Nurses perceptions of sleep in the intensive care unit environment: A literature review

Parents' perceptions of factors influencing sleep in pediatric intensive care units: A qualitative study

PURPOSE

The purpose of this study is to explore factors influencing sleep in pediatric intensive care units as perceived by parents of critically ill children.

DESIGN AND METHODS

This descriptive qualitative study used individual semistructured interviews. Parents were recruited through purposive sampling from two pediatric intensive care units at two locations in one university hospital in Norway. Ten parents were interviewed. The interviews were analyzed using a six-phase reflexive thematic analysis.

FINDINGS

The analysis produced 17 subthemes under four main themes: environmental factors in the pediatric intensive care unit disturb children's sleep, children need trust and safety to sleep, nurses' cooperation with parents influences children's sleep, and nurses' structuring of their practices is fundamental to sleep promotion.

CONCLUSION

The parents found that the environment disturbed their children's sleep, and environmental factors were easier to control in single rooms than in multibed rooms. Children slept better when they felt safe and trusted the nurses, and parents desired more cooperation in promoting sleep for their children, which may be an essential and overlooked part of sleep promotion. Nurses varied considerably in how they prioritized sleep and structured their practices to promote sleep.

PRACTICE IMPLICATIONS

Nurses should take parents' experiences into account to better promote sleep for patients. By limiting environmental disturbances, building relationships with children to make them feel safe, including parents in sleep promotion, and prioritizing sleep in their practices, nurses could improve sleep quality and limit the consequences of sleep disturbance.

Study on the Sleep Quality Classification and Influencing Factors of Adult ICU Awake Patients Based on Latent Profile Analysis: A Cross-Sectional Survey

Objective

To explore the potential category characteristics of sleep quality in conscious adult patients in the intensive care unit (ICU) and to analyze the differences in characteristics of different categories of conscious adult patients in the ICU.

Methods

From 5/4/2023 to 30/6/2023, we selected ICU patients of a Class iii Grade A hospital in Wuhan as subjects by simple random sampling. The general information questionnaire, Acute Physiology and Chronic Health Evaluation II, Numerical Rating Scale (NRS)/Critical Care Pain Observation Tool (CPOT) and Richards-Campbell Sleep Questionnaire (RCSQ) were used for investigation. To analyze the latent profile of sleep quality characteristics of adult ICU awake patients and to identify the influencing factors of the latent profile through univariate analysis and logistic regression analysis.

Results

A total of 298 awake ICU patients were investigated. There were three potential profiles of sleep quality characteristics, namely "low sleep quality" type (16.31%), "medium sleep quality" type (52.11%), and "high sleep quality" type (31.57%). Logistic regression analysis showed that age (36-60), disease type admitted to ICU, oxygen administration method, CPOT or NRS score, postoperative or not, use of analgesic drugs or not, and use of sleep-promoting drugs or not were the factors affecting the sleep quality of adult ICU awake patients (P < 0.05).

Conclusion

The sleep quality of adult ICU awake patients has obvious classification characteristics. Health professionals can carry out individualized interventions according to the influencing factors of different potential profiles to improve the sleep quality of adult ICU awake patients.

Promoting sleep in hospitals: An integrative review of nurses' attitudes, knowledge and practices

AIMS

To explore nurses' knowledge, attitudes and practices related to improving hospitalized patients' sleep.

DESIGN

Integrative review.

DATA SOURCES

We searched CINAHL, PubMed and PsycInfo electronically including a manual search of references listed within the relevant studies. Original, peer-reviewed studies published in English between 2000 and 2022 evaluating nurses' sleep knowledge, attitudes, or practices to improve inpatients' sleep were reviewed.

REVIEW METHODS

This review was guided by Whittemore and Knafl method and followed PRISMA guidelines to search the literature. Fifteen articles reporting nurses' sleep knowledge, attitudes or practices to improve inpatients' sleep were included. The quality appraisal was done using the Mixed Methods Appraisal Tool version 2018.

RESULTS

Inadequate training of nurses regarding sleep hygiene and insufficiency in sleep-promoting practices were apparent. Most studies reported that nurses hold positive attitudes about sleep. The acuity of patients' health conditions affected their perception of sleep priorities. Lack of organizational sleep policies/protocols and coworkers' attitudes negatively impacted nurses' motivation to implement sleep hygiene interventions. Interventions reported in the studies were reducing noise and nursing interventions at night, using a clock for time orientation, earplugs, reducing light, keeping patients awake during the daytime, maintaining comfortable room temperature and managing patients' stress. These practices were hindered by poor knowledge, negative attitudes, patients' acuity and lack of sleep assessment tools.

