Sleep and quality of life assessment in patients undergoing coronary artery bypass grafting

Can we let our patients sleep in the hospital? A randomized controlled trial of a pragmatic sleep protocol in surgical oncology patients

BACKGROUND

Postoperative inpatients experience increased stress due to pain and poor restorative sleep than non-surgical inpatients.

OBJECTIVES AND METHODS

A total of 101 patients, undergoing major oncologic surgery, were randomized to a postoperative sleep protocol (n = 50) or standard postoperative care (n = 51), between August 2020 and November 2021. The primary endpoint of the study was postoperative sleep time after major oncologic surgery. Sleep time and steps were measured using a Fitbit Charge 4®.

RESULTS

There was no statistically significant difference found in postoperative sleep time between the sleep protocol and standard group (median sleep time of 427 min vs. 402 min; p = 0.852, respectively). Major complication rates were similar in both groups (7.4% vs. 8.9%). Multivariate analysis found sex and Charlson Comorbidity Index to be significant factors affecting postoperative sleep time and step count. Postoperative delirium was only observed in the standard group, although this did not reach statistical significance. There were no in hospital mortalities.

CONCLUSION

The use of a sleep protocol was found to be safe in our study population. There was no statistical difference in postoperative sleep time or major complications. Institution of a more humane sleep protocol for postoperative inpatients should be considered.

S-Ketamine Improves Slow Wave Sleep and the Associated Changes in Serum Protein Among Gynecological Abdominal Surgery Patients: A Randomized Controlled Trial

Purpose

This study aims to evaluate the effect of S-ketamine on slow wave sleep (SWS) and the related changes in serum protein in gynecological patients after open abdomen surgery.

Methods

This was a randomized controlled trial. One hundred gynecological patients undergoing open abdomen surgery were randomized into an S-ketamine group (group S) or placebo group (0.9% saline; group C). During operation, patients in group S received adjuvant S-ketamine infusion (0.2 mg·kg-1·h-1) while those in group C received 0.9% saline. All patients were connected to patient-controlled intravenous analgesia (PCIA) pump in the end of the surgery and the patients in group S with an additional S-ketamine in PCIA pump. Polysomnogram (PSG) was monitored during the next night after surgery with PCIA pump. Blood samples were collected for proteomic analysis at 6:00 AM after PSG monitoring. The primary outcome was the percentage of SWS (also known as stage 3 non-rapid eye movement sleep, stage N3) on the next night after surgery, and the secondary outcome was subjective sleep quality, pain scores, and the changes in serum proteomics.

Results

Complete polysomnogram recordings were obtained from 64 study participants (31 in group C and 33 in group S). The administration of S-ketamine infusion resulted in a significant increase in the percentage of SWS/N3 compared to the control group (group C, median (IQR [range]), 8.9 (6.3, 12.5); group S, median (IQR [range]), 15.6 (12.4, 18.8), P<0.001). However, subjective evaluations of sleep quality revealed no significant variances between the two groups. The protein affected by S-ketamine was primarily associated with posttranslational modification, protein turnover, carbohydrate transport, and metabolism.

Conclusion

In patients undergoing open gynecological surgery, S-ketamine enhanced the percentage of objective sleep of SWS during the next night after surgery. Additionally, there were differences observed in serum protein levels between the two groups.

Trial Registration

ChiCTR2200055180. Registered on 02/01/2022.

Effect of mini-dose dexmedetomidine supplemented intravenous analgesia on sleep structure in older patients after major noncardiac surgery: A randomized trial

STUDY OBJECTIVES

In previous studies, low-dose dexmedetomidine supplemented opioid analgesia improved sleep architecture but increased sedation level. Herein we tested the hypothesis that mini-dose dexmedetomidine supplemented analgesia improves sleep structure without increasing sedation.

METHODS

In this randomized trial, 118 older patients (≥65 years) following major noncardiac surgery were randomized to receive patient-controlled intravenous analgesia supplemented with either placebo or dexmedetomidine (median 0.02 μg kg^-1 h^-1) for up to 3 days. Polysomnogram was monitored from 9:00 p.m. on the day of surgery until 6:00 a.m. on the first day after surgery. Our primary outcome was the percentage of non-rapid eye movement stage 2 (N2) sleep. Secondary outcomes included other sleep structure parameters during the night of surgery and the sedation score during the first five postoperative days.

RESULTS

All 118 patients completed the study; of these, 85 were included in sleep structure analysis. Dexmedetomidine supplemented analgesia increased the percentage of N2 sleep (median difference, 10%; 95% CI, 1%-20%; P = 0.03). It also prolonged total sleep time (median difference, 78 min; 95% CI, 21 to 143; P = 0.01), increased sleep efficiency (median difference, 14%; 95% CI, 4%-26%; P = 0.01), decreased percentage of N1 sleep (median difference, -10%; 95% CI, -20% to -1%; P = 0.04), and lowered sleep fragmentation index (median difference, -1.6 times⋅h^-1; 95% CI, -3.7 to 0.1; P = 0.04). Sedation score within 5 days did not differ between the two groups.

CONCLUSIONS

Supplementing intravenous analgesia with mini-dose dexmedetomidine improved sleep structure without increasing sedation in older patients recovering from major surgery.

CLINICAL TRIALS

www.

CLINICALTRIALS

gov (NCT03117790), registered 2 April 2017.

Sleep in hospitalized pediatric and adult patients – A systematic review and meta-analysis

Background

Sleep is essential for recovery from illness. As a result, researchers have shown a growing interest in the sleep of hospitalized patients. Although many studies have been conducted over the past years, an up to date systematic review of the results is missing.

Objective

The objective of this systematic review was to assess sleep quality and quantity of hospitalized patients and sleep disturbing factors.

Methods

A systematic literature search was conducted within four scientific databases. The search focused on synonyms of 'sleep’ and 'hospitalization’. Papers written in English or Dutch from inception to April 25th,2022 were included for hospitalized patients >1 year of age. Papers exclusively reporting about patients receiving palliative, obstetric or psychiatric care were excluded, as well as patients in rehabilitation and intensive care settings, and long-term hospitalized geriatric patients. This review was performed in accordance with the PRISMA guidelines.

