The importance of sleep and the sensory environment to critically ill patients

A comparison of sleep assessment tools by nurses and patients in critical care

AIM

The aim of this critical care sleep assessment pilot study was to evaluate the usefulness of three sleep assessment tools to identify which, if any, provided the closest comparison between the nurses' judgement and the patients' experience of their sleep. The study objectives were to: (i) compare patients' and nurses' assessment of sleep using three different rating tools. (ii) Ascertain patients' preferences with non-interventional, user friendly, practical tools in critical care. (iii) Recommend changes and improvements to the way that sleep is assessed and documented.

BACKGROUND

Sleep is important for promoting critical care recovery and sleep disturbance is known to cause irritability, aggression and increased stress levels. The availability and use of valid critical care sleep assessment tools is limited.

DESIGN

A descriptive comparative study using three sleep assessment-rating scales were constructed to provide easy to understand tools for completion by both patients and nurses in critical care.

METHODS

Structured interviews were undertaken with 82 patients and 82 nurses using a convenience sample from four multispecialty critical care units in one large teaching trust. Patients were included in the study if they met a list of pre-defined criteria to obtain responses from lucid orientated patients.

RESULTS

No tool produced a close association between the nurses' assessment of the patients sleep and the patients' assessment of their sleep. Patients found two of the three tools easy to use when rating their sleep. Discussion. Objective invasive measurements of sleep as well as complex subjective tools appear inappropriate to be used as a part of daily critical care practice. The application of simple rating scores has a high degree of error when nurses assess patients' sleep, even though high levels of patient observation and assessment are practiced in critical care.

CONCLUSIONS

More research is needed to examine the assessment of sleep in critical care, particularly linking rating scales to alternative methods of physiological assessment of sleep. Findings indicate nurses are unable to accurately assess critical care patients' sleep using rating assessment tools. However patients were found to prefer two sleep assessment tools, one banded in hours to assess sleep quantity and one as a comparison against normal sleep to assess sleep quality.

RELEVANCE TO CLINICAL PRACTICE

This study reviews the importance of sleep assessment and the diverse methods available for assessing sleep focussing on the critically ill patient. More noteworthy it highlights how nurses sole judgements of patients sleep is not a reliable method in clinical practice, however it provides some indication on the application of 'easy to use' tools to assist in the patients assessments of their sleep.

Sleep disturbance after burn injury

This study describes sleep disturbance and related factors in a group of 74 patients at 1 week after discharge using a sleep problems questionnaire developed by the authors. Results indicated that a significant proportion of patients reported a problem with their sleep (73%). Several items were identified as highly prevalent, including frequent nighttime awakenings (87%), napping during the daytime (65%), sleeping alone (64%), experiencing pain during the night (62%), and difficulties with sleep onset (62%). Results suggest numerous possible interventions to improve patients' sleep quality. The usefulness of a more extensive questionnaire was also indicated.

Transfer anxiety: preparing to leave intensive care

There is much literature to substantiate the inadvertent emotional and psychological trauma associated with critical care areas. However, alongside this, there is a growing body of knowledge to show that these intense and specialized areas are actually perceived as secure, safe and familiar environments by some patients and family members. Transfer from the intensive care unit is not always perceived in a positive light and often the transition is dreaded by both the patient and his family. The evidence would suggest that discharge from specialized care environments can actually be as traumatic as admission. This phenomenon has become known as transfer anxiety, relocation anxiety, or translocation anxiety. There is the possibility that transfer may induce stress or distress in some patients, especially when routines, environments and/or invasive monitoring procedures are altered or ceased without prior knowledge, preparation or adequate explanation. If healthcare personnel fail to identify and meet the psychological needs of patients and families relocating from these areas, the detrimental effects may extend far beyond discharge from ICU. For relocating patients, transfer from the ICU can be presented as a positive step. However, treatment to minimize transfer anxiety will only be successful when all healthcare personnel recognize and react positively to the psychological factors that affect patients adversely.