CONCLUSION

It is essential to support nursing practice to improve patients' sleep in hospitals through interventions that target nurses' knowledge, attitudes and confidence towards implementing sleep hygiene interventions to improve patients' sleep and, consequently, their health outcomes during hospitalization.

IMPACT

This integrative review explored nurses' knowledge, attitudes and practices to improve patients' sleep during hospitalization. It revealed that expanding nurses' sleep knowledge and empowering them to implement sleep promotion practices are needed. Nursing educators and leaders need to be involved.

NO PATIENT OR PUBLIC CONTRIBUTION

This paper is an integrative review and does not include patient or public contribution.

An Update on Prevalence, Assessment, and Risk Factors for Sleep Disturbances in Patients with Advanced Cancer—Implications for Health Care Providers and Clinical Research

Simple Summary

This review focuses on sleep in patients with advanced cancer. Cancer patients experience multiple symptoms and they receive concomitant medications. These are all factors that may affect sleep. In this paper, we present recommendations on sleep assessment in patients with advanced cancer and highlight cancer-related factors that may contribute to insomnia. Sleep is an essential aspect of health-related quality of life; therefore, it is important for health care providers to focus on sleep to improve patient care.

Abstract

Patients with advanced cancer experience multiple symptoms, with fluctuating intensity and severity during the disease. They use several medications, including opioids, which may affect sleep. Sleep disturbance is common in cancer patients, decreases the tolerability of other symptoms, and impairs quality of life. Despite its high prevalence and negative impact, poor sleep quality often remains unrecognized and undertreated. Given that sleep is an essential aspect of health-related quality of life, it is important to extend both the knowledge base and awareness among health care providers in this field to improve patient care. In this narrative review, we provide recommendations on sleep assessment in patients with advanced cancer and highlight cancer-related factors that contribute to insomnia. We also present direct implications for health care providers working in palliative care and for future research.

Factors affecting sleep quality in Intensive Care Units

OBJECTIVE

To report sleep quality and identify related factors.

DESIGN

A descriptive cross-sectional study was made with a convenience sample of 129 patients. The differences between 3 periods were evaluated using the Wilcoxon test and Spearman correlation r. Multiple regression analyses were performed to relate independent variables to sleep quality.

SETTING

The Department of Intensive Care Medicine of a tertiary hospital.

PARTICIPANTS

Patients admitted between February 2016 and December 2017.

INTERVENTIONS

Questionnaire administration.

VARIABLES

Items of the modified Freedman questionnaire, and demographic and clinical variables.

RESULTS

External factors interfering with sleep quality were noise and constant light exposure in the 3 periods, with significant differences between these periods in nursing care (P = 0.005) and nursing activities (P = 0.019). The other factors affecting sleep quality and identified by the multivariate regression model were age (P = 0.012), daily alcohol intake (P = 0.023), benzodiazepine use during admission to the ICU (P = 0.01) and comorbidities (P = 0.005). There were significant differences in sleepiness between discharge and the first day (P ≤ 0.029) and between discharge and half stay (P = 0.001).

CONCLUSIONS

Noise and light were the most annoying factors, but statistical significance was only reached for nursing activities and care. Age, alcohol intake, benzodiazepine use in the ICU and a higher comorbidity index had a negative impact upon sleep. Sleepiness was reduced at the end of stay.

Factors contributing to poor sleep in critically ill patients: A systematic review and meta-synthesis of qualitative studies

OBJECTIVE

To examine the causes of poor sleep in critically ill patients from nurses' experiences.

REVIEW METHODOLOGY

A meta-synthesis following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement was conducted. Articles were searched systematically in the CINAHL, MEDLINE and Embase databases up to January 2020. Study selection and data extraction were performed by two authors working independently. Included articles were critically evaluated by both authors using the Critical Appraisal Screening Programme tool.

FINDINGS

The meta-synthesis resulted in four analytical themes: (1) Inherent factors of critical illness, (2) Lack of implementation of evidence-based practice, (3) Lack of relational collaboration, (4) Hospital organisation and culture.

CONCLUSION

This literature review indicates that promoting critically ill patients' sleep is difficult. Evidence-based interventions should be implemented into practice in order for nurses to be able to meet the patients' needs and improve sleep. Furthermore, the team surrounding the patient must have support from the health care organisation, and a culture change is necessary to improve communication between them to reach a shared goal to improve critically ill patients' sleep.

