Noise control: a nursing team's approach to sleep promotion

Intraoperative dexmedetomidine on postoperative sleep disturbance in older patients undergoing major abdominal surgery: A randomized controlled trial protocol

Background

Postoperative sleep disturbance (PSD) occurs frequently in patients who undergo major abdominal surgical procedures. Dexmedetomidine is a promising agent to improve the quality of sleep for surgical patients. We designed this trial to investigate the effects of two different doses of intraoperative dexmedetomidine on the occurrence of PSD in elderly patients who have major abdominal surgery.

Methods

In this randomized, double-blind, controlled trial, 210 elderly patients aged ≥65 years will be randomized, with an allocation ratio of 1:1:1, to two dexmedetomidine groups (intraoperative infusion of 0.3 or 0.6 μg/kg/h) and a normal saline placebo group. The primary endpoint is the occurrence of PSD on the first night after surgery, assessed using the Athens Insomnia Scale. The secondary endpoints are (1) the incidence of PSD during the 2nd, 3rd, 5th, 7th, and 30th nights postoperatively; (2) pain at rest and on movement at 24 and 48 h postoperatively, assessed using the Numerical Rating Scale; (3) the incidence of postoperative delirium during 0-7 days postoperatively or until hospital discharge, assessed using the 3-min Confusion Assessment Method; (4) depressive symptoms during 0-7 days postoperatively or until hospital discharge, assessed using the 15-items Geriatric Depression Scale; and (5) quality of recovery on postoperative days 1, 2, and 3, assessed using the 15-items Quality of Recovery Scale. Patients' sleep data will also be collected by Xiaomi Mi Band 7 for further analysis.

Discussion

The findings of this trial will provide clinical evidence for improving the quality of sleep among elderly patients undergoing major abdominal surgery.

Ethics and dissemination

This trial was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (No. 2023-160). The results will be published in a peer-reviewed journal.

Trial registration

Chinese Clinical Trial Registry (ChiCTR2300073163).

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Insomnia Symptoms and Environmental Disruptors: A Preliminary Evaluation of Veterans in a Subacute Rehabilitation

OBJECTIVES

Evaluate insomnia symptoms and environmental disruptors at admission and discharge in a subacute rehabilitation care setting.

METHODS

Veterans (age ≥50) admitted to a Veterans Health Administration (VA) Hospital subacute rehabilitation between March and August 2022 completed baseline (N = 46) and follow up (N = 33) assessments with the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), Epworth Sleepiness Scale (ESS), and an assessment of environmental sleep disruptors. Veterans were offered sleep resources after admission evaluations and outpatient referrals after discharge evaluations. Pearson correlation determined associations between length of stay (LOS), ISI, SNQ, and ESS scores at admission and discharge; chi-square and Wilcoxon Signed Rank Tests compared insomnia at admission and discharge.

RESULTS

One-half of participants reported clinically meaningful insomnia symptoms and sleep needs at baseline with no significant change at discharge. Almost all (89.1%) Veterans reported sleep was disturbed by environmental factors, primarily staff awakenings. LOS was correlated with ESS scores at discharge (r = .52, p = .002).

CONCLUSIONS

Environmental sleep disruption was common during a subacute rehabilitation admission and were not adequately addressed through sleep resources and treatment due to low uptake.

CLINICAL IMPLICATIONS

Providers should assess sleep at admission and lessen environmental sleep disruptors by reducing noise, light, and non-essential awakenings at night.

Noise exposure among staff in intensive care units and the effects of unit-based noise management: a monocentric prospective longitudinal study

BACKGROUND

Intensive care units (ICUs) are often too noisy, exceeding 70-80 dBA, which can have negative effects on staff. The corresponding recommendation of the World Health Organization (average sound pressure level below 35 dBA) is often not achieved. To date there is a lack of intervention studies examining the extent to which unit-based noise management in ICUs contributes to a reduction in noise exposure for the staff. The study therefore aims to provide answers to 1) how unit-based noise management sustainably reduces the subjective noise exposure among staff, and 2) how this intervention affects other noise-related topics.

METHODS

We performed a monocentric prospective longitudinal study with three measurement points in a German university hospital in three ICUs. We collected data from different healthcare professionals and other professional groups between October 2021 and August 2022 using an online questionnaire. Data were analyzed using descriptive and inference statistics.

RESULTS

A total of n = 179 participants took part in the surveys. The majority of participants were nurses or pediatric nurses. Most participants worked more than 75% full-time equivalent. Staff on the three ICUs reported high levels of noise exposure. No significant changes in noise exposure over time were observed. Participants were already aware of the topic and believed that a behavior change could positively influence the noise environment.

CONCLUSIONS

This study provides an initial insight into how a unit-based noise management could contribute to a reduction in the subjective noise exposure among staff in ICUs. The results of this study highlight the importance of this topic. Future studies should aim to research aspects of adherence and their facilitators or barriers, which promote the sustained implementation of noise-reducing measures by staff.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00025835; Date of registration: 12.08.2021.

Sleep promotion for hospitalised children: Developing an evidence-based guideline for nurses

BACKGROUND

Adequate sleep in hospitalised children is important for a variety of physiological and psychological processes associated with growth, development, and recovery from illness and injury. Hospitalisation often prioritises clinical care activities at the expense of age-appropriate sleep. Nurses and the wider healthcare team contribute to this paradox. However, through conscious practice and partnering with mothers, nurses are able to enact change and promote sleep.

OBJECTIVES

To adopt, adapt or contextualise existing guidelines to develop an evidence-based practice guideline to promote sleep-friendly ward environments and routines facilitated by nurses, and in partnership with mothers.

METHOD

A six-step methodology for guideline adaptation was followed, as recommended by the South African Guidelines Excellence project: (1) existing guidelines and protocols were identified and (2) appraised using the AGREE II instrument; (3) an evidence base was developed; (4) recommendations were modified, (5) assigned levels of evidence and grades of recommendation; and (6) end user guidance was developed. Expert consultation was sought throughout.

RESULTS

Existing relevant guidance comprised 61 adult-centric recommendations. Modification of the evidence base led to six composited recommendations that facilitate sleep in hospitalised children: (1) prioritising patient safety; (2) collaborating with the mother or caregiver to promote sleep; (3) coordinating ward routine and (4) environment to improve sleep; (5) work with clinical and non-clinical staff; and (6) performing basic sleep assessments. Practice recommendations were aligned to the South African regulatory framework for nursing.