Results

Out of 542 full text studies assessed for eligibility, 203 were included, describing sleep quality and/or quantity of 17,964 patients. The median sample size of the studies was 51 patients (IQR 67, range 6–1472). An exploratory meta-analysis of the Total Sleep Time showed an average of 7.2 h (95%-CI 4.3, 10.2) in hospitalized children, 5.7 h (95%-CI 4.8, 6.7) in adults and 5.8 h (95%-CI 5.3, 6.4) in older patients (>60y). In addition, a meta-analysis of the Wake After Sleep Onset (WASO) showed a combined high average of 1.8 h (95%-CI 0.7, 2.9). Overall sleep quality was poor, also due to nocturnal awakenings. The most frequently cited external factors for poor sleep were noise and number of patients in the room. Among the variety of internal/disease-related factors, pain and anxiety were most frequently mentioned to be associated with poor sleep.

Conclusion

Of all studies, 76% reported poor sleep quality and insufficient sleep duration in hospitalized patients. Children sleep on average 0.7–3.8 h less in the hospital than recommended. Hospitalized adults sleep 1.3–3.2 h less than recommended for healthy people. This underscores the need for interventions to improve sleep during hospitalization to support recovery.

•

An overview of the magnitude of sleep deprivation in hospitalized patients.

•

A meta-analysis of studies reporting on some of the main sleep outcomes.

•

An overview of internal and external factors affecting sleep in hospitalized patients.

•

Guidance for potential interventions to improve sleep during clinical admission.

•

Uncovers a knowledge gap regarding the sleep quality of hospitalized children and daytime sleep of hospitalized adults.

Zolpidem improves patients' sleep quality after surgical treatment for infective endocarditis: a prospective observational study

PURPOSE

The objective of this study was to investigate the efficacy of zolpidem for improving post-operative sleep quality among patients with infective endocarditis (IE) and to identify the potential risk factors for impaired sleep quality at 6 months after surgery.

METHODS

Patients with IE who underwent surgical treatment were divided into two groups according to zolpidem usage. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to evaluate patients' sleep quality and daytime sleepiness at baseline, which was the second day after transferal, and at 6 months after surgery. Logistic regression was used to identify potential risk factors.

RESULTS

There were 32 patients in the zolpidem group and 42 in the control group. The PSQI and ESS scores at 6 months after surgery were significantly lower than those at baseline in both groups (P = 0.04). Additionally, 9 patients (28%) in the zolpidem group and 22 patients (52%) in the control group suffered poor sleep quality. Multivariate analysis identified age (odds ratio [OR] = 1.26, 95% confidence interval [CI]: 1.12-1.42), baseline PSQI score (OR = 2.66, 95%CI: 1.55-4.65), and no zolpidem usage (OR = 45.48, 95%CI: 3.01-691.23) as independent factors for poor sleep quality.

CONCLUSIONS

Poor sleep quality after IE surgery was prevalent among patients even 6 months after IE surgery. Age, baseline PSQI score and no zolpidem usage were independently associated with poor sleep quality. Therefore, zolpidem has the potential to be an effective part of a treatment arsenal for poor sleep quality after surgical treatment for IE.

Sleep Quality in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI)

The present study aimed to analyze sleep quality and quality of Life (QoL) in patients undergoing Transcatheter Aortic Valve Implantation (TAVI). It was conducted at the Interventional Cardiology Unit of the Department of Cardiac, Thoracic, Vascular Sciences and Public Health of the University of Padova on 27 adult patients who underwent TAVI via the transfemoral approach. Patients completed two validated instruments, i.e., the Pittsburgh Sleep Quality Index (PSQI) and the EuroQoL (EQ-5D-5L), on the day of discharge and one month after the hospital discharge. Twenty-seven patients were enrolled with a severe aortic stenosis diagnosis, treated with transfemoral TAVI procedure. The study population included seventeen poor sleepers and ten good sleepers with a median age of 81.92 years overall. The global PSQI evaluation revealed a small significant improvement at follow-up (p-value 0.007). Small positive changes were detected in the Self-care and Usual activity domains of the EQ-5D-5L and the EQ-VAS. No correlation was detected between EQ-5D-5L and sleep quality. The present study confirms the importance of sleep quality monitoring in patients who undergo TAVI procedure for aortic stenosis treatment.

Atypical Sleep and Postoperative Delirium in the Cardiothoracic Surgical Intensive Care Unit: A Pilot Prospective Study

PURPOSE

Postoperative delirium (POD) is a very common and serious neurological complication in patients admitted to the cardiothoracic surgical intensive care unit (CSICU). We aimed to identify a novel potential sleep-based marker for POD and investigate the relevance between atypical sleep and POD.

PATIENTS AND METHODS

This was a prospective, observational study of patients admitted to the CSICU between December 2019 and February 2020 at our center. Sleep characteristics from 21:00 on postoperative day 1 to 07:00 on postoperative day 2 were assessed using polysomnography (PSG). POD from the end of PSG monitoring until postoperative day 5 was evaluated using the Confusion Assessment Method for the Intensive Care Unit.

RESULTS

This analysis included 20 patients admitted to the CSICU. The incidence of atypical sleep was 45.0%. Compared to patients without delirium, those with delirium had less delta power, less percentage REM sleep, and a higher proportion of atypical sleep and REM sleep loss (P < 0.05).

CONCLUSION

The presence of atypical sleep and the absence of REM sleep were associated with POD in patients admitted to the CSICU.

Characterizing Patient-Centered Postoperative Recovery After Adult Cardiac Surgery: A Systematic Review

Background

Improving postoperative recovery is important, with a national focus on postacute care, but the volume and quality of evidence in this area are not well characterized. We conducted a systematic review to characterize studies on postoperative recovery after adult cardiac surgery using patient‐reported outcome measures.

Methods and Results

From MEDLINE and Web of Science, studies were included if they prospectively assessed postoperative recovery on adult patients undergoing cardiac surgery using patient‐reported outcome measures. Six recovery domains were defined by prior literature: nociceptive symptoms, mental health, physical function, activities of daily living, sleep, and cognitive function. Of the 3432 studies, 105 articles met the inclusion criteria. The studies were small (median sample size, 119), and mostly conducted in single‐center settings (n=81; 77%). Study participants were predominantly men (71%) and white (88%). Coronary artery bypass graft was included in 93% (n=98). Studies commonly selected for elective cases (n=56; 53%) and patients with less comorbidity (n=67; 64%). Median follow‐up duration was 91 (interquartile range, 42–182) days. Studies most commonly assessed 1 domain (n=42; 40%). The studies also varied in the instruments used and differed in their reporting approach. Studies commonly excluded patients who died during the follow‐up period (n=48; 46%), and 45% (n=47) did not specify how those patients were analyzed.

