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Nursing and Health Sciences (2015), 17, 354–361
Research Article
Sleep and nursing care activities in an intensive care unit Marita Ritmala-Castren, RN, MNSc,1,3 Irina Virtanen, MD, PhD,2 Sanna Leivo, BLS, MHSc,2 Kirsi-Maija Kaukonen, MD, PhD, EDIC1 and Helena Leino-Kilpi, RN, PhD, FEANS3,4 1
Department of Anesthesiology and Intensive Care, Helsinki University Central Hospital, 2Department of Clinical Neurophysiology, Turku University Hospital, 3Department of Nursing Science, University of Turku, and 4Hospital District of Southwest Finland, Turku, Finland
Abstract
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.
Key words
intensive care unit, nursing care, physiological needs, polysomnography, sleep, Finland.
INTRODUCTION Sleep is important for the recovery of the body and mind from the day’s work and for reloading the energy stores of both the body and brain. Lack of sleep is known to cause decreased resistance to infections (Ganz, 2012), decreased secretion of growth hormone (Banks & Dinges, 2011), decreased glucose tolerance and an increase in sympathetic activity (Spiegel et al., 1999). Alterations in cognitive functions, such as short-term memory loss and difficulties in planning or prioritizing have been described (Bonnet, 2011). There may also be a connection between sleep deprivation and delirium (Trompeo et al., 2011). Thus, sleep can be assumed to be vital for patients’ recovery from an illness or trauma. Patients sleep poorly in hospital (Hedges, 2005; Lei et al., 2009), and especially in an intensive care unit (ICU). Several studies have described the low sleep quality of ICU patients receiving mechanical ventilation (e.g. Edell-Gustafsson et al., 1999; Cooper et al., 2000; Gabor et al., 2003; Bosma et al., 2007; Kondili et al., 2012), while the evidence of the sleep quality of non-intubated patients is minimal. Elliott et al. (2013) have reported that the amount of sleep of Correspondence address: Marita Ritmala-Castren, Department of Anesthesiology and Intensive Care, Helsinki University Central Hospital, Po BOX 340, Helsinki FI-00029 HUS, Finland. Email: [email protected] The authors have no conflicts of interest. Received 22 January 2014; revision received 5 November 2014; accepted 7 November 2014
© 2015 Wiley Publishing Asia Pty Ltd.
non-intubated patients was less than in mechanically ventilated patients, while awakenings were more frequent. Mechanical ventilation is considered one of the main sleep disturbing factors (Boyko et al., 2012). The total sleep time (TST) in intubated, mechanically ventilated patients varies from 3 h (Cooper et al., 2000) to 5.5 h (Bosma et al., 2007), while adults sleep 7.5 to 8.5 h/night (Carskadon & Dement, 2011). Normal sleep consists of multiple sleep stages: light sleep (stages N1 and N2), deep sleep (N3), and rapid eye movement (REM) sleep, which alternate in cycles of approximately 90 min. In critically ill patients, the amount of the deep sleep varies from 0% (Parthasarathy & Tobin, 2002) to 13% and REM sleep from 0% to 12% (Alexopoulou et al., 2007). In normal sleep, the amount of deep sleep varies from 13% to 23% and that of REM sleep from 20% to 25%. Arousals and awakenings may occur up to 79 times/h in critically ill patients (Parthasarathy & Tobin, 2002), while normally arousals and awakenings are very few per night (Carskadon & Dement, 2011). Reported sleep parameters of non-intubated patients with non-invasive ventilation fall within the above-mentioned extremes in intubated patients (Roche Campo et al., 2010). Several factors may influence patients’ sleep in an ICU (Elliott et al., 2011). Nursing care includes many activities such as caring for patients’ physical needs, observing, responding to patients’ requests, relieving pain, and providing comfort and information to the patient (Larrabee & Bolden, 2001). Research regarding the effect of nursing care on sleep has only included activities such as monitoring vital doi: 10.1111/nhs.12195
ICU patients’ sleep and nursing care