CONCLUSION

Hospitalisation is a time of physiological and psychological dysregulation for children, which is amplified by poor sleep in a hospital. Nurses have the opportunity to promote sleep during hospitalisation by implementing this African-centric guideline in partnership with mothers.

Reducing Delirium in Hospitalized Adults Through a Structured Sleep Promotion Program

BACKGROUND

Delirium affects approximately 1 in 4 patients during their hospitalization and is associated with numerous complications. Sleep deprivation is a significant risk factor for developing delirium and is a patient dissatisfier.

PROBLEM

An internal assessment revealed that up to 25% of all patients on medical-surgical units had a diagnosis of delirium while in the hospital.

APPROACH

An evidence-based practice project was implemented to reduce the development of delirium through sleep promotion on 2 inpatient units. A dedicated time was selected, and key strategies were identified to promote sleep with minimal interruptions.

OUTCOMES

Delirium decreased by 33% and 45% on the 2 units over 1 year. Overall, patient satisfaction for quietness at night survey responses also increased (P = .0005; CI, 0.05 to 0.67) with ongoing sustainment.

CONCLUSIONS

Implementation of a dedicated period to sleep was associated with a reduction in delirium and increased patient satisfaction for quietness at night.

Conducive environments reduce sleep disturbances and improve sleep quality: a quality improvement project

AIM

The current implementation project aimed to improve patients' sleep quality in a hospital by implementing targeted interventions to reduce sleep disturbances.

METHODS

The Silent Night project was implemented in two general units of an academic tertiary hospital. The project comprised three phases: preimplementation, implementation, and postimplementation. Patient surveys were administered to obtain patients' perspectives on the sources of noise disturbances at night. Noise-monitoring machines were installed in two wards to obtain objective data on noise levels at night. Concurrently, data were collected on noise-generating activities that were observed.

RESULTS

The overall quality of sleep reported by patients improved by 17% (from 73.5 to 88.9%). Patients' survey reported reduced noise disturbances from direct care activities, environmental noise and medical equipment alarms. The mean noise level in the orthopedics unit reduced significantly from 57.04 to 55.22 dB with a corresponding decrease in noise generating activities by 60% (from 362 to 144). In the geriatric unit, the mean noise level increased from 51.36 to 53.12 dB but is within the National Environmental Agency's permissible noise level of 55 dB even though the noise generating activities reduced significantly by 92.2% (from 954 to 74).

CONCLUSION

The 'Silent Night' project has successfully reduced noise disturbances generating from environment and nursing care activities and improved patients' sleep quality in the hospital. Sharing sessions regarding sources of noise and the 'Silent Night' poster promoted the awareness of noise disturbances in healthcare professionals, visitors, and patients.

Deep Sleep and Beeps: Sleep Quality Improvement Project in General Surgery Patients

BACKGROUND

Poor sleep leads to poor health outcomes. Inpatient sleep disturbance has been studied primarily in the ICU. Minimal research exists on sleep in surgical populations.

METHODS

We recruited patients undergoing elective, inpatient general surgery procedures. Participants wore Fitbit trackers while inpatient to measure total sleep time (CDC recommendation is 7 or more hours per night). At discharge, patients completed the Richards-Campbell Sleep Questionnaire (RCSQ) to measure inpatient sleep quality. The RCSQ combines 5 domains into a cumulative score (0 to 100); a higher score means better sleep quality. Patients also completed the outpatient Pittsburgh Sleep Quality Index preoperatively and postoperatively. The primary end point was percentage of patients with total sleep score ≥ 50. Secondary outcomes included mean RCSQ domain scores, Fitbit total sleep time, and percentage with Pittsburgh Sleep Quality Index Score indicating poor sleep.

RESULTS

We included 64 patients (mean ± SD age 55.0 ± 14.1 years). Mean ± SD RCSQ total sleep score was 49 ± 20.5 and 53.1% with total sleep score < 50. Mean ± SD RCSQ domain scores were Awakenings: 40.4 ± 22.8, Sleep Quality: 49.1 ± 27.9, Sleep Latency: 49.2 ± 25.3, Sleep Depth: 50.2 ± 26.5, Returning to Sleep: 55.9 ± 28.1, and Noise Disturbance: 59.1 ± 27.9. On night one, 25 devices (40%) had recorded sleep data due to enough sleep. Mean ± SD total sleep time on night 1 was 4.7 ± 2.8 hours. Mean total sleep time for nights 2, 3, and 4 remained fewer than 7 hours. Percentages for each night that achieved the CDC goal of 7 or more hours were as follows: night one 10.9%, night two 32.8%, night three 35.3%, and night four 27.6%. Per the Pittsburgh Sleep Quality Index, 88.1% of patients were poor sleepers preoperatively and 84.5% were poor sleepers at follow-up (p = 0.6).

CONCLUSIONS

Elective general surgery patients experience a severe inpatient sleep disturbance, worse than in similarly studied ICU cohorts. This disturbance is driven primarily by nighttime awakenings.

Development and Validation of Nomogram Prediction Model for Postoperative Sleep Disturbance in Patients Undergoing Non-Cardiac Surgery: A Prospective Cohort Study

PURPOSE

To develop a risk prediction nomogram of postoperative sleep disturbance (PSD) in patients undergoing non-cardiac surgery.

PATIENTS AND METHODS

Data on 881 consecutive patients who underwent non-cardiac surgery at the Affiliated Hospital of Xuzhou Medical University between June 2020 and April 2021 were prospectively collected. Of these, we randomly divided 881 non-cardiac patients into two groups, training cohort (n = 617) and validation cohort (n = 264) at the ratio of 7:3. Characteristic variables were selected based on the data of training cohort through least absolute shrinkage and selection operator (LASSO) regression. Multivariate logistic regression was used to identify the independent risk factors associated with PSD that then were incorporated into the nomogram. The predictive performance of the nomogram was measured by concordance index (C index), receiver operating characteristic (ROC) curve, and calibration with 1000 bootstrap samples to decrease the over-fit bias.

