ‘‘doctor’s rounds’’ (three, 12%), ‘‘administration of antibiotics’’ (three, 12%) and ‘‘blood gas control’’ (six, 24%). None of the respondents reported that they would wake the patient for ‘‘central venous catheter care’’ or ‘‘visit by relatives.’’ A total of 14 (56%) respondents would not wake up the patient for any of these care interventions.
Discussion Noise and light Noise and light reduction interventions during night- and daytime are presented in Table 1. Noise and light reduction were reported to be prioritised for nighttime sleep and less so for daytime sleep. Preventing conversations from being held near the patient’s bedside was reported to be highly prioritised during both night- and daytime. Other inter-
The aim of this study was to investigate the perceptions of the sleep-promoting interventions that ICU nurses believe they provide. Our main finding is an overall interest and awareness in sleep-promoting interventions, but some discrepancies exist between strategies suggested in the literature and interventions reportedly performed by the nurses.
Sleep promotion in the intensive care unit—–A survey of nurses’ interventions
Noise and light Previous studies reported that noise is the most disruptive factor to sleep for patients in the ICU (Richardson et al., 2007) and that ICU nurses have little knowledge of the impact of noise exposure (Christensen, 2005). Staff conversations and alarms were rated as the most disturbing noises for patients asleep in the ICU (Xie et al., 2009). Nurses can control these two factors, and our results show that nurses reported that they avoid staff conversations near the patient’s bedside when the patient is asleep during either the night or the day, but only half of the responders reported that they reduced the alarm levels on the monitors and ventilators. The reason for this is unknown. ICU nurses usually work bedside, and frequent alarms are not always perceived as helpful in the ICU setting (Chambrin, 2001). Lights are always present in the ICU, but night light levels have been measured to be low (Walder et al., 2000). We found that turning off lamps was reported to be highly prioritised for night sleep and to a lesser extent for day sleep. The reason for this could be that lights cannot be dimmed to such a degree that patient assessment is negatively impacted; furthermore, bright lights are required for several procedures (Richardson et al., 2007), which are performed more frequently during day shifts than night shifts. The use of earplugs and eye masks allows longer and more satisfactory sleep amongst critically ill patients (Richardson et al., 2007; Scotto et al., 2009). In our study, 72% of the nurses reported that they offered the patient earplugs for night sleep, but less than half of the respondents offered earplugs for daytime sleep. Only one respondent offered eye masks, only for daytime sleep. Intervention studies that have been performed in the ICU include only patients who are alert, oriented and able to remove the intervention themselves (Richardson et al., 2007; Scotto et al., 2009). This is not always the case with critically ill patients in the ICU, and because of this, the nurses in our study may have been reluctant to use such interventions. Patients can feel anxious when not hearing background noise, and decreasing the ability to hear and see can be frightening for ICU patients who struggle to orientate themselves.
Patient comfort The inability to relax caused by factors such as unsynchronised ventilator—patient breathing (Gabor et al., 2001), pain, anxiety or uncomfortable positions in bed (Parker, 1995) are reported to be important causes of sleep deprivation in the ICU. The nurses in our study reportedly adjusted the patient’s position in the bed, synchronised the ventilator with the patient’s breathing and provided adequate pain relief for both nighttime and daytime sleep, but mouth care and massage were less prioritised, especially for daytime sleep. It could be that such care-giving interventions are performed in connection with other caring routines, as was reported by one of the respondents, and therefore are not considered as sleep-promotion interventions. As all respondents reported that they informed the patient when it was time to sleep, it seems as though communicating the ‘‘permission to sleep’’ is considered essential. This is important to prepare the patient for planned activities, to
141
orientate the patient with respect to time (Friese, 2008) and to reassure the patient that sleeping is accepted and that the patient will be looked after when sleeping (Evans and French, 1995).
Patient care activities ICU patients rate nursing interventions to be as disruptive to sleep as noise (Freedman et al., 1999). Clustering of care has been recommended to allow for uninterrupted sleep periods, but studies from both medical and surgical ICUs show that 40—50 care interventions typically occur per patient per night shift (Celik et al., 2005; Tamburri et al., 2004). This leaves little opportunity for patients to sleep during the night. In our study, 72% of the respondents planned a sleep period for their patient during the dayshift. Two-thirds of the respondents reported that they would let the patient sleep for two hours or more; the remaining one-third would wake the patient after one hour. One hour of sleep is not sufficient time to experience the healing process of going through a full cycle of the different sleep stages. Only a few of the respondents would wake the sleeping patient for the various interventions listed in the questionnaire, and more than half of the respondents would not wake the patient for any of these interventions. It could be argued that nurses have an around-the-clock presence and coordinating function in the ICU and should be able to coordinate nursing care with other activities to allow for patient sleep periods.