signs, administering medication, nursing interventions, and respiratory care. Critically ill patients require constant observation, and numerous nursing care activities are performed as often as hourly, day and night (Meyer et al., 1994). The difference between nursing care of spontaneously and mechanically ventilated patients has only been studied in a step-down unit, where no difference was discovered (Fanfulla et al., 2011). The amount of nursing care that patients require is not directly proportional to the severity of their illness, but to the nature of their health problems (Pyykko et al., 2001). Patients have rated night-time nursing care less disrupting than noise when seven sleep disrupting factors (noise, light, nursing interventions, diagnostic testing, vital signs, blood samples, administration of medications) were measured. Nursing care rated between 4 and 5 on a scale 1 (no disruption) to 10 (significant disruption) (Freedman et al., 1999; Li et al., 2011; Elliott et al., 2013). Patients in Freedman et al.’s (1999) study rated nursing interventions the fifth most disruptive to sleep, unlike in the more recent studies where it was rated the third (Li et al., 2011; Elliott et al., 2013). Nurses perceive nursing care as much more disturbing than patients do (Zhang et al., 2013). In retrospective studies of nurses’ documentation, the mean amount of night-time nursing care interactions varies from 42.6 (Tamburri et al., 2004) to 51 (Celik et al., 2005) during the night from 7:00 pm to 7:00 am, which judging by the time frame may include all the preparations for the night. The mean of nursing care activities in 24 h varies from 7.8 per hour in intubated patients (Gabor et al., 2003) to 1.7 in a patient group where 54% received mechanical ventilation (Elliott et al., 2013). Clustering of nursing care activities has been suggested (Tamburri et al., 2004; Monsen & Edell-Gustafsson, 2005) after Edwards and Schuring (1993) and Meyer et al. (1994) demonstrated that ICU patients do not have any 60-min periods of undisturbed sleeping time at night.
Study aims The aims of this study were: (i) to describe the amount and quality of sleep of non-intubated ICU patients; (ii) to describe the night-time nursing care activities; and (iii) to evaluate the effect of nursing care activities on the quality of sleep. The purpose was to analyze the delivery of nursing care activities during the night by documenting them and analyzing their effect on patients’ sleep, so that this information could ultimately be used to improve patients’ sleep quality.
METHODS Setting and patient selection The study was performed in a university-affiliated, 24-bed, level-three mixed adult ICU that cared for the most critically ill patients, who were mainly mechanically ventilated and sedated. The unit operated both as a critical care unit and as a step-down unit. Patient rooms had beds for two to five patients, and each nurse took care of one or two patients at
355
night. At least one nurse was required to remain in each patient room at all times. It was customary to dim the lights in patients’ rooms for the night. All patients were consecutively screened daily by the attending physician and the researcher (MRC) for eligibility to participate in the study. The inclusion criteria were: adult (over 18 years); medical or surgical patient; non-intubated, alert, and oriented, with a Glasgow Coma Score of ≥ 13, that is, eyes open to minimum of tactile stimuli (2–4 points), oriented (5 points), motor response of “obeys commands” (6 points), and Richmond Agitation Sedation Scale −1 (drowsy) to +1 (restless) (Sessler et al., 2002); no traumatic brain injury; and no continuous sedation. When the criteria were met, for example a patient was extubated during the day and expected to remain in the ICU, he/she was approached by a researcher and asked to participate in the study the following night. From May to August 2009, 29 patients fulfilled the inclusion criteria. Eight patients refused and 21 agreed to participate in the study.