RESULTS

PSD was found in 443 of 617 patients (71.8%) and 190 of 264 patients (72.0%) in the training and validation cohorts, respectively. The perioperative risk factors associated with PSD were female sex, anxiety, dissatisfaction of ward environment, absence of combined regional nerve block, postoperative nausea and vomiting (PONV), the longer duration stayed in post anesthesia care unit (PACU), the higher dose of midazolam and sufentanil, the higher postoperative numeric rating score for pain (NRS) score. Incorporating these 9 factors, the nomogram achieved good concordance indexes of 0.82 (95% confidence interval [CI], 0.78-0.85) and 0.80 (95% CI, 0.74-0.85) in predicting PSD in the training and validation cohorts, respectively, and obtained well-fitted calibration curves. The sensitivity and specificity (95% CIs) of the nomogram were calculated, resulting in sensitivity of 74.0% (70.0-78.2%) and 75.3% (68.4-81.7%) and specificity of 79.3% (72.5-85.2%) and 70.3% (58.4-80.7%) for the training and validation cohorts, respectively. Patients who had a nomogram score of less than 262 or 262 or greater were considered to have low or high risks of PSD presence, respectively.

CONCLUSION

The proposed nomogram achieved an optimal prediction of PSD in patients undergoing non-cardiac surgery. The risks for an individual patient to harbor PSD can be determined by this model, which can lead to a reasonable preventive and treatment measures.

A quality improvement project to improve pediatric medical provider sleep and communication during night shifts

QUALITY PROBLEM OR ISSUE

Night-shift medical providers frequently experience limited sleep resulting in fatigue, often because of paging activity. Streamlined medical-specific communication interventions are known to improve sleep and communication among these providers.

INITIAL ASSESSMENT

We found that non-urgent paging communication occurred frequently during night-shifts, leading to provider sleep disturbances within our institution. We tested a quality improvement (QI) intervention to improve paging practices and determined its effect on provider sleep.

CHOICE OF SOLUTION

We used a Plan-Do-Study-Act QI model aimed at improving clinician sleep and paging communications.

IMPLEMENTATION

We initially conducted focus groups of nurses and physician trainees to inform the creation of a standardized paging intervention. We collected actigraphy and sleep log data from physicians, nurse practitioners, and physician trainees and performed electronic collection of paging frequency data.

EVALUATION

Data were collected between December 2015 and March 2017 from pediatric residents, pediatric hematology/oncology (PHO) fellows, hospitalist medicine nocturnists and nurses working during night-shift hours in PHO inpatient units. We collected baseline data before implementation of the QI intervention and at 1 month post-implementation. Although objective measures and provider reports demonstrated improved medical-specific communication paging practices, provider sleep was not affected.

LESSONS LEARNED

Provider-based standardization of paging communication was associated with improved medical-specific communication between nurses and providers; however, provider sleep was not affected. The strategies used in this intervention may be transferable to other clinics and institutions to streamline medical-specific communication.

Noise Levels in an Acute Psychiatric Unit: An Exploratory Observational Study

Background: Noise is an important aspect of the ward atmosphere climate - the combination of the architectural solutions, organizational features, the psychological traits of the operators and their interactions, and the patients' characteristics. Despite its importance noise levels have been less analyzed than other aspects of the ward atmosphere climate. Aim: In this study the aim is to identify the sources of noise and the sound pressure level in an acute psychiatric ward, and secondly to ascertain whether this is perceived by inpatients as disturbing. Method: The sound pressure levels were measured during three nonconsecutive mornings, three afternoons, and three nights. A questionnaire was administered to ascertain patients' opinions about the noise in the ward. Results: The average noise level in the ward was 62.5 dB(A)eq in the morning, 55.8 in the afternoon, and 51.5 at night. A total of 23 patients took part in the study: 65.2% of this sample did not perceive the noise in the ward as disturbing. Conclusion: In a psychiatric ward, the main source of noise is the verbal communication, and acoustic pressure also derived from care activities based around relationships. Other sources of noise perceived as disturbing came from the opening and closing of doors and the entry doorbell. Adopting relational and architectural-structural measures could reduce the sound pressure, with a view to further improving the ambience in the ward.

Environmental Noise around Hospital Areas: A Case Study

Due to the particular characteristics of hospitals, these buildings are highly sensitive to environmental noise. However, they are usually located close or within urban agglomerations. Hence, hospitals are, in many cases, exposed to high levels of environmental noise. A study of one of the main hospitals in the Extremadura region (Spain) is presented here to allow a global assessment of the acoustic impact of outdoor sound sources. Both long- and short-term measurements were carried out, and a software model was developed. The measured values exceed the World Health Organisation reference value of 50 dBA for daytime and evening, and are even higher than the 55 dBA limit at which severe annoyance is generated. Taking into account the results obtained, the noise impact on this hospital is primarily influenced by three sound sources: road traffic, cooling towers of the hospital and the emergency helicopter. Their relative importance depends on the facade under consideration. It can therefore be concluded that the overall situation of the hospital needs to be improved. Thus, a series of solutions are proposed for a possible action plan based on interventions regarding the main sound sources and the location of the most sensitive areas to environmental noise.

Incorporating Nurse Input and Evidence Into a Newly Designed Unit to Improve Patient and Nursing Outcomes

OBJECTIVE

The aim of this study was to identify processes, outcomes, and lessons learned from designing a new evidence-based unit. A research study was conducted simultaneously to rigorously measure changes in patient and staff outcomes.

BACKGROUND

Nursing leadership and frontline nursing engagement are critical in evidence-based design to promote positive outcomes and workflow.

METHODS

Quality indicators were tracked premove and postmove. Nursing workflow was tracked, and teamwork was examined.

RESULTS

The incidence of falls and methicillin-resistant Staphylococcus aureus decreased on the new unit. Patient satisfaction improved; the greatest improvement was noise reduction. Teamwork remained stable. Nurses spent significantly more time in the patient rooms on the new unit.

CONCLUSIONS

This hospital found nursing engagement in the unit design process to be imperative to promote positive patient outcomes and stable or improved teamwork. Nursing leaders should be involved at the onset of the design process to facilitate optimal outcomes.

Sleep as an Occupational Need

In the same way the human body requires food, hydration, and oxygen, it also requires sleep. Even among healthy people, the amount and quality of sleep substantially influence health and quality of life because sleep helps regulate physiological functioning. Given the impact of sleep on participation, the American Occupational Therapy Association reclassified sleep from an activity of daily living to an occupational domain. Poor sleep is a frequent medical complaint, especially among populations with neurological impairment. Occupational therapy practitioners should consider routinely screening for factors affecting their clients’ sleep. By addressing such factors, as well as related routines and habits, practitioners can enhance the effectiveness of rehabilitation, promote health and well-being, and increase engagement and life quality. Practitioners should acknowledge the importance of sleep in practice, and the study of sleep should be prioritized by researchers in the field to meet client needs and establish evidence for interventions.