Nurses’ interventions to promote sleep in the intensive care unit Our findings show an overall interest and awareness in sleep-promoting interventions. The underlying challenge of around-the-clock care for critically ill patients may impact which interventions are prioritised. Problems related to sleep deprivation in the ICU have been addressed in several studies but remain overlooked despite the impact on healing, patient well-being and length of hospital stay (Honkus, 2003; Redeker, 2008). It has been suggested that nurses may be desensitised to the constant chaos in the ICU (Fontana and Pittiglio, 2010) and forget about the stimuli negatively impacting patient sleep. The traditional priorities related to care-giving in the ICU may work as barriers to the incorporation of sleep promotion strategies and make nurses downgrade sleep (Evans and French, 1995). Working in an action-oriented subculture such as the ICU environment may influence nursing behaviours and actions (Evans and French, 1995). ICU patients are in need of bedside observations and specialised nursing care because of their critical condition. Routine interventions necessary to prevent complications and life-threatening emergency situations both require action on the part of the nurse. Still, nursing care activities may be performed as part of a routine, and the nurse has to remain aware of the problem of sleep deprivation and to prioritise which activities are important for the individual patient. Another barrier to the delivery of evidence-based sleep-promoting interventions may be gaps in the quantity and quality of research findings in this area of study. However, there has been an exponential growth in the knowledge of the importance of sleep amongst critically
142 ill patients over the last few years (Redeker, 2008). This may further increase the awareness of sleep-promoting interventions amongst ICU nurses. Creation of a sleep-promoting environment by reducing sleep-disturbing stimuli, coordinating care activities and preparing the patient for sleep should continue to be encouraged in the ICU.
Study limitations Self-reported data may produce a bias, and some respondents may have given expected answers. Although it has been found that nurses prioritising sleep also initiate more sleep-promoting interventions (Pulling, 1991), the coherence between what is reported and what is actually performed is not known. The questionnaire was developed by the researchers and was not subject to formal validation tests. Generalisation is limited due to the small sample size, lack of randomisation and the fact that the study was conducted in only one ICU. Nurses who did not read their hospital e-mails during the data collection period due to vacation or sick leave were not excluded, and this may have negatively influenced the response rate.
Conclusion ICU nurses report an overall interest and awareness in sleep-promoting interventions. However, the challenge of caring for critically ill patients who require frequent assessment and nursing actions influences which interventions are prioritised. Nurses must continue to improve the ICU environment to enhance patient sleep by coordinating care activities, preparing the patient for sleep and reducing the prevalence of disturbing stimuli.
Conflict of interest statement None.
References Bijwadia JS, Ejaz MS. Sleep and critical care. Curr Opin Crit Care 2009;15:25—9. Celik S, Oztekin D, Akyolcu N, Issever H. Sleep disturbance: the patient care activities applied at the night shift in the intensive care unit. J Clin Nurs 2005;14:102—6. Chambrin MC. Alarms in the intensive care unit: how can the number of false alarms be reduced? Crit Care 2001;5:184—8. Christensen M. What knowledge do ICU nurses have with regard to the effects of noise exposure in the Intensive Care Unit? Intensive Crit Care Nurs 2005;21:199—207. Evans JC, French DG. Sleep and healing in intensive care settings. Dimens Crit Care Nurs 1995;14:189—99.