Conclusions

Studies of postoperative patient‐reported outcome measures are low in volume, most often single site without external validation, varied in their approach to missing data, and narrow in the domains and diversity of patients. The evidence base for postoperative patient‐reported outcome measures needs to be strengthened.

Sleeping pattern before thoracic surgery: A comparison of baseline and night before surgery

Background

Sleep deprivation is considered a stress factor in the perioperative period. There are several studies on sleep disturbance after surgery but very limited literature available on preoperative sleep patterns, predictors of sleep disturbance and its effect on surgical outcome.

Methodology

Patients scheduled for thoracic surgery were asked to fill out a written Pittsburgh Sleep Quality Index (PSQI) questionnaire. The primary investigator explained this form to all the patients. This was filled out before premedication for subjective assessment of sleeping pattern at two different time point. Only those patients included who spent the previous night at home. Participants were asked to respond to the questions regarding their baseline sleeping pattern and compare it with last night.

Results

Total eighty-three patients with a mean age of 47.83 ± 17.88 were included in the study. Overall mean PSQI scores were significantly higher (p-value < 0.01) during the night before surgery (6.94 ± 2.115) when compared with baseline (3.88 ± 1.877). Sleep latency was also significantly affected when last night-1 (the night before admission) was compared with usual sleep latency. Twenty patients were unable to sleep more than 5 hrs at night before admission which was significant when compared with their last month status (20 vs 3). Logistic regression model demonstrated the age and Timing of surgery as a strong predictors of poor sleep (defined as PSQI ≥ 5).

Conclusion

Quality of sleep was profoundly affected at night before thoracic surgery, mainly due to a significant change in sleep latency and sleep duration. Although age and Timing of surgery were strong predictors of poor sleep we were unable to find any association between quality of sleep and type of surgery.

Symptom management strategies of Jordanian patients following coronary artery bypass grafting surgery

The aim of this study was to explore the symptom management strategies utilized by post coronary artery bypass graft (CABG) patients and its associations with demographic variables. A clear understanding of the use of symptom management strategies following CABG surgery may help nurses in developing educational program and interventions that help patients and their families during recovery period after discharge. A cross-sectional, descriptive design was utilized. A convenience sample of 100 Jordanian patients post CABG surgery selected from five hospitals was surveyed between November 2012 and June 2013 using the Cardiac Symptom Survey. Chi squared analyses were used to examine the associations between the symptoms management strategies and selected demographic variables. Frequency of symptom management strategies utilized by post CABG patients revealed that most frequently employed strategies were use of medications (79%), repositioning (54%) and the rest (45%). Symptom management strategies utilized for poor appetite, sleeping problem and fatigue had significant associations with demographic variables. By providing information about the symptoms expected after surgery and possible ways to manage them, will strengthen the patients psychologically and will make CABG experience within the realm of self-management and coping.

Circadian Rhythm Disruption in the Critically Ill: An Opportunity for Improving Outcomes

OBJECTIVES

Circadian rhythms are severely disrupted among the critically ill. These circadian arrhythmias impair mentation, immunity, autonomic function, endocrine activity, hormonal signaling, and ultimately healing. In this review, we present a modern model of circadian disruption among the critically ill, discuss causes of these circadian arrhythmias, review observational and intervention studies of the effects of circadian-rhythm-restoring factors on medical outcomes, and identify needed key trials of circadian interventions in the critically ill.

DATA SOURCES

MEDLINE, EMBASE, PsychINFO, Google Scholar through December 2014.

STUDY SELECTION

Articles relevant to circadian rhythms, melatonin, and light in the critically ill were selected.

DATA EXTRACTION AND DATA SYNTHESIS

Articles were synthesized for this review of circadian arrhythmia and the use of circadian-rhythm-restoring interventions among the critically ill.

CONCLUSIONS

Circadian disruption often demonstrates serial degradation: initially, the amplitude attenuates along with delayed circadian phase. With increasing acuity of illness, circadian rhythmicity may be lost entirely. Causes of chronodisruption may be environmental or internal to the patient. In particular, inadequate daytime illumination and nocturnal light pollution disrupt healthy circadian periodicity. Internal causes of circadian arrhythmia include critical illness itself and subjective experience of distress and pain. Observational studies of windowed rooms and real-time ambient lighting have found that physiologic light-dark patterns may support recovery from critical illness. Studies of early morning bright light or evening melatonin agonists have found improved rates of delirium, enhanced sleep, and lower arrhythmia prevalence. The current evidence base emphasizes that lighting and melatoninergic interventions deserve to be tested in full-scale trials.

Sleep Quality and Emotional Correlates in Taiwanese Coronary Artery Bypass Graft Patients 1 Week and 1 Month after Hospital Discharge: A Repeated Descriptive Correlational Study

Background

Poor sleep quality is a common health problem for coronary artery bypass graft patients, however few studies have evaluated sleep quality during the period immediately following hospital discharge.

Purpose

The aim of this study was to investigate changes in sleep quality and emotional correlates in coronary artery bypass graft patients in Taiwan at 1 week and 1 month after hospital discharge.

Methods

We used a descriptive correlational design for this study. One week after discharge, 87 patients who had undergone coronary artery bypass surgery completed two structured questionnaires: the Pittsburgh Sleep Quality Index and the Hospital Anxiety and Depression Scale. Three weeks later (1 month after discharge) the patients completed the surveys again. Pearson correlations, t-tests, ANOVA and linear multiple regression analysis were used to analyze the data.

Results

A majority of the participants had poor sleep quality at 1 week (82.8%) and 1 month (66.7%) post-hospitalization, based on the global score of the Pittsburgh Sleep Quality Index. Despite poor sleep quality at both time-points the sleep quality at 1 month was significantly better than at 1-week post hospitalization. Poorer sleep quality correlated with older age, poorer heart function, anxiety and depression. The majority of participants had normal levels of anxiety at 1 week (69.0%) and 1 month (88.5%) as measured by the Hospital Anxiety and Depression Scale. However, some level of depression was seen at 1 week (78.1%) and 1 month (59.7%). Depression was a significant predictor of sleep quality at 1 week; at 1 month after hospital discharge both anxiety and depression were significant predictors of sleep quality.

Conclusion

Sleep quality, anxiety and depression all significantly improved 1 month after hospital discharge. However, more than half of the participants continued to have poor sleep quality and some level of depression. Health care personnel should be encouraged to assess sleep and emotional status in patients after coronary artery bypass surgery and offer them appropriate management strategies to improve sleep and reduce anxiety and depression.