Data collection The 21 patients’ sleep was recorded with EMBLA® (A10, Somnologica 3.3.2 software), a standard polysomnograph (PSG) device. Polysomnography is the most objective measure of sleep and is considered the gold standard of sleep study (Kushida et al., 2005). It measures the time of falling asleep, total sleep time (TST), sleep stages, number of arousals and awakenings, and changes in respiration and heart rate. In this study the recording consisted of electrical brain wave detection (electroencephalography, EEG) with four electrodes (Fp2, C4, O2, M1), muscle tension (electromyography), eye movements (electro-oculography), respiratory flow by nasal cannula, thoracic and abdominal movement detection, position and general movement detection, and pulse oximetry. The PSG was set up by a qualified sleep technician (SL) or by a trained and registered ICU nurse (MRC). The recording was initiated when the bedside nurse had finished care activities preparing the patient for the night, and marked in the patient record that the patient could go to sleep. This time point was on average at 9:37 pm, varying from 8:37 to 11:29 pm. Recording was finished when the patient woke up after 5:00 am and did not fall back to sleep, or at the latest at 7:00 am. A data collection instrument to document all nursing care activities that involved physical touching of the patient was developed for this study. Each nurse who participated in data collection was provided an instruction sheet with examples of different nursing care activities, along with verbal instructions. Nurses were instructed to deliver care “as usual,” since we wanted to collect data matching a normal situation instead of creating the specific condition for research purposes. Care activities were chosen from earlier studies (Freedman et al., 1999; Calvete Vazquez et al., 2000; Gabor et al., 2003; Tamburri et al., 2004) and pre-classified as patient assessment/vital signs, care of hygiene, repositioning, oxygen delivery, airway suctioning, breathing exercise, enteral nutrition, medication and fluid therapy, blood sampling, and other nursing care. If care activity did not require touching the patient, for example, changing a fluid container, it was not © 2015 Wiley Publishing Asia Pty Ltd.
356
considered disturbing the patient and therefore not recorded as a nursing activity. Nurses documented in the electronic patient care record all care activities as they were performed, during the PSG recording. The number of mechanically ventilated or loudly delirious patients in the room and admissions during the night were also recorded. Patient demographic and medical information collected from the medical record included age, gender, reason for current ICU admission, length of ICU stay, and medications given on the night of the study. Additionally, three measures of the severity of illness were collected from the patients’ records for the description of the participants and exploration of possible correlations. The measures were Acute Physiology and Chronic Health Evaluation II (APACHE II) (Knaus et al., 1985) and Simplified Acute Physiology Score II (SAPS II) (Le Gall et al., 1993) documented within the first 24 h of admission, and Sequential Organ Failure Assessment (SOFA) score (Arts et al., 2005) documented at midnight during the PSG recording. Higher score values represent more severe illness.
Analysis The PSG data were scored manually in 30-s epochs according to the American Academy of Sleep Medicine (AASM) scoring criteria (Iber et al., 2007) by the clinical neurophysiologist (IV) blinded to the patients’ clinical background. The TST, percentage of each sleep stage, number of arousals lasting over 3 s, awakenings lasting for at least one 30-s epoch per hour, and fragmentation index (FI) were calculated for each patient. Nursing care activities were clustered into one if they were performed within a 5-min time frame. The number of nursing care activities per hour and the times between them were calculated. Patients’ wake or sleep stage prior to nursing care activities was analyzed from the PSG recording to identify the cases where patients were woken for nursing care activities. The nurses’ documentations of the cause for awakening (spontaneous, noise, light, or touch) were checked for confirmation of whether the patient had woken for touch, that is, nursing care activity, or something else. The data were summarized statistically and are expressed as number (percentage) or median (interquartile range; IQR). The normality of the distribution of study parameters was analyzed by the Kolmogorov–Smirnov test of normality. The correlations between patient characteristics, the amount of care activities, and sleep indices were studied with a nonparametric Spearman correlation coefficient test. A P-value below 0.05 was considered statistically significant.
Ethical considerations The study protocol was approved by the Ethics Committee of the Hospital District of Southwest Finland, and the purpose and protocol of the study were explained to all patients who met the inclusion criteria. Patients were informed of the anonymity within data collection and voluntary nature of participation, and that they could withdraw from the study any time without negative consequences. Written informed consent © 2015 Wiley Publishing Asia Pty Ltd.
M. Ritmala-Castren et al.
was obtained on the day of the planned recording from each participating patient or the next-of-kin if the patient was unable to sign the consent due to the physical limitations of his/her condition.
RESULTS A total of 187 h of PSG recording time was obtained from 21 patients, ranging from 7.3 to 10.3 h/patient. Nursing care activities were recorded on only 19 patients as two nurses had not recorded any activities on their patients.