K.M. Eliassen, L.A. Hopstock Fontana CJ, Pittiglio LI. Sleep deprivation among critical care patients. Crit Care Nurs Quart 2010;33:75—81. Freedman NS, Gazendam J, Levan L, Pack AI, Schwab RJ. Abnormal sleep/wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit. Am J Respir Crit Care Med 2001;163:451—7. Freedman NS, Kotzer N, Schwab RJ. Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Respir Criti Care Med 1999;159:1155—62. Friese RS. Sleep and recovery from critical illness and injury: a review of theory, current practice, and future directions. Crit Care Med 2008;36:697—705. Gabor JY, Cooper AB, Hanly PJ. Sleep disruption in the intensive care unit. Curr Opin Crit Care 2001;7:21—7. Hardin KA. Sleep in the ICU: potential mechanisms and clinical implications. Chest 2009;136:284—94. Honkus VL. Sleep deprivation in critical care units. Crit Care Nurs Quart 2003;26:179—89. Krachman SL, D’Alonzo GE, Criner GJ. Sleep in the intensive care unit. Chest 1995;107:1713—20. McFadden EH, Giblin EC. Sleep deprivation in patients having openheart surgery. Nurs Res 1971;20:249—54. Parker KP. Promoting sleep and rest in critically ill patients. Crit Care Nurs Clin North Am 1995;7:337—49. Parthasarathy S, Tobin MJ. Sleep in the intensive care unit. Intensive Care Med 2004;30:197—206. Patel M, Chipman J, Carlin BW, Shade D. Sleep in the intensive care unit setting. Crit Care Nurs Quart 2008;31:309—18. Pulling CA. ‘The relationship between critical care nurses’ knowledge about sleep, and the initiation of sleep promoting nursing interventions. AXON 1991;13:57—62. Redeker NS. Sleep in acute care settings: an integrative review. J Nurs Scholarsh 2000;32:31—8. Redeker NS. Challenges and opportunities associated with studying sleep in critically ill adults. AACN Adv Crit Care 2008;19:178—85. Richardson A, Allsop M, Coghill E, Turnock C. Earplugs and eye masks: do they improve critical care patients’ sleep? Nurs Crit Care 2007;12:278—86. Scotto CJ, McClusky C, Spillan S, Kimmel J. Earplugs improve patients’ subjective experience of sleep in critical care. Nurs Crit Care 2009;14:180—4. Tamburri LM, DiBrienza R, Zozula R, Redeker NS. Nocturnal care interactions with patients in critical care units. Am J Crit Care 2004;13:102—12. Tembo AC, Parker V. Factors that impact on sleep in intensive care patients. Intensive Crit Care Nurs 2009;25:314—22. The Health Research Act. ACT 2008-06-20 no. 44. http://www.ub.uio.no/ujur/ulovdata/lov-20080620-044eng.pdf [accessed December 8, 2010]. Walder B, Francioli D, Meyer JJ, Lancon M, Romand JA. Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels. Crit Care Med 2000;28:2242—7. Xie H, Kang J, Mills GH. Clinical review: the impact of noise on patients’ sleep and the effectiveness of noise reduction strategies in intensive care units. Crit Care 2009;13:208.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
Sleep promotion in the intensive care unit—–A survey of nurses’ interventions Kirsten M. Eliassen a,∗, Laila A. Hopstock b a
Department of Cardiology, Division of Cardiothoracic and Respiratory Medicine, University Hospital of Northern Norway, Tromsø, Norway b Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway Accepted 4 March 2011
KEYWORDS Sleep; Sleep deprivation; Intensive care units; Nursing
Summary Sleep deprivation is common amongst patients in intensive care units (ICU) and can lead to physiological and psychological dysfunctions that affect the healing process and increase morbidity and mortality. A focus on the effects of the ICU environment on patient sleep quality has lead to strategies for improvements in patient care. The aim of this smallscale study was to investigate the perceptions of the sleep-promoting interventions that ICU nurses believe they provide. A review of the literature identified four main approaches, i.e., noise reduction, light reduction, patient comfort improvement and clustering of patient care activities, to allow uninterrupted time for adequate sleep. A questionnaire was created to collect information on the nurses’ interventions to promote night- and daytime patient sleep in accordance with the literature findings. A total of 25 ICU nurses working in an ICU with medical and surgical patients at the University Hospital of Northern Norway completed the email-administered web-based questionnaire. The ICU nurses reported an overall interest and awareness in sleep-promoting interventions utilising all four approaches, but the challenge of caring for critically ill patients with demands of frequent assessment and nursing may influence which interventions are prioritised. © 2011 Elsevier Ltd. All rights reserved.