Building a framework for getting evidence into critical care education and practice

One challenge for nurse educators is how best to enhance the integration of theory and practice elements in relation to critical care nursing. Practice should be evidence-based, i.e. the best available empirical evidence, including recent research findings, should be applied in practice in order to aid clinical decision-making. Barriers to the implementation of research exist at many levels including the individual practitioner, the clinical team, the practice setting and wider organizational factors. The authors propose that clinical guidelines can provide a vital link between theory and practice. At varying levels the use of care protocols, clinical pathways and algorithmic guidelines (provided they are rigorously reviewed and evidence-based) can help infuse research into practice, thereby promoting quality and standardization of care. The purpose of this paper is to discuss the value and use of these frameworks in promoting and raising awareness of the need for and use of evidence-based approaches to critical care education and practice. In this paper, we present outline information relating to an assessment method, adopted for continuing education courses in critical care within our department. This approach is designed to combine the best available evidence with reflective practice through the assessment process.

Disturbed memory and amnesia related to intensive care

Patients, when admitted to an intensive care unit (ICU), have one thing in common: their illness is life-threatening. Patients may remain on ICU in a critical condition, needing support with their breathing, circulation, and/or kidneys for varying lengths of time, from days to weeks. During that time the patients will receive sedative and analgesic drugs to ensure compliance with artificial ventilation. Patients recovering from critical illness frequently have little or no recall of their period in ICU, or remember nightmare, hallucinations, or paranoid delusions. The nature, extent and reason for these difficulties, have been under-reported and consequently our purpose was to conduct a review of memory problems experienced by ICU patients. A systematic literature review of computer databases (Medline, PsycLit, and CINAHL) identified 25 relevant papers. In addition, other relevant articles were obtained, citation lists and associated articles retrieved. Due to lack of research on processes underlying memory problems in ICU patients all articles that introduced an insight into possible mechanisms were included in the review. There seem to be two possible processes contributing to memory problems in ICU patients. First the illness and treatment may have a general dampening effect on memory. Delirium and sleep disturbance are both common in ICU patients. Delirium can result in a profound amnesia for the period of confusion. Sleep deprivation exacerbates the confusional state. Slow wave sleep is important for the consolidation of episodic memories. Treatment administered to patients in ICU can have effects on memory. Opiates, benzodiazepines, sedative drugs such as propofol, adrenaline, and corticosteroids can all influence memory. In addition, the withdrawal of drugs, such as benzodiazepines, can cause profound withdrawal reactions, which may contribute to delirium. Second, we hypothesise that there is a process that affects memory negatively for external events but enhances memory for internal events. The physical constraints and social isolation experienced by ICU patients and the life-threatening nature of the illness may increase the experience of hypnagogic hallucinations. Attentional shift during hypnagogic images from external stimuli to internally generated images would explain why ICU patients have such poor recall of external ICU events, but can clearly remember hallucinations and nightmares. Patients describe these memories as being very vivid and this is explored in terms of flashbulb memory formation. The absence of memories for real events on ICU can result in ICU patients remembering paranoid delusions of staff trying to kill them, with little information to reject these vivid memories as unreal. This has implications for patients' future psychological health.

Acute confusion and unreal experiences in intensive care patients in relation to the ICU syndrome. Part II

The intensive care unit syndrome (ICU syndrome) is defined as an altered emotional state occurring in a highly stressful environment, which may manifest itself in various forms such as delirium, confusion, crazy dreams or unreal experiences. The purpose of this part of a study of patients' experiences is to describe and illuminate patients' experiences of acute confusion, disorientation, wakefulness, dreams and nightmares during and after their stay in the ICU. The data were obtained from 19 ventilated patients, who were interviewed twice and had stayed at least 36 hours in the ICU, the first interview being about one week after discharge from the ICU, and the second 4-8 weeks later. The hermeneutic approach used when interpreting and analysing the text from the interviews revealed that patients' experiences of unreal experiences were often associated with intense fear. Intense or continuous unbearable fear seems to result in frightening unreal experiences, which further increase the level of fear. Care actions or caring relationships with relatives or nurses can reduce this fear, which can help to prevent the occurrence and/or duration and intensity of the unreal experiences. Trust and confidence in nurses or significant others and feelings of self-control or trust in self-control seemed to reduce the risk of unreal experiences so that adverse stimuli might only trigger a mild confusion.