Patients The participating patients were not extremely ill, judging by the illness severity scores (Table 1). Patients’ SOFA (rho = 0.59, P = 0.005) and SAPS (rho = 0.52, P = 0.015) scores increased with patients’ age. Nineteen patients were treated for pain with an opiate, and six patients received one dose of a sedative or a sleep medication during the recording. There were three new admissions in the room during the 21 recordings. No disturbances from delirious patients were noted. There were mechanically ventilated patients in each room during the study night.
Sleep characteristics The median TST was 6.5 h (2.8, 8.1) ranging from 0 to 10.3 h (Table 2). Seven patients slept longer than 7.5 h, and five patients slept less than 2 h. The percentage of light sleep, stages N1 and N2, was 78%.The amount of deep sleep ranged from none in 13 patients to 42% in one patient who slept the total of 10.3 h. The amount of REM sleep ranged from none in 10 patients to 65% in one patient who slept 7.7 h. Only five patients had at least small periods of all four sleep stages during the study night. The amount of arousals and awakenings varied from two to 73 per hour (MD 27 (15, 39)). Patients who slept longer had less fragmented sleep (rho = −638, P = 0.002). No similarities were found among the patients who slept over 7.5 h or had the highest FI’s regarding the use of analgesic or sedative medication, noradrenalin, or whether the admission was surgical or medical. Patients with higher APACHE II scores had less awakenings (rho = −0.64, P = 0.002) indicating that more severely ill patients’ sleep was less fragmented.
Nursing care activities Nurses recorded a total of 144 individual nursing care activities which involved touching the patient, for 19 patients. After clustering the nursing care activities performed within a 5-minute time frame (17 clusters), activities were performed 120 times, with a median of 0.6 (0.5, 0.9) per hour for each patient. Care activities were performed rather evenly throughout the night (Fig. 1). The amount of nursing care activities increased with patients’ age (rho = 0.59, P = 0.008). The most common nursing care activities were changing the patients’ position and obtaining a blood sample (Table 3).
ICU patients’ sleep and nursing care
357
Table 1. Baseline characteristics of study participants (n = 21) Variable Gender Male Female Age (years) ICU stay (days) Admitting reason Medical Respiratory insufficiency Other Surgical Cardiac Abdominal Urinary tract Other Vasoactive medication SOFA APACHE II SAPS II
n
Median
IQR
Minimum
Maximum
18 3
– – 65 3
– – 58, 72 2, 7
– – 19 1
– – 84 31
7 4 3 14 6 4 3 1 5
– – –
– – –
– – –
– – –
– – – –
– – – –
– – – –
– – – –
6 16 32
4, 7 12, 21 23, 41
2 7 10
11 27 58
IQR, interquartile range; ICU, intensive care unit; SOFA, sequential organ failure assessment (range 0–24); APACHE acute physiology and chronic health evaluation (range 0–71); SAPS, simplified acute physiology score (range 0–163).
Table 2.
The characteristics of patients’ (n = 21) sleep
Sleep characteristic TST (min) N1/TST (%) N2/TST (%) N3/TST (%) REM/TST (%) SE (%) Arousals/hr of sleep (n) Awakenings/hr of sleep (n) FI (n)
Median
Interquartile range
Minimum
Maximum
Normal values†
387 27 32 0 1 76 12 5 27
170, 486 19, 97 2, 67 0, 8 0, 8 35, 87 2, 20 2, 13 15, 39
0 1 0 0 0 0 0 0 2
621 100 88 42 65 99 69 53 73
450–510 2–5 45–55 13–23 20–25 –
Nursing and Health Sciences (2015), 17, 354–361
Research Article
Sleep and nursing care activities in an intensive care unit Marita Ritmala-Castren, RN, MNSc,1,3 Irina Virtanen, MD, PhD,2 Sanna Leivo, BLS, MHSc,2 Kirsi-Maija Kaukonen, MD, PhD, EDIC1 and Helena Leino-Kilpi, RN, PhD, FEANS3,4 1
Department of Anesthesiology and Intensive Care, Helsinki University Central Hospital, 2Department of Clinical Neurophysiology, Turku University Hospital, 3Department of Nursing Science, University of Turku, and 4Hospital District of Southwest Finland, Turku, Finland
Abstract
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.
Key words
intensive care unit, nursing care, physiological needs, polysomnography, sleep, Finland.