Introduction Sleep deprivation has been identified as a challenge for patients in the intensive care unit (ICU) for four decades (McFadden and Giblin, 1971) and has been well documented
∗ Corresponding author at: Department of Heart Disease, Division of Cardiothoracic and Respiratory Medicine, University Hospital of Northern Norway, N-9038 Tromsø, Norway. Tel.: +47 07766; fax: +47 77669320. E-mail address: [email protected] (K.M. Eliassen).
in review articles (Bijwadia and Ejaz, 2009; Parthasarathy and Tobin, 2004; Redeker, 2000). Sleep deprivation may lead to a variety of physiological and psychological dysfunctions (Friese, 2008) that affect the healing process and increase morbidity and mortality amongst ICU patients (Krachman et al., 1995). Factors contributing to sleep deprivation are multifactorial; however, the most important contributor to sleep deprivation is the ICU environment (Krachman et al., 1995). Environmental stimuli such as noise, lighting and frequent patient care activities are prevalent in the ICU during day and night (Honkus, 2003) and will, together with suboptimal nursing care, hinder patient sleep. These well-
0964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2011.03.001
Sleep promotion in the intensive care unit—–A survey of nurses’ interventions known threats to patient sleep quality have led to strategies for improvements in patient care (Friese, 2008). It is of interest to know whether interventions to improve sleep quality are implemented by nurses. The aim of this small-scale study was to investigate the perceptions of the sleep-promoting interventions that ICU nurses believe they provide.
Literature review We searched MEDLINE, CINAHL and the British Nursing Index with the following combination of MeSH-headings: ‘‘sleep’’ OR ‘‘sleep deprivation’’ AND ‘‘intensive care units’’ OR ‘‘intensive care’’ OR ‘‘critical care’’ OR ‘‘critical illness.’’ The search was limited to the English language and yielded 184, 58 and 12 hits, respectively; each study was reviewed to determine the relevance to critical care nursing. Four recent review studies (Fontana and Pittiglio, 2010; Friese, 2008; Patel et al., 2008; Tembo and Parker, 2009) and three earlier overview articles (Evans and French, 1995; Honkus, 2003; Parker, 1995) suggesting strategies to improve sleep in the ICU were examined. We chose to exclude pharmacologic interventions from this study. Four main approaches were identified: noise reduction, light reduction, improvement of patient comfort and clustering of patient care activities to allow uninterrupted time for adequate sleep (Evans and French, 1995; Fontana and Pittiglio, 2010; Friese, 2008; Honkus, 2003; Parker, 1995; Patel et al., 2008; Tembo and Parker, 2009). Noise reduction can be achieved by liberalising monitor and ventilator alarm settings (Friese, 2008), minimise conversations near the patient bedside (Fontana and Pittiglio, 2010), and by offering the patient earplugs (Evans and French, 1995; Friese, 2008; Patel et al., 2008). Light reduction can be achieved by dimming the light (Evans and French, 1995; Fontana and Pittiglio, 2010; Honkus, 2003; Patel et al., 2008) and offering the patient an eye mask (blindfolds) (Friese, 2008). Improvements in patient comfort include interventions such as adjustments to achieve optimal patient—ventilator synchrony, adequate pain relief (Friese, 2008; Patel et al., 2008), control of patient position and bed adjustments (Honkus, 2003; Parker, 1995), relaxation techniques such as massage or mouth care (Honkus, 2003; Parker, 1995; Patel et al., 2008), and communicating to the patient when it is time to sleep (Evans and French, 1995). Patient care activities can be coordinated and clustered (Fontana and Pittiglio, 2010; Friese, 2008; Parker, 1995; Tembo and Parker, 2009) to allow uninterrupted sleep. Normal sleep architecture is divided to non-rapid eye movement (NREM) sleep (consisting of stage 1, stage 2 and stage N, formerly known as stage 3/4) and rapid eye movement (REM) sleep (Patel et al., 2008). ICU patients suffer from both quantitative and qualitative sleep deprivation (Hardin, 2009). Some ICU patients sleep as little as 1.7 hours per day and experience predominantly light stage 1 sleep and decreased or absent stages 2, 3/4 and REM sleep (Freedman et al., 2001). A full cycle through the different stages of sleep normally requires 90—110 minutes (Gabor et al., 2001). Patient sleep time is often overestimated by nurses, and a minimum of two hours of uninterrupted sleep is preferable (Honkus, 2003) for daytime and nighttime sleep periods.
139
Methods Participants and setting The study was conducted in an ICU with medical and surgical patients at the University Hospital of Northern Norway. To be included in the study, the respondents had to be registered nurses with continuing education as critical care nurses and with permanent positions in the ICU. A total of 49 nurses fulfilled the inclusion criteria.