Sleep Deprivation Etiologies Among Patients in the Intensive Care Unit: Literature Review

BACKGROUND

Sleep deprivation among patients is a common problem in the intensive care unit (ICU). Studies have tried to find the etiologies of sleep deprivation. Poor sleep quality in the ICU has effects such as delirium, weakening the wound healing, and anxiety. Researches have concluded that the etiologies for sleep deprivation are multifactorial.

OBJECTIVES

The aim of this review is to discuss the etiologies of sleep deprivation among ICU patients. This review also aims to discuss effects of sleep deprivations and provide implications for promoting sleep quality in the ICU.

METHODS

For this literature review, ProQuest, MEDLINE, and Up To Date were used to find articles about sleep deprivation among ICU patients. The search was narrowed to articles between 2008 and 2019. A total of 23 articles were included that were found to match the inclusion criteria.

RESULTS

Findings indicated that sleep deprivations etiologies among ICU patients can be environmental and nonenvironmental. Sensory overload, sensory deprivation, and patients' care activities are environmental etiologies for sleep deprivation. The nonenvironmental factors include pharmacological, physical, and psychological factors.

DISCUSSION

Sleep deprivation etiologies are multifactorial and have several effects on ICU patients. Sleep protocol and staff training should be introduced to reduce unnecessary interventions by ICU staff. Tele-ICU monitoring can also be introduced to reduce unnecessary interventions where clinicians can monitor patients remotely and therefore enhance sleep in the ICU. During their stay in the ICU, patients can be instructed to wear earplugs and also have aromatherapy massage to reduce stress and enhance sleep quality. More research on the physical pain and the psychological factors using objective methods should be conducted in the future.

Factors affecting sleep quality in Intensive Care Units

OBJECTIVE

To report sleep quality and identify related factors.

DESIGN

A descriptive cross-sectional study was made with a convenience sample of 129 patients. The differences between 3periods were evaluated using the Wilcoxon test and Spearman correlation r. Multiple regression analyses were performed to relate independent variables to sleep quality.

SETTING

The Department of Intensive Care Medicine of a tertiary hospital.

PARTICIPANTS

Patients admitted between February 2016 and December 2017.

INTERVENTIONS

Questionnaire administration.

VARIABLES

Items of the modified Freedman questionnaire, and demographic and clinical variables.

RESULTS

External factors interfering with sleep quality were noise and constant light exposure in the 3periods, with significant differences between these periods in nursing care (P=0.005) and nursing activities (P=0.019). The other factors affecting sleep quality and identified by the multivariate regression model were age (P=0.012), daily alcohol intake (P=0.023), benzodiazepine use during admission to the ICU (P=0.01) and comorbidities (P=0.005). There were significant differences in sleepiness between discharge and the first day (P≤0.029) and between discharge and half stay (P=0.001).

CONCLUSIONS

Noise and light were the most annoying factors, but statistical significance was only reached for nursing activities and care. Age, alcohol intake, benzodiazepine use in the ICU and a higher comorbidity index had a negative impact upon sleep. Sleepiness was reduced at the end of stay.

Sleep assessment and interventions for patients living with cancer from the patients' and nurses' perspective

BACKGROUND

Difficulty sleeping is a common symptom for patients living with cancer that significantly affects their lives. However, although sleep disorders are common, it is an overlooked problem in cancer care.

PURPOSE

This study assessed the prevalence of sleep disturbances among patients living with cancer, and assessed the adequacy of sleep assessment and intervention for patients from both nurses' and patients' perspectives.

METHOD

Descriptive, cross-sectional and correlational design was used in this study. A convenience sample of 129 patients with cancer and 113 registered nurses working with cancer patients was recruited. A structured face-to-face interview was used to complete the patients' questionnaires and a self-administered questionnaire was given to nurses.

FINDINGS

The majority of patients with cancer reported having poor sleep quality (69.8%). About 86.7% (n=98) of nurses reported that they have never screened patients with cancer for any sleep problems, and 76.7% (n=99) of the patients reported that they have never been assessed for sleep problems by the nursing staff during hospitalisation. Only 8% of patients with cancer who reported having problems sleeping to a nurse received interventions to promote better sleep.