INTRODUCTION Sleep is important for the recovery of the body and mind from the day’s work and for reloading the energy stores of both the body and brain. Lack of sleep is known to cause decreased resistance to infections (Ganz, 2012), decreased secretion of growth hormone (Banks & Dinges, 2011), decreased glucose tolerance and an increase in sympathetic activity (Spiegel et al., 1999). Alterations in cognitive functions, such as short-term memory loss and difficulties in planning or prioritizing have been described (Bonnet, 2011). There may also be a connection between sleep deprivation and delirium (Trompeo et al., 2011). Thus, sleep can be assumed to be vital for patients’ recovery from an illness or trauma. Patients sleep poorly in hospital (Hedges, 2005; Lei et al., 2009), and especially in an intensive care unit (ICU). Several studies have described the low sleep quality of ICU patients receiving mechanical ventilation (e.g. Edell-Gustafsson et al., 1999; Cooper et al., 2000; Gabor et al., 2003; Bosma et al., 2007; Kondili et al., 2012), while the evidence of the sleep quality of non-intubated patients is minimal. Elliott et al. (2013) have reported that the amount of sleep of Correspondence address: Marita Ritmala-Castren, Department of Anesthesiology and Intensive Care, Helsinki University Central Hospital, Po BOX 340, Helsinki FI-00029 HUS, Finland. Email: [email protected] The authors have no conflicts of interest. Received 22 January 2014; revision received 5 November 2014; accepted 7 November 2014
© 2015 Wiley Publishing Asia Pty Ltd.
non-intubated patients was less than in mechanically ventilated patients, while awakenings were more frequent. Mechanical ventilation is considered one of the main sleep disturbing factors (Boyko et al., 2012). The total sleep time (TST) in intubated, mechanically ventilated patients varies from 3 h (Cooper et al., 2000) to 5.5 h (Bosma et al., 2007), while adults sleep 7.5 to 8.5 h/night (Carskadon & Dement, 2011). Normal sleep consists of multiple sleep stages: light sleep (stages N1 and N2), deep sleep (N3), and rapid eye movement (REM) sleep, which alternate in cycles of approximately 90 min. In critically ill patients, the amount of the deep sleep varies from 0% (Parthasarathy & Tobin, 2002) to 13% and REM sleep from 0% to 12% (Alexopoulou et al., 2007). In normal sleep, the amount of deep sleep varies from 13% to 23% and that of REM sleep from 20% to 25%. Arousals and awakenings may occur up to 79 times/h in critically ill patients (Parthasarathy & Tobin, 2002), while normally arousals and awakenings are very few per night (Carskadon & Dement, 2011). Reported sleep parameters of non-intubated patients with non-invasive ventilation fall within the above-mentioned extremes in intubated patients (Roche Campo et al., 2010). Several factors may influence patients’ sleep in an ICU (Elliott et al., 2011). Nursing care includes many activities such as caring for patients’ physical needs, observing, responding to patients’ requests, relieving pain, and providing comfort and information to the patient (Larrabee & Bolden, 2001). Research regarding the effect of nursing care on sleep has only included activities such as monitoring vital doi: 10.1111/nhs.12195
ICU patients’ sleep and nursing care
signs, administering medication, nursing interventions, and respiratory care. Critically ill patients require constant observation, and numerous nursing care activities are performed as often as hourly, day and night (Meyer et al., 1994). The difference between nursing care of spontaneously and mechanically ventilated patients has only been studied in a step-down unit, where no difference was discovered (Fanfulla et al., 2011). The amount of nursing care that patients require is not directly proportional to the severity of their illness, but to the nature of their health problems (Pyykko et al., 2001). Patients have rated night-time nursing care less disrupting than noise when seven sleep disrupting factors (noise, light, nursing interventions, diagnostic testing, vital signs, blood samples, administration of medications) were measured. Nursing care rated between 4 and 5 on a scale 1 (no disruption) to 10 (significant disruption) (Freedman et al., 1999; Li et al., 2011; Elliott et al., 2013). Patients in Freedman et al.’s (1999) study rated nursing interventions the fifth most disruptive to sleep, unlike in the more recent studies where it was rated the third (Li et al., 2011; Elliott et al., 2013). Nurses perceive nursing care as much more disturbing than patients do (Zhang et al., 2013). In retrospective studies of nurses’ documentation, the mean amount of night-time nursing care interactions varies from 42.6 (Tamburri et al., 2004) to 51 (Celik et al., 2005) during the night from 7:00 pm to 7:00 am, which judging by the time frame may include all the preparations for the night. The mean of nursing care activities in 24 h varies from 7.8 per hour in intubated patients (Gabor et al., 2003) to 1.7 in a patient group where 54% received mechanical ventilation (Elliott et al., 2013). Clustering of nursing care activities has been suggested (Tamburri et al., 2004; Monsen & Edell-Gustafsson, 2005) after Edwards and Schuring (1993) and Meyer et al. (1994) demonstrated that ICU patients do not have any 60-min periods of undisturbed sleeping time at night.