Data collection and analysis The head nurse of the ICU department provided a hospital e-mail address list of nurses fulfilling the inclusion criteria. A web-based anonymous questionnaire (in Norwegian) was administered by e-mail via the QuestBack program (SaaS, QuestBack, Oslo, Norway). The nurses could choose to participate by clicking a link to the online questionnaire. To improve the response rate, a short orientation was administered by the head nurse at a staff meeting, where the nurses were requested to check their e-mail inbox for a questionnaire on patient sleep. After 10 days, a reminder was sent by e-mail. Due to in house regulation for the use of the Questback programme, the questionnaire was only available on the web for 18 days and then closed. Descriptive statistics were calculated with the QuestBack program. Results are presented as numbers and percentages.
Instrument The questionnaire was designed to collect information from the respondents with regard to the interventions they believe to provide to promote night- and daytime patient sleep, as presented in the literature review. The first part of the questionnaire contained six questions on nursing interventions such as reduction of noise and light and improvements related to patient comfort. Closed-ended questions were used, as the respondent was expected to choose one or more options from a list of answers. Each question also had an answer option called ‘‘other,’’ where the respondent could fill in comments. The next part of the questionnaire contained closed-ended questions on whether the nurse informed the patient when it was time to sleep (‘‘yes often’’/‘‘no seldom’’) or scheduled patient sleep time during daytime (‘‘yes often’’/‘‘no seldom’’). At the end, two questions were posed, with the following answer options: ‘‘Your patient has slept little last night, how long will you let him sleep on this dayshift?’’ (‘‘one hour’’, ‘‘two hours’’ or ‘‘until he wakes up by himself’’) and ‘‘Which patient care interventions will make you wake up a patient who is sleeping during the daytime and slept little last night?’’ (‘‘central venous catheter care’’, ‘‘physiotherapy’’, ‘‘X-ray’’, ‘‘doctor’s rounds’’, ‘‘administration of antibiotics’’, ‘‘visit by relatives’’ and ‘‘blood gas control’’). To check for representativeness, the respondents were asked questions related to years of work experience in an ICU and whether the respondent had more night shifts than day or afternoon shifts. To test the instrument, a small pilot study was undertaken with two intensive
140
K.M. Eliassen, L.A. Hopstock
Table 1 Nurses’ self reported use of patient sleep promoting interventions in the intensive care unit during nightshifts and dayshifts (N = 25). Values are n (percentages). Sleep promoting interventions
Nighttime n (%)
Noise reduction Reduce alarm levels on monitor 13 (52) Reduce alarm levels on ventilator 15 (60) Avoid bedside staff conversations 22 (88) Offer earplugs 18 (72) Lighting practices Turn off small lamps 19 (76) Turn off ceiling lamps 25 (100) Pulling down window shades 17 (68) Offer eye masks 0 (0) Patient comfort Bed adjustments/patient position 24 (96) Patient—ventilator synchrony 18 (72) Adequate pain relief 23 (92) Massage, mouth care 14 (56)
Daytime n (%) 10 11 21 12
(40) (44) (84) (48)
17 (68) 15 (60) 9 (36) 1 (4) 24 17 22 8
(96) (68) (88) (32)
care nurses at another ICU in the same hospital. As they found no difficulties in completing the questionnaire, only minor corrections were made.
Ethical considerations The respondents received written information about participation in the study being voluntary and anonymous and were informed that the investigators would have no access to identifiable data. Research on anonymous data does not fall within the Norwegian legislation of health research (The Health Research Act, 2008) and is therefore not considered by The Regional Board of Research Ethics. The participants’ completion and return of the questionnaire was considered to represent consent. Approval to perform the study was obtained by the head of the ICU Department.
Results Respondents A total of 25 (51%) of the nurses answered the questionnaire. Amongst the respondents, 10 (40%) had more night shifts than day or afternoon shifts. Five (20%) respondents had up to four years of work experience in an ICU; six (24%) had five to nine years of experience and 14 (56%) had worked 10 years or more in an ICU. All respondents answered all the questions in the questionnaire.
ventions described as answers to the open-ended question regarding nighttime sleep were lowering of the voice and asking other staff members to do the same and adjusting time intervals between non-invasive blood-pressure measurements. For daytime sleep, the respondents reported that they shielded the patient from the activities in the unit by pulling the curtains and placing a ‘‘the patient is sleeping’’ note on the curtains or the door. One nurse reportedly offered the use of an eye mask during the daytime, whilst none offered the use of an eye mask during nighttime. One respondent commented that some procedures required light. One respondent commented that offering eye masks on a regular basis could be the solution to work difficulties related to light reduction.