Sleep and nursing care activities in an intensive care unit

This study aimed to describe the quality of sleep of non-intubated patients and the night-time nursing care activities in an intensive care unit. The study also aimed to evaluate the effect of nursing care activities on the quality of sleep. An overnight polysomnography was performed in 21 alert, non-intubated, non-sedated adult patients, and all nursing care activities that involved touching the patient were documented by the bedside nurse. The median (interquartile range) amount of sleep was 387 (170, 486) minutes. The portion of deep non-rapid-eye-movement (non-REM) sleep varied from 0% to 42% and REM sleep from 0% to 65%. The frequency of arousals and awakenings varied from two to 73 per hour. The median amount of nursing care activities was 0.6/h. Every tenth activity presumably awakened the patient. Patients who had more care activities had more light N1 sleep, less light N2 sleep, and less deep sleep. Nursing care was often performed while patients were awake. However, only 31% of the intervals between nursing care activities were over 90 min. More attention should be paid to better clustering of care activities.

Intensive care unit depth of sleep: proof of concept of a simple electroencephalography index in the non-sedated

INTRODUCTION

Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with possible detrimental effects on short- and long- term outcomes. Investigation into the exact causes and effects of disturbed sleep has been hampered by cumbersome and time consuming methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep analysis, the ICU depth of sleep index (IDOS index), using single channel electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is shown in non-sedated ICU patients.

METHODS

Polysomnographic (PSG) recordings of five ICU patients and 15 healthy outpatients were analyzed using the IDOS index, based on the ratio between gamma and delta band power. Manual selection of thresholds was used to classify data as either wake, sleep or slow wave sleep (SWS). This classification was compared to visual sleep scoring by Rechtschaffen & Kales criteria in normal outpatient recordings and ICU recordings to illustrate face validity of the IDOS index.

RESULTS

When reduced to two or three classes, the scoring of sleep by IDOS index and manual scoring show high agreement for normal sleep recordings. The obtained overall agreements, as quantified by the kappa coefficient, were 0.84 for sleep/wake classification and 0.82 for classification into three classes (wake, non-SWS and SWS). Sensitivity and specificity were highest for the wake state (93% and 93%, respectively) and lowest for SWS (82% and 76%, respectively). For ICU recordings, agreement was similar to agreement between visual scorers previously reported in literature.

CONCLUSIONS

Besides the most satisfying visual resemblance with manually scored normal PSG recordings, the established face-validity of the IDOS index as an estimator of depth of sleep was excellent. This technique enables real-time, automated, single channel visualization of depth of sleep, facilitating the monitoring of sleep in the ICU.

Sleep, sleepiness, and fatigue outcomes for parents of critically ill children

OBJECTIVES

To describe sleep quantity, sleep patterns, fatigue, and sleepiness for parents of critically ill hospitalized children.

DESIGN

Prospective observational study.

SETTING

Quaternary academic PICU.

PARTICIPANTS

One hundred eighteen parents of 91 children recruited during their child's PICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

For 5 days and nights, parents wore an actigraph to determine objective sleep-wake times and reported sleep location, level of fatigue (Fatigue Visual Analogue Scale), and sleepiness (Stanford Sleepiness Scale). Mean amounts of nocturnal sleep were less than recommended for optimal health (398 min, fathers vs 422 min, mothers; p = 0.04). Parents woke frequently (7.8 wakes, fathers; 7.2 wakes, mothers) and spent over an hour awake at night (65 min, fathers; 60 min, mothers). On 130 nights (26%), parents slept less than 6 hours and 209 nights (44%) were evaluated as "worse" sleep than usual. Fifty-four parents (53%) experienced more than 30% difference in minutes of sleep between consecutive nights. Mean morning fatigue levels (41 mm, fathers vs 46 mm, mothers; p = 0.03) indicated clinically significant fatigue. Sleeping in a hotel, parent room, or residence was associated with 3.2 more wakes per night (95% CI, 0.61-5.78; p = 0.015) than sleeping in a hospital lounge or waiting room.

CONCLUSIONS

We performed a prospective observational study of 118 parents of critically ill children using objective measures of sleep and validated scales to assess fatigue and sleepiness. We found that more than a quarter of nights met criteria for acute sleep deprivation, there was considerable variability in the amount of nocturnal sleep that individual participants slept on different nights, and sleep was fragmented with a large portion of the night spent awake. Future research should focus on interventions that improve parents' ability to return to sleep upon awakening and maintain regular sleep-wake schedules.

Evaluating adult patients' sleep: an integrative literature review in critical care

BACKGROUND

Patients in a critical care unit sleep quite poorly even when they appear to be sleeping. Sleep is light and fragmented. Acute lack of sleep causes patients suffering in the form of fatigue, irritability, disorientation and hallucinations. It may also affect their recovery and immune defence. To promote sleep, nurses must be able to evaluate patients' sleep reliably.

AIM AND OBJECTIVES

Our aim was to form a comprehensive overview of the sleep evaluation methods in critical care. Our objectives were to determine the content and the quality of the methods as reported by the researchers. This overview hopefully improves the use of the sleep evaluation methods as part of sleep promoting nursing interventions and practices.

METHOD

The literature search was performed from the Ovid MEDLINE, CINAHL, an 'All EBM Reviews', and PsycINFO databases. The search terms sleep, evaluating sleep and critical care were used. An integrative review method was used to analyse the data.

RESULTS

According to the 52 articles of this review, there is a wide variety of methods to evaluate patients' sleep in critical care by observation, by asking for patient's own perception and by objective measures. Most instruments evaluate only total sleep time or the quality of sleep in general. The validity and reliability of the instruments has been insufficiently reported. Some questionnaires for patients' perception have been tested and used in several studies.

CONCLUSION

Sleep evaluation instruments do not cover all dimensions of sleep since they mostly measure total sleep time or estimate the overall quality of sleep. The quality of the sleep evaluation instruments varies from scientifically tested tools to untested instruments. This review will allow nurses to recognise the strengths and limitations of sleep evaluation instruments when selecting one to be used in critical care. Valid information about patients' sleep enables nurses to facilitate it.

Characterisation of sleep in intensive care using 24-hour polysomnography: an observational study

INTRODUCTION

Many intensive care patients experience sleep disruption potentially related to noise, light and treatment interventions. The purpose of this study was to characterise, in terms of quantity and quality, the sleep of intensive care patients, taking into account the impact of environmental factors.