Noise pollution in the hospital environment of a developing country: A case study of Lahore (Pakistan)

The present study investigates the noise pollution levels in public- and private-sector hospitals of Lahore. The noise pollution parameters were investigated from 20 public and 10 private hospitals. We observed that the equivalent continuous sound level (Leq) values varied significantly in different departments of the hospitals as well as at different times of the day. The public-sector hospitals had significantly higher noise pollution compared to the private-sector hospitals. The Wilcoxon Mann-Whitney two-sample rank-sum test revealed significant difference between noise levels in intensive care unit (ICU) during morning and in emergency, waiting area, intensive care unit (ICU), and reception during daytimes. However, no significant differences were found for any department during the evening. The Leq values were found to be higher than the international norms (WHO standards) for all hospitals, higher than USEPA for 29 hospitals and higher than local standards for 27 hospitals. Overall, significantly lower sound levels were always observed in private hospitals.

Factors Affecting Acoustics and Speech Intelligibility in the Operating Room: Size Matters

Supplemental Digital Content is available in the text.

INTRODUCTION:

Noise in health care settings has increased since 1960 and represents a significant source of dissatisfaction among staff and patients and risk to patient safety. Operating rooms (ORs) in which effective communication is crucial are particularly noisy. Speech intelligibility is impacted by noise, room architecture, and acoustics. For example, sound reverberation time (RT₆₀) increases with room size, which can negatively impact intelligibility, while room objects are hypothesized to have the opposite effect. We explored these relationships by investigating room construction and acoustics of the surgical suites at our institution.

METHODS:

We studied our ORs during times of nonuse. Room dimensions were measured to calculate room volumes (V_R). Room content was assessed by estimating size and assigning items into 5 volume categories to arrive at an adjusted room content volume (V_C) metric. Psychoacoustic analyses were performed by playing sweep tones from a speaker and recording the impulse responses (ie, resulting sound fields) from 3 locations in each room. The recordings were used to calculate 6 psychoacoustic indices of intelligibility. Multiple linear regression was performed using V_R and V_C as predictor variables and each intelligibility index as an outcome variable.

RESULTS:

A total of 40 ORs were studied. The surgical suites were characterized by a large degree of construction and surface finish heterogeneity and varied in size from 71.2 to 196.4 m³ (average V_R = 131.1 [34.2] m³). An insignificant correlation was observed between V_R and V_C (Pearson correlation = 0.223, P = .166). Multiple linear regression model fits and β coefficients for V_R were highly significant for each of the intelligibility indices and were best for RT₆₀ (R² = 0.666, F(2, 37) = 39.9, P < .0001). For D_max (maximum distance where there is <15% loss of consonant articulation), both V_R and V_C β coefficients were significant. For RT₆₀ and D_max, after controlling for V_C, partial correlations were 0.825 (P < .0001) and 0.718 (P < .0001), respectively, while after controlling for V_R, partial correlations were −0.322 (P = .169) and 0.381 (P < .05), respectively.

CONCLUSIONS:

Our results suggest that the size and contents of an OR can predict a range of psychoacoustic indices of speech intelligibility. Specifically, increasing OR size correlated with worse speech intelligibility, while increasing amounts of OR contents correlated with improved speech intelligibility. This study provides valuable descriptive data and a predictive method for identifying existing ORs that may benefit from acoustic modifiers (eg, sound absorption panels). Additionally, it suggests that room dimensions and projected clinical use should be considered during the design phase of OR suites to optimize acoustic performance.

New predictors of sleep efficiency

Sleep efficiency is a commonly and widely used measure to objectively evaluate sleep quality. Monitoring sleep efficiency can provide significant information about health conditions. As an attempt to facilitate less cumbersome monitoring of sleep efficiency, our study aimed to suggest new predictors of sleep efficiency that enable reliable and unconstrained estimation of sleep efficiency during awake resting period. We hypothesized that the autonomic nervous system activity observed before falling asleep might be associated with sleep efficiency. To assess autonomic activity, heart rate variability and breathing parameters were analyzed for 5 min. Using the extracted parameters as explanatory variables, stepwise multiple linear regression analyses and k-fold cross-validation tests were performed with 240 electrocardiographic and thoracic volume change signal recordings to develop the sleep efficiency prediction model. The developed model's sleep efficiency predictability was evaluated using 60 piezoelectric sensor signal recordings. The regression model, established using the ratio of the power of the low- and high-frequency bands of the heart rate variability signal and the average peak inspiratory flow value, provided an absolute error (mean ± SD) of 2.18% ± 1.61% and a Pearson's correlation coefficient of 0.94 (p < 0.01) between the sleep efficiency predictive values and the reference values. Our study is the first to achieve reliable and unconstrained prediction of sleep efficiency without overnight recording. This method has the potential to be utilized for home-based, long-term monitoring of sleep efficiency and to support reasonable decision-making regarding the execution of sleep efficiency improvement strategies.

Assessment of noise pollution in and around a sensitive zone in North India and its non-auditory impacts

Noise pollution in hospitals is recognized as a serious health hazard. Considering this, the current study aimed to map the noise pollution levels and to explore the self reported non-auditory effects of noise in a tertiary medical institute. The study was conducted in an 1800-bedded tertiary hospital where 27 sites (outdoor, indoor, road side and residential areas) were monitored for exposure to noise using Sound Level Meter for 24h. A detailed noise survey was also conducted around the sampling sites using a structured questionnaire to understand the opinion of the public regarding the impact of noise on their daily lives. The equivalent sound pressure level (Leq) was found higher than the permissible limits at all the sites both during daytime and night. The maximum equivalent sound pressure level (Lmax) during the day was observed higher (>80dB) at the emergency and around the main entrance of the hospital campus. Almost all the respondents (97%) regarded traffic as the major source of noise. About three-fourths (74%) reported irritation with loud noise whereas 40% of respondents reported headache due to noise. Less than one-third of respondents (29%) reported loss of sleep due to noise and 8% reported hypertension, which could be related to the disturbance caused due to noise. Noise levels in and around the hospital was well above the permissible standards. The recent Global Burden of Disease highlights the increasing risk of non communicable diseases. The non-auditory effects studied in the current work add to the risk factors associated with non communicable diseases. Hence, there is need to address the issue of noise pollution and associated health risks specially for vulnerable population.