Patients' experience of being critically ill or severely injured and cared for in an intensive care unit in relation to the ICU syndrome. Part I

The intensive care unit (ICU) syndrome is regarded principally as a complex interaction of several contributory factors, all of which can be seen as partly responsible for the development of the syndrome. The purpose of this study was to describe and give a deeper insight into patients' experiences and memory recall, both during and after their stay in the ICU. Nineteen patients who had been respirator treated (ventilated), and had stayed at least 36 hours in the ICU, were interviewed about one week after discharge, and again 4-8 weeks after their discharge from the ICU. Patients' experiences are interpreted and related to previous views held concerning the syndrome, together with an awareness of other important and significant phenomena, i.e. a hermeneutic approach. This study partly confirms the findings of earlier studies concerning the ICU syndrome, but also reveals some new aspects, which have not previously been considered. The patients described themselves as experiencing some sort of state of chaos following the onset of their sickness, injury or accident, which resulted in feelings of extreme instability, vulnerability and fear, often experienced as prolonged inner tension. It was reported that even the most trivial events in circumstances or routines could trigger changes-either an increase or decrease-in patients' feelings of fear or inner tension. The caring relationship was perceived as providing an important degree of security and comfort. Nursing care actions can therefore be seen as vital factors in patients overcoming the accompanying horrific experiences to which they can be subjected. This state of chaotic feeling, and how it is combated and treated, appear to be one critical factor in the development and progression of the ICU syndrome.

Sensory deprivation and chronic pain: a review of the literature

AIMS AND OBJECTIVES

The aim of this paper is to explore the literature into the use of 'Snoezelen' (Sensory Stimulation) for the management of chronic pain. Within the literature there are a number of research studies which have investigated the concept of sensory deprivation and these are considered. The studies indicate the potential of sensory input as a field of research in particular relation to the care of patients within hospital settings where they are removed from their 'normal' level of sensory input and could subsequently experience sensory deprivation. The relationship between sensory restriction and chronic pain is emphasized. This links with investigations of sensory stimulation (Snoezelen) as a potential strategy for the management of chronic pain.

CONCLUSIONS

In conclusion, it is suggested that sensory deprivation cannot exist and the term 'sensory restriction' would be more appropriate. It is proposed that there is a need to develop a tool to assist carers in identifying the existence of sensory restriction in their specific client groups to provide a basis for intervention.

Snoezelen and chronic pain: developing a study to evaluate its use (Part I)

Chronic pain can be devastating, it impinges upon the life of the sufferer, causing psychological, physical, social and financial problems, leaving the individual searching for an explanation and a cure. Although there are no major epidemiological studies to date, it has been suggested that the impact of chronic pain, not only to the patient, but also to society and the NHS is phenomenal, with loss of production and costs of treatments (Fordyce 1995). Specialists within the field of chronic pain have advocated the use of the multidisciplinary approach to deal with the problems and thus suggest the use of the pain management programme, which is designed to teach the patient coping strategies. Recently, however, there has been a call within the literature to identify the effectiveness of singular strategies, which may be equally as effective and less expensive (Keefe et al 1992). The purpose of these papers is to introduce one such strategy, which has been evaluated over the past four years in order to investigate the use of the sensory environment (Snoezelen) for the management of chronic pain. In part II of this paper, an evaluation of Snoezelen and chronic pain will be presented, along with the findings of an investigation into its use.

Patient perception of fatigue while undergoing long-term mechanical ventilation: incidence and associated factors

OBJECTIVE

To describe a chronically critically ill population of patients receiving long-term ventilatory assistance, including patient perception of fatigue and the associated factors of nutritional status, depression, and sleep-rest.

DESIGN

Prospective, descriptive correlational design.

SETTING

Two tertiary care, university-affiliated medical centers.

SUBJECTS

Twenty subjects who were undergoing mechanical ventilation for at least 7 days and who were in the process of weaning.

RESULTS

Descriptive, correlational, and t test statistics were used in the data analysis. There was a 100% prevalence rate of fatigue, and with a 10-cm visual analogue scale, 45% of the subjects rated their fatigue as severe (> or = 6.0 cm) in intensity. The sample's mean serum albumin was 2.7 gm/dl, and mean hemoglobin was 10.1 gm/dl, but there were no statistically significant relationships between fatigue and nutritional status. Subjects' depression scores were in the moderate range, and they evaluated their sleep as fragmented and only moderately effective. Fatigue and depression were strongly correlated (r = 0.61; p = 0.004); there were no statistically significant relationships between fatigue and the sleep-rest scales.