METHODS

This observational study was conducted in the adult ICU of a tertiary referral hospital in Australia, enrolling 57 patients. Polysomnography (PSG) was performed over a 24-hour period to assess the quantity (total sleep time: hh:mm) and quality (percentage per stage, duration of sleep episode) of patients' sleep while in ICU. Rechtschaffen and Kales criteria were used to categorise sleep. Interrater checks were performed. Sound pressure and illuminance levels and care events were simultaneously recorded. Patients reported on their sleep quality in ICU using the Richards Campbell Sleep Questionnaire and the Sleep in Intensive Care Questionnaire. Data were summarised using frequencies and proportions or measures of central tendency and dispersion as appropriate and Cohen's Kappa statistic was used for interrater reliability of the sleep data analysis.

RESULTS

Patients' median total sleep time was 05:00 (IQR: 02:52 to 07:14). The majority of sleep was stage 1 and 2 (medians: 19 and 73%) with scant slow wave and REM sleep. The median duration of sleep without waking was 00:03. Sound levels were high (mean Leq 53.95 dB(A) during the day and 50.20 dB(A) at night) and illuminance levels were appropriate at night (median<2 lux) but low during the day (median: 74.20 lux). There was a median 1.7 care events/h. Patients' mean self-reported sleep quality was poor. Interrater reliability of sleep staging was highest for slow wave sleep and lowest for stage 1 sleep.

CONCLUSIONS

The quantity and quality of sleep in intensive care patients are poor and may be related to noise, critical illness itself and treatment events that disturb sleep. The study highlights the challenge of quantifying sleep in the critical care setting and the need for alternative methods of measuring sleep. The results suggest that a sound reduction program is required and other interventions to improve clinical practices to promote sleep in intensive care patients.

TRIAL REGISTRATION

Australian New Zealand clinical trial registry (http://www.anzctr.org.au/): ACTRN12610000688088.

Patients' experiences with symptoms and needs in the early rehabilitation phase after coronary artery bypass grafting

BACKGROUND

The first month after discharge for Coronary artery bypass graft (CABG) is particularly challenging for the patients. A larger interview study is warranted to elicit CABG patients' detailed experiences, and give direction for future clinical practice.

AIM

To explore the CABG patients' symptoms and needs in the early rehabilitation phase.

METHODS

A qualitative, mixed method design integrating qualitative and quantitative approaches was used. Ninety-three CABG patients aged 39-77, participated in interviews at home after 2 and 4 weeks. The semi-structured interview guide covered: experiences of relief of angina pectoris after surgery, experiences with prescribed discharge medications, psychological experiences: anxiety, depression, sexuality, health professional contact persons, and patient defined experiences.

RESULTS

Two weeks after CABG the patients symptoms and needs were characterised by a substantial amount of uncertainty and worries related to what to expect and what was normal for postoperative pain, assessment and sensation of surgical site, different experiences with physical activity/exercise, uncertainty about medications, difficulties with sleep pattern, irritability, postoperative complications,uncertainty about return to work, and insufficient information at discharge. Four weeks after surgery the patients' symptom level was decreased, and they experienced life beginning to return back to normal. Patency with grafts after CABG, decision to drive a car, impotence (erectile dysfunction), and a missing link to the hospital remained challenges.

CONCLUSION

CABG patients' experiences indicate a need to extend the hospital's discharge care to the first month after surgery for specific themes to promote rehabilitation outcomes.

Sleep quality and sleepiness in persons with implantable cardioverter defibrillators: outcome from a clinical randomized longitudinal trial

BACKGROUND

Patients receiving an implantable cardioverter defibrillator (ICD) report various types and degree of sleep disruptions, but little is known regarding their characteristics, duration, and associated factors. The purposes of this study were: (1) to describe the effect of a psychoeducational intervention on sleep quality and daytime sleepiness, (2) to describe patterns of sleep over time, and (3) to identify predictors of poor sleep in an ICD population.

METHODS

A randomized longitudinal intervention trial was designed to test the effects of a psychoeducational intervention, which included a sleep education and counseling session in patients receiving their initial ICD. Patients (n=236; 75% men; mean age 58.4 [±11.2] from the PsychoEducationAl Intervention for ICD PatiEnts (PEACE) trial comprised the study population. Variables related to sleep were measured by the Pittsburgh Sleep Quality Inventory (PSQI) and Epworth Sleepiness Scale (ESS).

RESULTS

No psychoeducational intervention effects on sleep outcomes were observed. However, 67.2% of the patients reported poor sleep quality at baseline, and 56.8% had low sleep quality at 6 months based on PSQI scores>5; one-third (32.6%) were excessively sleepy based on ESS scores≥10 at 6 months. Anxiety, depression, physical function, pain intensity, and pain severity were all highly correlated to each other across time. Female gender was a significant covariate for the PSQI. New York Heart Association (NYHA) class was a significant covariate for sleepiness (Epworth).

CONCLUSIONS

Low sleep quality and daytime sleepiness are found at time of insertion and over time in patients with ICD. Female gender, higher NYHA class, as well as two latent factors encompassing increased anxiety, depressive symptoms, and decreased physical function and increased pain, were significant predictors of poor sleep quality and sleepiness over time. These data help identify those at higher risk for sleep problems after ICD.

Comparison of Sleep and Mood in Patients After On-Pump and Off-Pump Coronary Artery Bypass Surgery

Background Off-pump coronary artery bypass surgical procedures have been advocated to reduce the adverse effects of cardiopulmonary bypass on the brain.

Objective To examine differences in objective and subjective characteristics of sleep and mood disturbance between patients after on-pump and off-pump coronary artery bypass surgery.

Methods In a secondary analysis of pooled data from 2 previous studies, sleep characteristics and mood disturbance on postoperative night 2 after transfer to the cardiac surgery step-down unit were compared in patients who had on-pump and off-pump cardiac surgery. The sample included 129 coronary artery bypass patients: 48 on-pump patients from one hospital and 81 off-pump patients from another hospital. Data were obtained with wrist actigraphs. Subjective characteristics of sleep were determined by using the Pittsburgh Sleep Quality Index and a sleep diary; mood disturbance was evaluated by using the short form of the Profile of Mood States.

Results Off-pump surgery was associated with better objective sleep continuity (decreased percentage of wake time after sleep onset and fewer awakenings) but not longer sleep duration after controlling for age and sex. The 2 groups of patients did not differ overall in subjective sleep characteristics, mood disturbance, or preoperative sleep quality.

Conclusion Use of off-pump coronary artery bypass surgery may improve sleep continuity during the early postoperative period. Prospective longitudinal studies are needed to evaluate the potential long-term benefits of this procedure during the different phases of recovery.