Geographical thinking in nursing inquiry, part two: performance, possibility, and non-representational theory

Part one in this two paper series reviewed the nature of geographical thinking in nursing research thus far. The current paper builds on it by looking forwards and providing a particular vision for future research. It argues that it is time to once again look to the parent discipline of human geography for inspiration, specifically to its turn towards non-representational theory, involving an emphasis on life that onflows prior to meaning, significance, and full cognition; on life's 'taking-place'. The paper introduces this way of viewing and animating the world. Some potential connections to nursing research and practice are suggested, as are some specific avenues for future inquiry. Explained is how, through non-representational theory, nursing might be re-imagined as something that reveals space-time.

Examining the evidence to guide practice: challenging practice habits

Nurses are the largest segment of the nation's health care workforce, which makes nurses vital to the translation of evidence-based practice as a practice norm. Critical care nurses are in a position to critically appraise and apply best evidence in daily practice to improve patients' outcomes. It is important for critical care nurses to continually evaluate their current practice to ensure that they are applying the current best evidence rather than practicing on the basis of tradition. This article is based on a presentation at the 2013 National Teaching Institute of the American Association of Critical-Care Nurses. Four practice interventions that are within the realm of nursing are critiqued on the basis of current best evidence: (1) turning critically ill patients, (2) sleep promotion in the intensive care unit, (3) feeding tube management in infants and children, and (4) prevention of venothromboembolism…again. The related beliefs, current evidence, and implications for practice associated with each topic are described.

The role of noise in clinical environments with particular reference to mental health care: A narrative review

BACKGROUND

There is a large literature suggesting that noise can be detrimental to health and numerous policy documents have promoted noise abatement in clinical settings.

OBJECTIVES

This paper documents the role of noise in clinical environments and its deleterious effects with a particular focus on mental health care. Our intention however, is to go beyond the notion that noise is simply undesirable and examine the extent to which researchers have explored the meaning of sound in hospital settings and identify new opportunities for research and practice.

DATA SOURCES AND REVIEW METHODS

This is a narrative review which has grouped the literature and issues in the field into themes concerning the general issues of noise in health care; sleep noise and hospital environments; noise in intensive care units; implications for service users and staff; and suggestions for new ways of conceptualising and researching clinical soundscapes. Data sources comprised relevant UK policy documents and the results of a literature search of Pubmed, Scopus and Web of Knowledge using terms such as noise, health, hospital, soundscape and relevant additional terms derived from the papers retrieved. In addition the references of retrieved articles were scanned for additional relevant material and historical items significant in shaping the field.

RESULTS

Excess unwanted noise can clearly be detrimental to health and impede recovery, and this is clearly recognised by policymakers especially in the UK context. We use the literature surveyed to argue that it is important also to see the noise in clinical environments in terms of the meaning it conveys and rather than merely containing unwanted sound, clinical environments have a 'soundscape'. This comprises noises which convey meaning, for example about the activities of other people, the rhythms of the day and the nature of the auditory community of the hospital. Unwanted sound may have unwanted effects, especially on those who are most vulnerable, yet this does not necessarily mean that silence is the better option. Therefore it is our contention that it is important to begin thinking about the social functions of sound in the mental health environment.

CONCLUSIONS

Whilst it can be stressful, sound can also be soothing, reassuring and a rich source of information about the environment as well. It may be used to secure a degree of privacy for oneself, to exclude others or as a source of solidarity among friends and colleagues. The challenge then is to understand the work that sound does in its ecological context in health care settings.

Room for improvement: noise on a maternity ward

BACKGROUND

For mothers who have just given birth, the postpartum hospital stay is meant to promote an environment where resting, healing and bonding can take place. New mothers, however, face many interruptions throughout the day including multiple visitors and noise caused by medical equipment, corridor conversations and intercom announcements. This paper argues that disruptions and noise on a maternity ward are detrimental to the healing process for new mothers and their newborns and healthcare decision-makers need to act to improve the environment for these patients. This paper also provides recommendations on how to reduce the noise levels, or at least control the noise on a maternity ward, through the implementation of a daily quiet time.

DISCUSSION

Hospital disruptions and its negative health effects in particular for new mothers and their children are illustrated in this paper. Hospital noise and interruptions act as a stressor for both new mothers and staff, and can lead to sleep deprivation and detrimental cardiovascular health effects. Sleep deprivation is associated with a number of negative mental and physical health consequences such as decreased immune function, vascular dysfunction and increased sympathetic cardiovascular modulation. Sleep deprivation can also increase the risk of postpartum mental health disorders in new mothers. Some efforts have been made to reduce the disruptions experienced by these patients within a hospital setting. For example, the introduction of a daily quiet time is one way of controlling noise levels and interruptions, however, these have mostly been implemented in intensive care units. Noise and disruptions are a significant problem during postpartum hospital stay. Healthcare institutions are responsible for patient-centered care; a quiet time intervention promises to contribute to a safe, healing environment in hospitals.

Sleep in the Intensive Care Unit

Patients in the intensive care unit (ICU) are susceptible to sleep deprivation. Disrupted sleep is associated with increased morbidity and mortality in the critically ill patients. The etiology of sleep disruption is multifactorial. The article reviews the literature on sleep in the ICU, the effects of sleep deprivation, and strategies to promote sleep in the ICU. Until the impact of disrupted sleep is better explained, it is appropriate to provide critically ill patients with consolidated, restorative sleep.

A five-senses perspective to quality in hospitals

Purpose

– The purpose of this paper is to report on research on the sensory perceptions that patients and bystanders experience during hospitalisation. Sight, hearing, smell, taste and touch influence both clinical outcomes and satisfaction. The paper offers suggestions to hospital management on ways to improve receivers’ sensory perceptions.

Design/methodology/approach

– Considering services as social interactions, a subjectivist view of reality is adopted and, accordingly, a qualitative research approach implemented. Data are collected through participant observation. Desk activity includes reasoned literature review, categorisation and model adaptation.

Findings

– A simplified system model for service provision in the hospital ward is proposed. A management tool is provided in the form of a check list that the ward management can employ to assess its service-provision system from a five-senses perspective.

Research limitations/implications

– The paper is affected by judgements subject to cultural biases. The validity of the management tool is still to be tested.