Patient comfort Patient comfort interventions during night- and daytime are presented in Table 1. Patient comfort strategies were commonly used to promote both night- and daytime sleep, except for massage and mouth care, which were considered less important to promote daytime sleep. Other interventions reported in answers to the open-ended question regarding nighttime sleep were performing foot- or hand massage, holding the patient’s hand, sitting within visual distance if the patient was anxious, or offering television, radio or music if the patient desired such entertainment before sleeping. For day-sleep, massage in connection to caring routines was also reported. One respondent reported engaging in all such efforts during all shifts. All respondents reported that they informed the patient when it was time to sleep.
Patient care activities A total of 18 respondents (72%) reported that they planned a sleep period for the patient during daytime. Uninterrupted sleep during daytime after a night with little sleep was reported to last for ‘‘one hour’’ (eight respondents, 32%), ‘‘two hours’’ (14, 56%) or ‘‘until he wakes up by himself’’ (three, 12%). Patient care interventions that would require the nurse to wake a patient sleeping during the daytime who had slept little the night before were reported as ‘‘physiotherapy’’ (two, 8%), ‘‘X-ray’’ (six, 24%), ‘‘doctor’s rounds’’ (three, 12%), ‘‘administration of antibiotics’’ (three, 12%) and ‘‘blood gas control’’ (six, 24%). None of the respondents reported that they would wake the patient for ‘‘central venous catheter care’’ or ‘‘visit by relatives.’’ A total of 14 (56%) respondents would not wake up the patient for any of these care interventions.
Discussion Noise and light Noise and light reduction interventions during night- and daytime are presented in Table 1. Noise and light reduction were reported to be prioritised for nighttime sleep and less so for daytime sleep. Preventing conversations from being held near the patient’s bedside was reported to be highly prioritised during both night- and daytime. Other inter-
The aim of this study was to investigate the perceptions of the sleep-promoting interventions that ICU nurses believe they provide. Our main finding is an overall interest and awareness in sleep-promoting interventions, but some discrepancies exist between strategies suggested in the literature and interventions reportedly performed by the nurses.
Sleep promotion in the intensive care unit—–A survey of nurses’ interventions
Noise and light Previous studies reported that noise is the most disruptive factor to sleep for patients in the ICU (Richardson et al., 2007) and that ICU nurses have little knowledge of the impact of noise exposure (Christensen, 2005). Staff conversations and alarms were rated as the most disturbing noises for patients asleep in the ICU (Xie et al., 2009). Nurses can control these two factors, and our results show that nurses reported that they avoid staff conversations near the patient’s bedside when the patient is asleep during either the night or the day, but only half of the responders reported that they reduced the alarm levels on the monitors and ventilators. The reason for this is unknown. ICU nurses usually work bedside, and frequent alarms are not always perceived as helpful in the ICU setting (Chambrin, 2001). Lights are always present in the ICU, but night light levels have been measured to be low (Walder et al., 2000). We found that turning off lamps was reported to be highly prioritised for night sleep and to a lesser extent for day sleep. The reason for this could be that lights cannot be dimmed to such a degree that patient assessment is negatively impacted; furthermore, bright lights are required for several procedures (Richardson et al., 2007), which are performed more frequently during day shifts than night shifts. The use of earplugs and eye masks allows longer and more satisfactory sleep amongst critically ill patients (Richardson et al., 2007; Scotto et al., 2009). In our study, 72% of the nurses reported that they offered the patient earplugs for night sleep, but less than half of the respondents offered earplugs for daytime sleep. Only one respondent offered eye masks, only for daytime sleep. Intervention studies that have been performed in the ICU include only patients who are alert, oriented and able to remove the intervention themselves (Richardson et al., 2007; Scotto et al., 2009). This is not always the case with critically ill patients in the ICU, and because of this, the nurses in our study may have been reluctant to use such interventions. Patients can feel anxious when not hearing background noise, and decreasing the ability to hear and see can be frightening for ICU patients who struggle to orientate themselves.