CONCLUSIONS

The descriptive findings suggest that patients receiving long-term ventilatory assistance are undernourished and experience fatigue, depressed mood state, and disruptions of their sleep-rest patterns.

Sensoristrain: an exploration of nursing interventions in the context of the Neuman systems theory

Defining what nurses do and why has been the endeavour of many researchers, both academic and clinical. Nursing interventions are a fundamental component of nursing practice and a focus on accountability means that nurses must be able to justify their actions. The sensoristrain experience of intensive care patients is widely acknowledged in nursing literature, though without the use of the word 'sensoristrain'. The aim in this paper is to place patients, their experience and the role of nurses within the practical framework of a suitable nursing theory which will elucidate and guide everyday practice in preventing and alleviating the causes (stressors), symptoms (reactions) and emotional aftermatch. Nursing interventions appropriate for the three modalities of intervention elucidated by the Neuman systems theory have been outlined, paralleled by a discussion of how these could relate to the three dimensions of nursing care: comfort care; knowing the patient; and the therapeutic presence of the nurse. Nurses must use each opportunity to advance practice through emphasizing the value of nursing in today's cost-conscious health care climate. In order to do this, and to ensure nurses' continued presence at the bedside, clear articulation of the contribution of nursing interventions to improved patient outcomes is essential.

A concept analysis of the sensoristrain experienced by intensive care patients

Psychological disturbances that patients may experience during admission to intensive care units (ICUs) can have distressing implications for their emotional and physical integrity, progress and subsequent recovery. It is widely believed by practitioners and reflected in professional literature that these disturbances are precipitated by sensory deprivation or overload in the physical environment of intensive care units. In this paper the sources and mechanism of the sensory imbalances experienced by these patients are examined. A new concept--sensoristrain--has been developed in an attempt to promote awareness and improve understanding of the phenomenon among nurses. Once this has been achieved, assessment and identification of patients at risk are optimized and appropriate interventions can be formulated. Using an eclectic approach to analyse sensoristrain, both causes and effects of the phenomenon have been identified from the literature. This information has been combined with practical examples in the development of a model of the concept sensoristrain. The paper concludes by outlining the resulting implications for nursing practice, which may be used to guide future research both in concept development and identification of effective prevention of the phenomenon conceptualized and interventions if it occurs.

Intensive care syndrome: a literature review

The aim in this literature review is to describe the definitions, denominations, clinical signs and symptoms, explanations, causative factors and interrelationships of the intensive care syndrome discussed since 1950. It was found that there is no agreement about which symptoms should be included in the syndrome, when the syndrome may appear and how many patients may be affected. Furthermore, it is unclear what causes the development of the syndrome; most authors conclude that there are many reasons for it. The syndrome has generally been examined by using a medical or psychological approach, but during the last few years it has also been described and analysed from a nursing care perspective. From this nursing perspective the syndrome may be seen as an individual pattern developed by patients during their stay in an intensive care unit (ICU) and sometimes this pattern of clinical signs and symptoms lasts for a shorter or longer period even after discharge from the unit. From a wider viewpoint the development of the syndrome can be seen as an increase by degrees or as a vicious circle. finally, most authors agree that the ICU syndrome consists of, and is caused by, a complex interaction between many factors.

Snoezelen: its potential for people with chronic pain

The purpose of this paper is to outline the application of a new form of chronic pain management which is currently under investigation by the writer as a PhD study with the University of Wales, Cardiff, UK. The study was initiated by the writer whilst working as a Senior Nurse Specialist in pain management. It is anticipated that the results of the study will be available by 1996. The concept of the Snoezelen will be discussed. Snoezelen has been used by many centres for the care of individuals with learning disabilities. The paper will also describe the Snoezelen centre based in Chesterfield, UK and some of the experiences that are available. Finally, the rationale behind the application of a strategy for the management of individuals experiencing chronic pain will be discussed relating to some of the appropriate literature. As a result of this study several pain clinics are interested in looking at the use of some of the concepts.

Reduction of noise levels in intensive care units for infants: evaluation of an intervention program

OBJECTIVE

To investigate whether educational information for nurses concerning causes of noise would decrease noise levels in an intensive care unit for term newborns and infants.

DESIGN

Pretest and posttest.

SETTING

Children's surgical ward in a university hospital in southern Sweden.

SUBJECTS

Fifty-two nurses in the surgical ward.

OUTCOME MEASURES

Noise levels.