Practical implications

– Once up and running, the model and the check list will be able to guide health managers towards improvements of satisfaction, clinical outcomes and working environment.

Originality/value

– The paper represents an original effort to adapt tools already used in the commercial field to influence health service receivers’ perceptions positively. While the positive results of improvements to a single sensory perception have been well documented, an integrated approach has not been put forward previously in the health industry.

Alarm setting for the critically ill patient: a descriptive pilot survey of nurses' perceptions of current practice in an Australian Regional Critical Care Unit

AIM

The aim of this survey was to assess registered nurse's perceptions of alarm setting and management in an Australian Regional Critical Care Unit.

BACKGROUND

The setting and management of alarms within the critical care environment is one of the key responsibilities of the nurse in this area. However, with up to 99% of alarms potentially being false-positives it is easy for the nurse to become desensitised or fatigued by incessant alarms; in some cases up to 400 per patient per day. Inadvertently ignoring, silencing or disabling alarms can have deleterious implications for the patient and nurse.

METHOD

A total population sample of 48 nursing staff from a 13 bedded ICU/HDU/CCU within regional Australia were asked to participate. A 10 item open-ended and multiple choice questionnaire was distributed to determine their perceptions and attitudes of alarm setting and management within this clinical area.

RESULTS

Two key themes were identified from the open-ended questions: attitudes towards inappropriate alarm settings and annoyance at delayed responses to alarms. A significant number of respondents (93%) agreed that alarm fatigue can result in alarm desensitisation and the disabling of alarms, whilst 81% suggested the key factors are those associated with false-positive alarms and inappropriately set alarms.

CONCLUSION

This study contributes to what is known about alarm fatigue, setting and management within a critical care environment. In addition it gives an insight as to what nurses' within a regional context consider the key factors which contribute to alarm fatigue. Clearly nursing burnout and potential patient harm are important considerations for practice especially when confronted with alarm fatigue and desensitisation. Therefore, promoting and maintaining an environment of ongoing intra-professional communication and alarm surveillance are crucial in alleviating these potential problems.

Analysis of the soundscape in an intensive care unit based on the annotation of an audio recording

The acoustic environments in hospitals, particularly in intensive care units (ICUs), are characterized by frequent high-level sound events which may negatively affect patient outcome. Many studies performed acoustic surveys, but the measurement protocol was not always reported in detail, and the scope of analysis was limited by the selected mode of sound level meters. Fewer studies systematically investigated the noise sources in ICUs by employing an observer in the patient room, which may potentially bias the measurement. In the current study, the soundscape of an ICU was evaluated where acoustic parameters were extracted from a ∼67-h audio recording, and a selected 24-h recording was annotated off-line for a source-specific analysis. The results showed that the patient-involved noise accounted for 31% of the acoustic energy and 11% of the predicted loudness peaks (PLPs). Excluding the patient-involved noise, the remaining acoustic energy was attributed to staff members (57%), alarms (30%), and the operational noise of life-supporting devices (13%). Furthermore, the contribution of each noise category to the PLPs was found to be more uneven: Staff (92%), alarms (6%), and device noise (2%). The current study suggests that most of the noise sources in ICUs may be associated with modifiable human factors.

Patients’ experiences of sleep in hospital: a qualitative interview study

Many patients experience sleep disturbances and a reduced quality of sleep while hospitalised. Studies have shown that a person with a disease and/or a bodily injury has an increased need for sleep. Patients' experiences of sleep should govern how sleep disturbances should be managed. It is thus necessary to focus upon and describe patients’ needs and experiences. The aim of this study was to explore and describe patients’ experiences of sleeping in hospital. This study is based on qualitative semi-structured interviews with 10 consecutively included patients. The interviews were conducted between October 2010 and March 2011 and were audio recorded and transcribed verbatim. Collected data were analysed by qualitative content analysis. The participants reported physical and psychological experiences that had affected their sleep. Their experiences were categorised using four themes: bedside manner, physical factors, being involved and integrity. Patients considered that experiencing some degree of control, feeling involved and preserving one’s integrity affect sleep during hospitalisation. Several factors have an impact on patients’ sleep. It is not only physical factors but also psychological factors such as bedside manner and having the opportunity to influence and be involved. The patients’ accounts provide a new perspective and open the door to changes in nursing care regarding patients’ sleep.

Effect of systematic relaxation techniques on anxiety and pain in older patients undergoing abdominal surgery

Inadequate pain control in older patients who have undergone abdominal surgery can lead to many complications. This study investigates the effect of systematic relaxation techniques on pain and anxiety in older patients undergoing abdominal surgery. One hundred twenty-four patients were randomly assigned into the experimental and control groups. The systematic relaxation techniques consisted of older patients in the experimental group slowly reading relaxing sentences during recovery in ambulation after the surgery. Patients' satisfaction with pain and anxiety relief was recorded, as was their use of opioid analgesia. Statistically significant differences in pain and anxiety, and in analgesic use, were reported between the patients in experimental and control groups after the intervention. These relaxation techniques can be incorporated into the care plan to reduce pain and anxiety after surgery as well as offering a measure for increasing the patients' independence in pain management control.

Sleep rounds: a multidisciplinary approach to optimize sleep quality and satisfaction in hospitalized patients

BACKGROUND

Poor sleep has adverse affects on heath, yet few studies have addressed the goal of improving sleep among hospitalized patients. We evaluated the effectiveness of a sleep-promoting intervention on the quality and quantity of sleep among inpatients.

METHODS

This study was conducted on a neurological ward in a large, tertiary care hospital. Sleep quality, quantity, and disruptors were assessed using questionnaires completed by patients during their hospital stay and Press Ganey surveys completed retrospectively. Room noise was also measured using noise meters. Data from each of 4 chronological phases of the study (baseline, basic intervention, "washout," and deluxe intervention) were analyzed. In the intervention phases, nurses conducted "Sleep Rounds" at bedtime, during which sleep-promoting practices were implemented, including lights out, television off, temperature adjustment, and a final restroom usage.

RESULTS

Patients reported 5 (interquartile range [IQR] 3) hours of sleep per night, awoke 3 (IQR 3) times nightly, and reported a median sleep latency of 11 to 15 minutes. Pain, staff interruptions, and roommates were the most significant barriers to good sleep. Noise levels were adequately low (35-40 dB) at night but were not positively impacted by our sleep-promoting interventions. Patients perceived noise on the unit to be worse during phases of the study in which there was no intervention.