Health outcomes of patients undergoing cardiac surgery: repeated measures using Short Form-36 and 15 Dimensions of Quality of Life questionnaire

OBJECTIVE

The study assessed health-related quality of life (HRQOL) of patients before and after cardiac surgery.

DESIGN

This was a prospective repeated-measures observational study.

SETTING

The study took place in a 650-bed tertiary referral hospital in Sydney, Australia.

METHODS

HRQOL was measured using the Medical Outcomes Study Short Form 36-item health survey (SF-36) and the 15 Dimensions of Quality of Life questionnaire before surgery, at hospital discharge, and 6 months postdischarge.

RESULTS

Participants were representative of the cardiac surgery population. Scores for several concepts deteriorated at hospital discharge when compared with presurgery. There were significant improvements in health status at 6 months postdischarge when compared with previous measures for the majority of SF-36 and 15 Dimensions of Quality of Life questionnaire concepts, although mental health and social functioning demonstrated significant deterioration. SF-36 scores were substantially lower than population norms, but similar to previous studies of patients undergoing cardiac surgery except for mental health.

CONCLUSION

Deterioration in health status at hospital discharge when compared with presurgery status reinforces the need for further patient care and support after discharge. All dimensions improved after 6 months, except mental health. This information can guide patient expectations regarding rehabilitation posthospitalization, and cardiac surgical services should implement and evaluate formal "outreach programs" for these patients.

Sleep, memory, and learning in off-pump coronary artery bypass patients

In this study, I examined sleep, memory, and learning in off-pump coronary artery bypass (OPCAB) patients. Sixty-six men and women aged >or=60 years wore actigraphs to record sleep and completed sleep diaries for two 24-hour periods following OPCAB surgery. Prior to discharge from the hospital, participants completed the Pittsburgh Sleep Quality Index (PSQI) and Rey Auditory Verbal Learning Test. No significant correlations were found between habitual sleep, sleep time, efficiency, number, and duration of awakenings, daytime napping, or memory and learning. Nighttime sleep was short with frequent disturbances, and daytime sleep accounted for half the daily sleep time. Participants scored low in learning and delayed recall. These findings suggest the need to assess sleep and cognition in patients recovering from OPCAB surgery.

Sleep Is Related to Physical Function and Emotional Well-Being After Cardiac Surgery

BACKGROUND

Emotional well-being and physical function are important quality-of-life outcomes after cardiac surgery. Alterations in sleep patterns, including sleep deprivation and altered circadian patterning, also are common. The relations among sleep pattern alterations, physical function, and emotional well-being are not well understood.

OBJECTIVE

This study aimed to examine the relations of sleep patterns to physical function and emotional well-being 4 and 8 weeks after cardiac surgery.

METHODS

Cardiac surgery patients (n = 72) wore wrist actigraphs and completed sleep diaries for 3 days during postoperative weeks 4 and 8. They also completed the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and the Medical Outcomes Survey Short Form 36 preoperatively and at postoperative weeks 4 and 8. Pearson correlations and hierarchical multiple regression analysis were used to analyze the data.

RESULTS

Mean sleep efficiency was 71% at 4 weeks and 74% at 8 weeks, as measured with wrist actigraphy. According to participants' self-report, 64% experienced sleep disturbance at 4 weeks and 47% at 8 weeks. Sleep pattern variables, including sleep efficiency and self-reported sleep quality, explained 16% of the variance in physical function at 4 weeks. Self-reported sleep quality explained 8% of the variance in physical function at 8 weeks as well as 12% of the variance in emotional well-being at postoperative week 4 and 13% of the variance at postoperative week 8, after control was used for the contributions of baseline physical function, emotional well-being, age, and sex.

CONCLUSIONS

The results suggest that sleep contributes to both physical functional and emotional well-being 4 and 8 weeks after cardiac surgery.

Patients’ sleep in an intensive care unit—patients’ and nurses’ perception

The main purpose of this study was to describe how patients treated in an intensive care unit (ICU) perceive their sleep and to compare patients' and nurses' perceptions of the patients' sleep. The study also determined the percentage of patients in the ICU who were able to fill in the Richard Campell Sleep Questionnaire (RCSQ). This instrument consists of six items and utilises a visual analogue scale (VAS). The results of five of the RCSQ questions are used to calculate a total sleep score, ranging between 0 and 100 (0=the worst possible sleep, 100=the best sleep).Approximately half of the patients were able to answer the RCSQ (n=31). The patients' rating of their sleep varied widely (total sleep score: range 0-97, mean 45.5). Patients who had received hypnotics or sedatives during the night (n=12) had a significantly lower total sleep score (mean=31.6) than the rest of the patients (mean 54.3; P=0.037). On comparing the patients' and the nurses' perceptions of the patients' sleep, no significant difference between the groups was seen. This indicates that nurses can use the RCSQ to assess the sleep of patients who are unable to report their sleep themselves.

Misrepresenting random sampling? A systematic review of research papers in the Journal of Advanced Nursing

AIM

This paper discusses the theoretical limitations of the use of random sampling and probability theory in the production of a significance level (or P-value) in nursing research. Potential alternatives, in the form of randomization tests, are proposed.

BACKGROUND

Research papers in nursing, medicine and psychology frequently misrepresent their statistical findings, as the P-values reported assume random sampling. In this systematic review of studies published between January 1995 and June 2002 in the Journal of Advanced Nursing, 89 (68%) studies broke this assumption because they used convenience samples or entire populations. As a result, some of the findings may be questionable.

DISCUSSION

The key ideas of random sampling and probability theory for statistical testing (for generating a P-value) are outlined. The result of a systematic review of research papers published in the Journal of Advanced Nursing is then presented, showing how frequently random sampling appears to have been misrepresented. Useful alternative techniques that might overcome these limitations are then discussed. REVIEW LIMITATIONS: This review is limited in scope because it is applied to one journal, and so the findings cannot be generalized to other nursing journals or to nursing research in general. However, it is possible that other nursing journals are also publishing research articles based on the misrepresentation of random sampling. The review is also limited because in several of the articles the sampling method was not completely clearly stated, and in this circumstance a judgment has been made as to the sampling method employed, based on the indications given by author(s).

CONCLUSION

Quantitative researchers in nursing should be very careful that the statistical techniques they use are appropriate for the design and sampling methods of their studies. If the techniques they employ are not appropriate, they run the risk of misinterpreting findings by using inappropriate, unrepresentative and biased samples.