INTERVENTION

An educational program consisting of a presentation of a videotape, presentation of the decibel values for various care activities, and a discussion of the problem.

RESULTS

Statistical analysis with a paired two-tailed t test showed significant differences to exist between measurements in a cot and an incubator before the intervention (p = 0.0001), and between cot measurements before and after the intervention program (p = 0.0007).

CONCLUSIONS

The results of this study show that through simple methods and without additional costs, and by making the staff aware of the problem, noise levels can be lowered considerably.

Preventing the ITU syndrome or how not to torture an ITU patient! Part 2

Admission to an intensive therapy unit (ITU) has been described as a 'necessary evil' (Barrie-Shevlin 1987), and some of the 'tortures' described in Part I of this article (Dyer 1995) may be an inevitable result of ITU care. This does not mean that the development of the ITU syndrome should be regarded as inevitable. Many potential causes of the syndrome can be avoided or at least ameliorated. Some suggested means of preventing the syndrome include designing ITUs with windows (Keep et al 1980), use of noise reducing materials when building ITUs (Hopkinson 1994, Topf & Davis 1993), using noise level as a criterion when purchasing equipment (Dracup 1988) or using remote telemetry for monitoring (Fisher & Moxham 1984). These would undoubtedly be beneficial but they are not practical propositions for nurses who wish to improve psychological care in the short term. For this reason, this article, concentrates mainly on immediately applicable, relatively cost-free interventions. Methods of preventing the syndrome should begin, whenever possible, before admission and should continue throughout the patients' stay. The main emphasis should be placed on prevention, but early detection and treatment of problems should also be given high priority. If a patient exhibits symptoms of psychological disturbance physical causes should be considered, but at the same time the ITU syndrome should be suspected and attempts made to alleviate possible causes of this. Nurses play a vital role in any attempts to alleviate problems and in 'humanising' the technical ITU environment (Ashworth 1987, Mackellaig 1990).(ABSTRACT TRUNCATED AT 250 WORDS)

Preventing the ITU syndrome or how not to torture an ITU patient! Part I

Staff working in intensive therapy units (ITUs) have known about the 'ITU syndrome' for many years. In spite of this the syndrome continues to occur. It is suggested that one of the reasons for this continued occurrence is that ITU staff place a lower priority on psychological care than they do on physical care. In this paper the potential seriousness of the ITU syndrome is emphasised by describing it as a form of torture. Publications from Amnesty International which describe methods of psychological torture are provided to support this suggestion. The analogies between psychological torture and ITU care are explored, and this is followed by consideration of ways of reducing the incidence of the syndrome and a suggested method of auditing an ITU in order to identify potential problem areas.

A review of literature relating to sleep in hospital with emphasis on the sleep of the ICU patient

The subject of this literature review is the sleep of hospitalised patients, with particular emphasis on the sleep of patients in intensive care units (ICUs). Initially there is an overview of the structure of sleep and the literature related to the main theories of sleep function in order to set the subject in context. A review of some of the work related to the sleep patterns of ICU patients outlines how severely sleep-deprived many patients are. Studies of sleep patterns implicate the environment of ICUs as an important factor in preventing sleep, but factors particular to patients which have an adverse effect on sleep are also reviewed, with particular reference to a study addressing the incidence of pain and discomfort of patients. Finally the sleep patterns of patients whose environment was carefully controlled to exclude factors known to disrupt sleep are reviewed. Thus the review moves from broad issues affecting sleep to the more focused issues personal to individual patients, with implications for nursing practice addressed as each point arises. In this way the complexity of the whole issue of sleep and the lack of sleep experienced by hospitalised patients is highlighted.

Sleep and intensive care

Human beings spend on average one third of their life sleep. Given that sleep places an individual and its species at a potential biological disadvantage it follows that this must be outweighed by the advantages which sleep has to offer. Why do people sleep? What are its functions? What happens to people during sleep and how can nurses help patients to a better night's sleep? These are just a few questions considered here in relation to patients needing intensive care.

Extended body image in the ventilated patient

This paper explores the experience of altered body image in unexpected critical illness, with particular interest in the extended body image of ventilated patients. It examines from the patients perspective, the impact that ventilation within the intensive care environment, can have on an individuals body image. The concept is developed to explore nursing strategies aimed to support and promote a positive body image in ventilated patients.