CONCLUSIONS

Patient perception of sleep experience improved during the phases in which Sleep Rounds were implemented, despite the fact that there was no measurable improvement in sleep or sleep-disrupting factors.

Noise levels in a burn intensive care unit

INTRODUCTION

Increased noise levels in hospitals, critical care units, and peri-operative areas have been associated with higher levels of sleep deprivation and patient stress. The World Health Organization (WHO) guidelines stipulate a limit of 35 decibels (dB(A)) equivalent continuous sound level (LEq) during the day and 30 dB(A) LEq at night in patients' rooms. To date, no quantitative studies of noise levels have been performed in burn units. The objective of this study was to quantify noise levels in a burn critical care unit to ascertain compliance with guidelines in order to minimize this potential insult.

METHODS

An A-weighted sound pressure level meter was used to measure the ambient noise levels in a burn intensive care unit. Maximum and minimum sound pressure levels were measured at 30-min intervals on 10 days over a 1 month period. Measurements were obtained during shift changes and random times during the day and night-time. Descriptive statistical analyses were performed, to calculate means and standard deviations. Noise measurements at specified times were compared using analysis of variance (ANOVA).

RESULTS

Mean dB(A) LEq values for shift changes, day, and night-time were 65.9 ± 2.8, 65.7 ± 2.6, and 60.9 ± 5.2 dB(A), respectively. There was no significant difference in dB(A)(max) or dB(A)(min) between shift changes, day or night-time (p>0.05). However, night-time minimum values were consistently lower. There was no significant difference between sound pressure level (SPL) inside and outside patients' rooms (p>0.05) at any time.

CONCLUSIONS

Irrespective of time or location, the mean dB(A) LEq in the burn unit was significantly greater than World Health Organization (WHO), National Institute for Occupational Safety and Health (NIOSH), and the Environmental Protection Agency (EPA) recommendations. Guidelines for decreasing noise exposure are necessary to reduce potential negative effects on patients, visitors, and staff.

Poor self-reported sleep quality predicts mortality within one year of inpatient post-acute rehabilitation among older adults

STUDY OBJECTIVE

To evaluate the association between self-reported sleep quality among older adults during inpatient post-acute rehabilitation and one-year survival.

DESIGN

Prospective, observational cohort study.

SETTING

Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration).

PARTICIPANTS

Older patients (aged ≥ 65 years, n = 245) admitted for inpatient post-acute rehabilitation.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Within one year of post-acute rehabilitation, 57 participants (23%) were deceased. Cox proportional hazards models showed that worse Pittsburgh Sleep Quality Index (PSQI) total scores during the post-acute care stay were associated with increased mortality risk when controlling for amount of rehabilitation therapy received, comorbidities, and cognitive functioning (Hazard ratio [95% CI] = 1.11 [1.02-1.20]). Actigraphically estimated sleep was unrelated to mortality risk.

CONCLUSIONS

Poorer self-reported sleep quality, but not objectively estimated sleep parameters, during post-acute rehabilitation was associated with shorter survival among older adults. This suggests self-reported poor sleep may be an important and potentially modifiable risk factor for negative outcomes in these vulnerable older adults. Studies of interventions to improve sleep quality during inpatient rehabilitation should therefore be undertaken, and the long-term health benefits of improved sleep should be explored.

Promoting sleep by nursing interventions in health care settings: a systematic review

BACKGROUND

Sleep disturbances are common problems among individuals in hospitals and institutions. Although several studies have explored this phenomenon, there is still a lack of knowledge about the effectiveness of sleep-promoting nursing interventions. This systematic review aims to describe and evaluate the effectiveness of sleep-promoting nursing interventions in health care settings.

APPROACH

A systematic review was performed. In June 2009, a literature search was carried out in the following databases: Academic Search Elite, CINAHL, the Cochrane Library and MedLine/PubMed. Fifty-two references were identified and after critical appraisal, nine studies were selected. A compilation of the results and the outcomes of the interventions were carried out. Furthermore, the evidence strength of the interventions was assessed.

FINDINGS

Little evidence for the nursing interventions, sleep hygiene, music, natural sound and vision, stimulation of acupoints, relaxation, massage and aromatherapy is found. However, large effect size of interventions were found when using massage, acupuncture and music, natural sounds or music videos. The use of sleep hygiene and relaxation, on the other hand, produced only small effects.

CONCLUSION

The lack of high evidence strength for the nursing interventions together with the uncertainty about their effects calls for more research before implementing these interventions into clinical practice.

Benefits of quiet time for neuro-intensive care patients

The primary mission of any intensive care unit (ICU) is to provide critically ill patients with high-quality care and an atmosphere in which to recuperate. However, all too often, the intensive environment, which is often busy, chaotic, and noisy, may contribute to just the opposite. Patients overstimulated with noise, lights, and other distractions often suffer from sleep deprivation. Research in medicine and nursing has shown that sleep deprivation can have detrimental effects on an ailing patient. Therefore, a quiet time program was developed in the neuro-ICU to reduce noise and light levels, with the ultimate goal to allow sleep. Quiet time, a period of reduced controllable noise and light, took place twice daily coinciding with circadian rhythms. The study included 50 neuro-ICU patients, 35 observed during day hours and 15 observed during night hours. Noise and light levels were measured at multiple locations before, during, and after quiet time hours. Patients' sleep behavior was recorded every half hour, beginning 1/2 hour before quiet time until 30 minutes after. Analysis of data, adjusted for multiple testing and repeated measures on patients, demonstrated significantly lower noise and light levels during day shift quiet time. In addition, patients were significantly more likely to be observed sleeping during day shift quiet time hours.