CONCLUSION

Assessment of sleep disturbances in patients with cancer should be unified using a comprehensive reliable valid instrument, as well as providing evidence-based interventions according to patient's need. A written policy should be introduced to encourage sleep documentation and to make sleep care for patients part of routine nursing care.

Patient-related factors may influence nursing perception of sleep in the Intensive Care Unit

Objective

There exist conflicting data regarding the accuracy of ICU nurses accurately assessing patient sleep using validated questionnaires. Using the Richards-Campbell Sleep Questionnaire (RSQ), we hypothesize that patient factors might influence nursing perception of their sleep.

Methods

Patients in the ICU who met the inclusion criteria were asked to complete the sleep questionnaire, as were their nurses and intraclass correlation analysis was done.

Results

38 paired patient-nurse surveys were included for analysis. The mean difference in total average score of the RSQ was not significantly different between patients and nurses. There was fair intraclass correlation by patient age, black race, and admission for respiratory illnesses. A good intraclass correlation existed for non-blacks and admission for non-respiratory reasons. Most striking was the intraclass correlation by sex, with poor intraclass correlation for women compared to an excellent correlation for men.

Conclusion

The results of our study confirm that patients in our ICU have poor sleep with a fair intraclass correlation. When examined by patient related factor, the greatest divergence between patient and nursing perception of sleep in the ICU using the RCSQ was patient female sex. More research is needed in this area to better understand the divergence and improve sleep in the ICU.

Psychometric evaluation of the Freedman questionnaire to assess sleep in critical patients

AIM

A study was made of the psychometric characteristics of the modified Freedman questionnaire to assess sleep in critical patients.

DESIGN

A psychometric study was carried out, with content validity being explored by a group of experts, and internal consistency based on Cronbach's alpha coefficient. Factor analysis was performed to explore construct validity, and stability was assessed by test-retest analysis.

SETTING

The Department of Intensive Care Medicine of a reference hospital.

PARTICIPANTS

Patients admitted between 23 February 2016 and 20 December 2017.

INTERVENTIONS

Questionnaire administration.

VARIABLES

Items of the modified Freedman questionnaire.

RESULTS

Item relevance and definition yielded scores >3 (Likert scale maximum=4). Cronbach's alpha showed a global value of 0.933. The intraclass correlation index was >0.75 for most of the items of the questionnaire. Factor analysis allowed the detection of specific associations between the studied variables and the four factors.

CONCLUSIONS

The modified Freedman questionnaire showed good psychometric characteristics. It may be a reliable instrument for assessing the quality of sleep in critically ill patients, as well as the environmental factors.

Sleep Deprivation in Intensive Care Unit - Systematic Review

Background

Sleep disturbances in intensive care unit (ICU) patients have been studied worldwide for over 30 years. Factors contributing to sleep disturbances are still being identified, and therapeutic procedures aimed at the mitigation of such ailments are consequently being developed.

Objectives

The aim of this study was to review the literature on sleep disturbances in intensive care unit patients.

Material and Methods

MEDLINE PubMed, OVID, Web of Science, and EBSCO databases have been searched using adequate keywords.

Results

Sleep disorders in ICUs were common among all of the analysed articles. Noise plays a significant role in sleep interruption (11.5 - 17% of awakenings). It was noted that the introduction of "white noise" into the ICU environment proved unsuccessful in reducing the magnitude of changing noise levels. Nursing care activities significantly disturb nocturnal rest, and 42.7 such procedures per every 12-hour night shift were registered. Aggregating nursing care interventions was suggested in order to reduce the number of stimuli experienced by the patient.

Conclusion

Changes in sleep structure developing during an ICU stay may significantly contribute to sleep disorders once the hospitalisation is over.

Safety and Security Concerns of Nurses Working in the Intensive Care Unit: A Qualitative Study

Intensive care units (ICUs) exist to serve as a safe place for critically ill patients to receive care from skilled practitioners. In this qualitative study, ICU nurses shared their perspectives on elements that promote safety and security on their units. After obtaining institutional review board approval, participants participated in telephone interviews with a nurse researcher who has experience as a bedside ICU nurse. Five categories and 14 themes were identified and then confirmed using member checking. Results indicate that participants prefer to provide care in ICUs with no more than 12 to 14 beds and provide the following: visibility of patients and coworkers; more than 1 way to exit; and can be locked in case of emergency or threat. Nearly all respondents mentioned adequate staffing as the most important attribute of a safe, secure care environment for patients and families. More research is needed to identify design features that make the most impact on providing a safe, secure ICU environment.