Nurses’ clinical experiences of the inverse bed position on a neurointensive care unit—a phenomenographic study

Our knowledge of unstable critically ill patients placed in an inverse bed position on the neurointensive care unit (NICU) is fairly limited. The purpose of this study was to ascertain the variation in nurses' conceptions of the impact of clinical experiences on the care and working environments among patients with the head towards the centre of the room on an NICU. An important research question was: how is the nursing care of patients facing inwards on an NICU perceived? Interviews were conducted and analysed with 15 nurses, using the method of phenomenography. From a nursing perspective, four descriptive categories were found, which partly distinguished the nursing psychosocial environment from the physical environment. These were safety and security of mobile computer tomography (CT) on the NICU, availability and overview, integrated holistic view in an open nursing psychosocial environment and adaptation of practical equipment. In conclusion, inverse bed position is important for more individualised neurointensive nursing care among unstable patients subjected to frequent CT scans on the unit. More stable patients should be turned back to the traditional bed position in order to promote their recovery process. This new knowledge is important for the development of quality assurance, with regard to, amongst other things, the patient's dignity.

Use of complementary and alternative therapies to promote sleep in critically ill patients

The efficacy of complementary and alternative therapies for sleep promotion in critically ill patients is largely unexamined. We found only seven studies (three on environmental interventions and one each on massage, music therapy, therapeutic touch, and, melatonin) that examined the effect of complementary and alternative therapies. A number of studies, however, have shown that massage, music therapy. and therapeutic touch promote relaxation and comfort in critically ill patients, which likely leads to improved sleep. Massage, music therapy, and therapeutic touch are safe for critically ill patients and should be routinely applied by ICU nurses who have received training on how to administer these specialized interventions. Environmental interventions, such as reducing noise, playing white noise such as ocean sounds, and decreasing interruptions to sleep for care, also are safe and logical interventions that ICU nurses should use to help patients sleep. Progressive muscle relaxation has been extensively studied and shown to be efficacious for improving sleep in persons with insomnia; however, progressive muscle relaxation requires that patients consciously attend to relaxing specific muscle groups and practice these techniques, which may be difficult for critically 11 patients. We do not currently recommend aromatherapy and alternative sedatives, such as valerian and melatonin, for sleep promotion in critically ill patients because the safety of these substances is unclear. In summary, we recommend that ICU nurses implement music therapy, environmental interventions, therapeutic touch, and relaxing massage to promote sleep in critically ill patients. These interventions are safe and may improve patient sleep, although randomized controlled trials are needed to test their efficacy. Aromatherapy and alternative sedatives require further investigation to determine their safety and efficacy.

Diminished Circadian Rhythm of Heart Rate Variability After Aortic Surgery Appears to Be Independent of Myocardial Ischemia

Impaired heart rate variability (HRV) has been described postoperatively. Diminished HRV may be related to myocardial ischemia and potentially causes circulatory instability. Cardiac ischemic events and a compromised cardiovascular function are not uncommon after aortic surgery. Circadian variation of HRV seems to be a prognostically more important parameter than HRV itself with respect to the development of cardiac dysfunction. We therefore investigated whether the diurnal rhythm of HRV is simultaneously altered postoperatively and the potential contribution of myocardial ischemia. After approval by the hospital ethics committee and having obtained informed consent, we studied 11 consecutive male patients undergoing elective aortic surgery. Patients were monitored with a Holter-ECG perioperatively. Spectral HRV measures (total, low, and high frequency power) were determined and night/day ratios calculated. Ischemic ECG changes were recorded and serum was sampled for troponin T analysis. A remarkable decline in circadian variation accompanied the decrease in all HRV parameters postoperatively. Five patients showed ECG changes suggestive of myocardial ischemia and two had increased levels of troponin T. These two patients showed greatly diminished HRV postoperatively with a similarly reduced circadian rhythm. We have demonstrated that the circadian rhythm of HRV is not preserved after aortic surgery. Diminished diurnal variability seems to be a general manifestation and myocardial ischemia may just be one contributing factor. An altered biorhythm in combination with stress related changes in the neuroendocrine system after surgery most likely have a more significant influence on the circadian rhythm of HRV.

Insufficient sleep, cognitive anxiety and health transition in men with coronary artery disease: a self-report and polysomnographic study

AIMS

To explore possible links between sleep quality, cognitive anxiety and the effects of sleep disturbances on health, daytime functioning and quality of life, for assessment in a larger study. Hypotheses were: (a) patients with coronary artery disease have insufficient sleep as measured by self-reported sleep and by polysomnography, (b) self-reported sleep is associated with polysomnographically measured sleep, (c) reduced sleep quality is associated with physical and mental health, and interferes with quality of life as measured by means of interviews and polysomnography, (d) reduced sleep quality is associated with reduced resilience to stress.

BACKGROUND

It has become increasingly evident that poor sleep with sleep initiation difficulties is an independent risk factor for cardiac events among men, and requires more attention in clinical nursing practice.

DESIGN

Descriptive, correlative and explorative study.

SAMPLE

Forty-four men, aged 45-70, about to undergo coronary artery bypass surgery at a Swedish University Hospital.

RESEARCH METHODS

Interviews and 24-hour continuous ambulatory polysomnography were performed. For the interviews, the Uppsala Sleep Inventory, Spielberger State Anxiety Scale and the Nottingham Health Profile instruments were used.

RESULTS

Seventeen patients (38.6%) had insufficient sleep and 12 had sleep initiation difficulties. Logistic regressions revealed that reduced stage 3-4 sleep predicted poorer overall health, initiation of sleep difficulties, predicted insufficient sleep and involuntary thoughts predicted fragmented sleep. Poorer quality of life was predicted by reduced deep sleep. Independent predictors for emotional distress were sleep efficiency below 85%, fragmented sleep and a daytime nap longer than 15 minutes.

CONCLUSIONS

Objective sleep was associated with several subjective sleep variables. The results provide empirical support for significant variables included in a theoretical framework relating to sleep quality, cognitive anxiety, health and quality of life. A larger study is recommended that includes both men and women.

The impact of foot massage and guided relaxation following cardiac surgery: a randomized controlled trial

BACKGROUND

Because of the widely presumed association between heart disease and psychological wellbeing, the use of so-called 'complementary' therapies as adjuncts to conventional treatment modalities have been the subject of considerable debate. The present study arose from an attempt to identify a safe and effective therapeutic intervention to promote wellbe ing, which could be practicably delivered by nurses to patients in the postoperative recovery period following coronary artery bypass graft (CABG) surgery. Aim. To investigate the impact of foot massage and guided relaxation on the wellbeing of patients who had undergone CABG surgery.