Ruído em uma Unidade de Terapia Intensiva neonatal: mensuração e percepção de profissionais e pais

OBJETIVO: Conhecer a percepção dos profissionais atuantes em Unidade de Terapia Intensiva Neonatal e dos pais dos recém-nascidos internados sobre o ruído existente, além de compará-la aos níveis de ruído mensurados. MÉTODOS: Por meio de questionário, investigou-se a percepção dos profissionais que atuam na unidade, bem como a dos pais dos recém-nascidos internados, quanto ao ruído existente no ambiente. Os níveis sonoros das três salas e do corredor da unidade foram registrados 24 horas/dia, por nove dias em cada local, com dosímetro Quest 400, e analisados pelo software QuestSuíteMR. Para comparar os níveis de ruído nos diferentes locais, aplicaram-se os testes de Kruskal-Wallis e Mann-Whitney, sendo significante p<0,05. RESULTADOS: Nas salas de cuidados intensivos e intermediários, no isolamento e no corredor da unidade foram registrados níveis médios de ruído de 64,8, 62,1, 63,8 e 61,9dBA, respectivamente, sendo diferentes entre si (p<0,001). Os profissionais da saúde consideraram o ruído presente e intenso e os pais, moderado. Só os primeiros julgam ruidoso o próprio comportamento. Os profissionais da saúde acreditam que tanto os recém-nascidos quanto as pessoas que trabalham nesse ambiente podem ser prejudicados pelo ruído, enquanto os pais acreditam que não. Todos os grupos julgam possível reduzir tal ruído. CONCLUSÕES: A opinião sobre a intensidade do ruído diferiu entre os profissionais da saúde e os pais dos recém-nascidos. Houve maior concordância entre o nível de ruído mensurado e a percepção do mesmo pelos profissionais da saúde.

Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff

BACKGROUND

Hospital routines frequently interrupt nighttime sleep. Sedatives promote sleep, but increase the risk of delirium and falls. Few interventional trials have studied sleep promotion in medical-surgical units and little is known about its impact on sedative use.

OBJECTIVE

To determine causes of sleep disruption, and assess whether decreasing sleep disruptions lowers sedative use in medical-surgical patients.

DESIGN AND SETTING

Interventional trial with historical controls on a medical-surgical unit of a community teaching hospital. Nurses, physicians, and patients were blinded to the measurement of as-needed sedative use.

PATIENTS

Consecutive eligible adults (n = 161 preintervention patients, n = 106 intervention patients).

INTERVENTION

We developed the "Somerville Protocol," which included the establishment of an 8-hour "Quiet Time" that began with automated lights-off and lullaby; staff-monitored noise; and avoidance of waking of patients for routine vital signs and medications.

MEASUREMENTS

As-needed sedative use, responses to a patient questionnaire, and responses to a modified Verran Snyder-Halpern (VSH) sleep scale.

RESULTS

Preintervention, "hospital staff " was the disturbance most likely to keep patients awake. The intervention decreased the proportion of patients reporting it from 42% to 26%, a 38% reduction (P = 0.009; 95% confidence interval [CI]: 0.0452-0.2765). Preintervention, 32% of patients received as-needed sedatives, compared to 16% with the intervention, a 49% reduction (P = 0.0041; 95% CI: 0.056-0.26), with a 62% decrease in patients over age 64 years (P = 0.005). VSH scores were unchanged.

CONCLUSIONS

Small modifications in hospital routines, especially in the timing of vital signs and routine medication administration, can significantly reduce sedative use in unselected hospital patients.

Noise Assessment in Intensive Care Units

Intensive Care Units are environments with numerous noise sources. In different hospital environments it is recommended to have a sound pressure level between 35 and 45db(A).

Aim

To measure the sound pressure levels in three ICU at a hospital in Jundiaí, State of São Paulo, Brazil.

Study Design

Observational.

Materials and Methods

we used a Minipa model MSL1532C (USA) sound meter, according to the Brazilian Technical Standards (NBR 10151), in order to measure sound levels in the ICUs at different moments, that is, the morning, afternoon and night at peak times of activity.

Results

The values found during the checking of the sound pressure levels were 64.1dB (A) in the First ICU, 58.9 dB (A) in the Coronary Unit and 64dB (A) in the second ICU.

Conclusion

High sound pressure levels in ICU still mean an important health-related problem for patients in these units. None of the three ICU pad levels above 85dB, showing that there is no occupational risk for the health care teams in the environments studied.

The knowledge and educational experiences of student nurses regarding sleep promotion in hospitals

AIM

This study explored the knowledge and educational experiences of student nurses regarding sleep and its promotion in hospitals.

BACKGROUND

Nurses have a key role to play in sleep promotion, with the knowledge of sleep an important component of skilled patient care. From a review of the literature, minimal research was found on what student nurses know, or how they learn about, sleep and its promotion.

METHODS

A mixed method approach was used. 1. Questionnaires were completed by student volunteers in the last six months of their nursing programme(n = 120) from four Higher Education Institutions.2. Semi-structured interviews were carried out with a sample of the students (n = 26).

RESULTS

The students lacked a complete knowledge about basic sleep physiology. Their knowledge of sleep disruption and sleep promoting factors was more evident, although this was generally not based on empirical evidence. The students viewed knowledge of sleep and its promotion positively, but reported that their educational programmes did not prepare them in this respect. The students felt that they had learnt most about sleep promotion through clinical experience, from staff, patients and their own life experiences, though this learning was unstructured.

CONCLUSIONS

These findings highlight the need to address the acquisition of knowledge and skills for the promotion of sleep in a structured learning framework in pre-registration nursing programmes. Academic and clinical staff need to be proactive in this respect.

The importance of quiet in the home: Teaching noise awareness to parents before the infant is discharged from the NICU

Research over several decades describes various adverse health effects of noise on the hospitalized neonate. Noise is a direct cause of long-lasting auditory problems and a significant cause of cardiovascular and respiratory problems and neurologic impairment. Many hospitals have turned the NICU into a quiet environment that promotes the neonate's health and well-being. But auditory pathways continue to develop during the neonatal period, reaching maturation at 12 months and beyond. Some of this development thus occurs after the neonate is discharged from the hospital. It is a responsibility of NICU professionals to teach families about the health benefits of noise modulation and planned quiet in the home environment. This teaching may make a world of difference to the continued healthy growth, development, and well-being of the infant.

Establishing an Acute Care Nursing Bed Unit Size: Employing a Decision Matrix Framework

Determining the number of patient rooms for an acute care (medical-surgical) patient unit is a challenge for both healthcare architects and hospital administrators when renovating or designing a new patient tower or wing. Discussions on unit bed size and its impact on hospital operations in healthcare design literature are isolated, and clearly there is opportunity for more extensive research. Finding the optimal solution for unit bed size involves many factors, including the dynamics of the site and existing structures. This opinion paper was developed using a “balanced scorecard” concept to provide decision makers a framework for assessing and choosing a customized solution during the early planning and conceptual design phases. The context of a healthcare balanced scorecard with the quadrants of quality, finance, provider outcomes, and patient outcomes is used to compare the impact of these variables on unit bed size.