Nursing Interactions With Intensive Care Unit Patients Affected by Sleep Deprivation: An Observational Study

BACKGROUND

Patients in intensive care units (ICUs) often experience sleep deprivation due to different factors. Its consequences are damaging both physiologically and psychologically. This study focuses particularly on nursing interactions as the main factor involved in sleep deprivation issues.

OBJECTIVES

The aims of this study were to examine the frequency, pattern, and types of nocturnal care interactions with patients in the respiratory and cardiology ICUs; analyze the relationship between these interactions and patients' variables (age, sex, recovery diagnosis, and acuity of care); and analyze the differences in patterns of nocturnal care interactions among the units.

METHODS

This is an observational retrospective study that analyzes the frequency, pattern, and types of nocturnal care interactions with patients between 7 PM and 6 AM recording data in the activity data sheets.

RESULTS

Data consisted of 93 data assessment sheets. The mean number of care interactions per night was 18.65 (SD, 3.71). In both ICUs, interactions were most frequent at 7 PM, 10 PM, and 6 AM. Only 8 uninterrupted sleep periods occurred. Frequency of interactions correlated significantly with patients' acuity scores and the number of nurse interventions in both ICUs.

CONCLUSIONS

Patients in ICUs have fragmented sleep patterns. This study underlines the need to develop new management approaches to promote and maintain sleep.

'Sorry, were you sleeping? Nurses' role in the promotion of sleep for critically ill patients

BACKGROUND

During critical illness sleep is important for immune function and restorative processes. Despite theoretical evidence and scientific understanding of the effects of sleep deprivation in the critically ill, research is yet to be entirely translated into institutional practices and department cultural norms.

OBJECTIVES

This article was adapted from an undergraduate essay that considered the nurse's role in addressing fragmented sleep in critical care patients'.

METHOD

The databases, PubMed, CINAHL and Science Direct were searched using the keywords sleep, critical care and nurs* resulting in the inclusion of 15 journal articles. Also utilised were nursing prescribed texts and professional websites.

RESULTS

Sleep deprivation has a multitude of intrinsic and extrinsic factors, however the healthcare environment has been established as the most common cause of sleep fragmentation.

CONCLUSIONS

A paradigm shift in nursing and institutional culture is required to implement sleep promotion research and strategies to minimise adverse outcomes for patients.

Sleep Disturbances and Critical Illness

Sleep disturbances are common in the intensive care unit setting. This article describes the causal factors associated with alterations in sleep in the intensive care setting, effects of sleep disturbances for patients, and strategies to mitigate sleep disturbances. A review of normal sleep architecture is provided, as is a discussion of the methods of measuring sleep in the critical care setting.

Nurses' experiences of hospitalised patients' sleep in Sweden: a qualitative study

AIMS AND OBJECTIVES

The aim was to describe nurses' experiences of patients' sleep at an emergency hospital and their perceptions of sleep-promoting interventions.

BACKGROUND

Promotion of patients' sleep during hospital care is an important intervention for the nursing profession. To promote sleep and to initiate sleep-promoting interventions, nurses need basic knowledge about sleep and its physiology. Therefore, it is of importance to explore and expand knowledge about how nurses experience patients' sleep and how they perceive working with it while providing care.

DESIGN

A qualitative descriptive design was used.

METHODS

Data were collected from four focus groups and seven individual interviews. A total of twenty-two registered nurses participated. Data were analysed using a qualitative content analysis.

RESULTS

Nurses expressed a desire and an ambition to work in ways that promote patients' sleep during hospitalisation. Nurses reported that health care services and emergency hospitals were not organised according to patients' perspective and needs. Furthermore, they did not have opportunities to work effectively to promote sleep according to the patients' wishes. Several nurses stated that they did not have sufficient knowledge about sleep and that they did the best they could under prevailing circumstances. Nurses emphasised the importance of sleep for patients and that it was an area that should be given far greater priority.

CONCLUSIONS

The results indicate that nurses currently have insufficient knowledge about sleep and sleep-promoting interventions. These aspects of nursing is based on personal experience and common sense rather than being evidence based. Furthermore, sleep as a nursing topic needs to be developed and given more focus in order for nurses to be able to deliver high quality care at emergency hospitals.

RELEVANCE TO CLINICAL PRACTICE

Nurses require more knowledge and education to gain deeper understanding of sleep and to deliver evidence-based, high quality care.