METHOD

Twenty-five subjects were randomly assigned to either a control or one of two intervention groups. Psychological and physical variables were measured immediately before and after the intervention. A discharge questionnaire was also administered.

RESULTS

No significant differences between physiological parameters were found. There was a significant effect of the intervention on the calm scores (ANOVA, P=0.014). Dunnett's multiple comparison showed that this was attributable to increased calm among the massage group. Although not significant the guided relaxation group also reported substantially higher levels of calm than control. There was a clear (nonsignificant) trend across all psychological variables for both foot massage and, to a lesser extent, guided relaxation to improve psychological wellbeing. Both interventions were well received by the subjects.

CONCLUSIONS

These interventions appear to be effective, noninvasive techniques for promoting psychological wellbeing in this patient group. Further investigation is indicated.

Fragmented sleep and tiredness in males and females one year after percutaneous transluminal coronary angioplasty (PTCA)

AIM

Reported sleep quality was examined in relation to anxiety, depression, selected psycho-physiological sleep disturbing symptoms, daytime dysfunctions according to poor sleep, and quality of life 1 year after percutaneous transluminal coronary angioplasty (PTCA). Furthermore, females were compared with age-matched males to examine any differences in sleep quality, psycho-physiological symptoms and quality of life.

STUDY DESIGN

A descriptive comparative study.

SAMPLE

Twenty-two females, mean age 62.7 (SD 5.7) and 70 men, mean age 60.4 (SD 6.7), were consecutively recruited.

METHOD

A mailed questionnaire was distributed, including the Uppsala Sleep Inventory, Spielberger State Anxiety scale, Zung's Self-rating Depression Scale and the Nottingham Health Profile instrument.

RESULTS

Forty-six per cent of the patients had a history of myocardial infarction and 40.2% hypertension. Seventy-two per cent of the patients were anxious and 30.4% depressed. Difficulty in getting to sleep was related to intrusive thoughts with increased feelings of anxiety and sensitivity. Difficulty in maintaining sleep was the most common sleep complaint (42.4%) and physical tiredness/fatigue was the greatest consequence of disturbed sleep (51.1%). Those with pain, palpitations or respiratory nocturnal sleep-disturbing symptoms were characterised by shorter sleep duration, emotional distress, cognitive dysfunction, tiredness and reduced quality of life. Greater difficulties initiating sleep and worse health related quality of life were revealed in females compared with aged-matched males.

CONCLUSION

Fragmented sleep is a problem partly because of psycho-physiological symptoms 1 year after PTCA, with reduced resilience to stress, increasing vulnerability or diminished coping ability and poorer quality of life.

Quality of life 12 months after coronary artery bypass graft surgery

OBJECTIVE

The primary purpose of this study was to assess the relationship between preoperative risk factors, postoperative chronic pain, sleep, and gender on perceptions of quality of life (QoL) in a sample of 123 coronary artery bypass graft (CABG) surgery patients 12 months after surgery. A secondary purpose was to determine whether there is concordance between spousal and patient reporting of QoL after CABG surgery.

DESIGN

A cross-sectional comparative study.

SETTING

The study setting included patients living in the community, who had had CABG surgery 12 months earlier at The Alfred hospital, a major metropolitan public acute care center, in Melbourne, Australia.

PARTICIPANTS

Study participants were 123 adult patients (mean age = 64 years) who had undergone CABG surgery and had participated in a recent clinical trial. These patients were followed up to 12 months. The patient's spouse or next of kin (NoK) was asked questions about their perception of change in the patient's QoL.

INSTRUMENTS

Results were assessed using The Medical Outcome Study Short Form-36 (SF-36) questionnaire and additional questions given at 12 months after CABG surgery. The Cleveland Clinic Clinical Severity Score (CSS) was used preoperatively as a tool to predict QoL outcome.

RESULTS

Significant improvements in QoL, as measured by the SF-36, were seen in physical functioning (P <.0001), bodily pain (P =.024), social functioning (P =.011), and role limitations resulting from emotional status (P =.003). Other significant associations (P =.002) were found between poor QoL and patients who reported severe pain or poor quality sleep. Low-risk patients, as identified by the preoperative CSS, were more likely to have improved QoL at 12 months. Alteration in QoL was reported equally by patients and their spouses or NoK. Short-term memory impairment was reported by 41% of spouses or NoK.

CONCLUSIONS

CABG surgery results in improved QoL for the majority of patients with extensive coronary artery disease. Nevertheless, some patients continue to have severe pain, sleep disturbances, and altered relationship with their spouse or NoK 12 months after surgery.

Respondent-generated quality of life measures: useful tools for nursing or more fool's gold?

Within health services research the quest for better ways of measuring quality of life as an outcome variable continues apace. Recent developments in this area have seen increasing attempts to incorporate individually generated content and values into quality of life measures while retaining valid psychometric measurement properties. Following a brief overview of current conceptual approaches to quality of life measurement, this paper reviews the development of two leading Respondent-generated instruments: the Schedule for the Evaluation of Individual Quality of Life (SEIQoL) and the Patient Generated Index (PGI). The relative strengths and weaknesses of these tools and their potential applications for nursing and nursing research are appraised. These measures both address and manifest a number of fundamental conceptual and methodological problems, and represent an innovative attempt to square the quantitative--qualitative circle. As such they offer challenging opportunities for nursing at a number of levels. Their elicitation and quantification of individual components of quality of life offer opportunities for nurses to plan care and goal set with patients. As yet, however, the validity, reliability, responsiveness and practicality of these instruments as outcome measures are debatable and require further testing. Nurse researchers could contribute to this process by using Respondent-generated measures as an adjunct to existing, established tools in outcome studies. Moreover, nursing is well placed to investigate and debate the validity of the conceptual assumptions underpinning these new instruments.

Creating a healing environment for elders

The number of elderly, both in society at large and in the critical care population, is increasing at an unprecedented rate. Critical care nurses must address how best to provide care to these elders. The authors focus on physiologic, cognitive, and psychosocial characteristics of the elderly that place them at risk for complications during their stay in critical care. The critical care environment also contributes to complications such as sleep deprivation, sensory deprivation or overload, painful procedures, and decreased social support. The critical care environment may also be a factor in facilitating delirium, common in critically ill elders. Critical care nurses can proactively help to create a healing environment for these elders by facilitating sleep, implementing strategies to reduce delirium, preventing or minimizing painful experiences, and liberalizing family visitations.