Patient comfort The inability to relax caused by factors such as unsynchronised ventilator—patient breathing (Gabor et al., 2001), pain, anxiety or uncomfortable positions in bed (Parker, 1995) are reported to be important causes of sleep deprivation in the ICU. The nurses in our study reportedly adjusted the patient’s position in the bed, synchronised the ventilator with the patient’s breathing and provided adequate pain relief for both nighttime and daytime sleep, but mouth care and massage were less prioritised, especially for daytime sleep. It could be that such care-giving interventions are performed in connection with other caring routines, as was reported by one of the respondents, and therefore are not considered as sleep-promotion interventions. As all respondents reported that they informed the patient when it was time to sleep, it seems as though communicating the ‘‘permission to sleep’’ is considered essential. This is important to prepare the patient for planned activities, to
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orientate the patient with respect to time (Friese, 2008) and to reassure the patient that sleeping is accepted and that the patient will be looked after when sleeping (Evans and French, 1995).
Patient care activities ICU patients rate nursing interventions to be as disruptive to sleep as noise (Freedman et al., 1999). Clustering of care has been recommended to allow for uninterrupted sleep periods, but studies from both medical and surgical ICUs show that 40—50 care interventions typically occur per patient per night shift (Celik et al., 2005; Tamburri et al., 2004). This leaves little opportunity for patients to sleep during the night. In our study, 72% of the respondents planned a sleep period for their patient during the dayshift. Two-thirds of the respondents reported that they would let the patient sleep for two hours or more; the remaining one-third would wake the patient after one hour. One hour of sleep is not sufficient time to experience the healing process of going through a full cycle of the different sleep stages. Only a few of the respondents would wake the sleeping patient for the various interventions listed in the questionnaire, and more than half of the respondents would not wake the patient for any of these interventions. It could be argued that nurses have an around-the-clock presence and coordinating function in the ICU and should be able to coordinate nursing care with other activities to allow for patient sleep periods.
Nurses’ interventions to promote sleep in the intensive care unit Our findings show an overall interest and awareness in sleep-promoting interventions. The underlying challenge of around-the-clock care for critically ill patients may impact which interventions are prioritised. Problems related to sleep deprivation in the ICU have been addressed in several studies but remain overlooked despite the impact on healing, patient well-being and length of hospital stay (Honkus, 2003; Redeker, 2008). It has been suggested that nurses may be desensitised to the constant chaos in the ICU (Fontana and Pittiglio, 2010) and forget about the stimuli negatively impacting patient sleep. The traditional priorities related to care-giving in the ICU may work as barriers to the incorporation of sleep promotion strategies and make nurses downgrade sleep (Evans and French, 1995). Working in an action-oriented subculture such as the ICU environment may influence nursing behaviours and actions (Evans and French, 1995). ICU patients are in need of bedside observations and specialised nursing care because of their critical condition. Routine interventions necessary to prevent complications and life-threatening emergency situations both require action on the part of the nurse. Still, nursing care activities may be performed as part of a routine, and the nurse has to remain aware of the problem of sleep deprivation and to prioritise which activities are important for the individual patient. Another barrier to the delivery of evidence-based sleep-promoting interventions may be gaps in the quantity and quality of research findings in this area of study. However, there has been an exponential growth in the knowledge of the importance of sleep amongst critically
142 ill patients over the last few years (Redeker, 2008). This may further increase the awareness of sleep-promoting interventions amongst ICU nurses. Creation of a sleep-promoting environment by reducing sleep-disturbing stimuli, coordinating care activities and preparing the patient for sleep should continue to be encouraged in the ICU.
Study limitations Self-reported data may produce a bias, and some respondents may have given expected answers. Although it has been found that nurses prioritising sleep also initiate more sleep-promoting interventions (Pulling, 1991), the coherence between what is reported and what is actually performed is not known. The questionnaire was developed by the researchers and was not subject to formal validation tests. Generalisation is limited due to the small sample size, lack of randomisation and the fact that the study was conducted in only one ICU. Nurses who did not read their hospital e-mails during the data collection period due to vacation or sick leave were not excluded, and this may have negatively influenced the response rate.
Conclusion ICU nurses report an overall interest and awareness in sleep-promoting interventions. However, the challenge of caring for critically ill patients who require frequent assessment and nursing actions influences which interventions are prioritised. Nurses must continue to improve the ICU environment to enhance patient sleep by coordinating care activities, preparing the patient for sleep and reducing the prevalence of disturbing stimuli.
Conflict of interest statement None.
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