Study aims The aims of this study were: (i) to describe the amount and quality of sleep of non-intubated ICU patients; (ii) to describe the night-time nursing care activities; and (iii) to evaluate the effect of nursing care activities on the quality of sleep. The purpose was to analyze the delivery of nursing care activities during the night by documenting them and analyzing their effect on patients’ sleep, so that this information could ultimately be used to improve patients’ sleep quality.
METHODS Setting and patient selection The study was performed in a university-affiliated, 24-bed, level-three mixed adult ICU that cared for the most critically ill patients, who were mainly mechanically ventilated and sedated. The unit operated both as a critical care unit and as a step-down unit. Patient rooms had beds for two to five patients, and each nurse took care of one or two patients at
355
night. At least one nurse was required to remain in each patient room at all times. It was customary to dim the lights in patients’ rooms for the night. All patients were consecutively screened daily by the attending physician and the researcher (MRC) for eligibility to participate in the study. The inclusion criteria were: adult (over 18 years); medical or surgical patient; non-intubated, alert, and oriented, with a Glasgow Coma Score of ≥ 13, that is, eyes open to minimum of tactile stimuli (2–4 points), oriented (5 points), motor response of “obeys commands” (6 points), and Richmond Agitation Sedation Scale −1 (drowsy) to +1 (restless) (Sessler et al., 2002); no traumatic brain injury; and no continuous sedation. When the criteria were met, for example a patient was extubated during the day and expected to remain in the ICU, he/she was approached by a researcher and asked to participate in the study the following night. From May to August 2009, 29 patients fulfilled the inclusion criteria. Eight patients refused and 21 agreed to participate in the study.
Data collection The 21 patients’ sleep was recorded with EMBLA® (A10, Somnologica 3.3.2 software), a standard polysomnograph (PSG) device. Polysomnography is the most objective measure of sleep and is considered the gold standard of sleep study (Kushida et al., 2005). It measures the time of falling asleep, total sleep time (TST), sleep stages, number of arousals and awakenings, and changes in respiration and heart rate. In this study the recording consisted of electrical brain wave detection (electroencephalography, EEG) with four electrodes (Fp2, C4, O2, M1), muscle tension (electromyography), eye movements (electro-oculography), respiratory flow by nasal cannula, thoracic and abdominal movement detection, position and general movement detection, and pulse oximetry. The PSG was set up by a qualified sleep technician (SL) or by a trained and registered ICU nurse (MRC). The recording was initiated when the bedside nurse had finished care activities preparing the patient for the night, and marked in the patient record that the patient could go to sleep. This time point was on average at 9:37 pm, varying from 8:37 to 11:29 pm. Recording was finished when the patient woke up after 5:00 am and did not fall back to sleep, or at the latest at 7:00 am. A data collection instrument to document all nursing care activities that involved physical touching of the patient was developed for this study. Each nurse who participated in data collection was provided an instruction sheet with examples of different nursing care activities, along with verbal instructions. Nurses were instructed to deliver care “as usual,” since we wanted to collect data matching a normal situation instead of creating the specific condition for research purposes. Care activities were chosen from earlier studies (Freedman et al., 1999; Calvete Vazquez et al., 2000; Gabor et al., 2003; Tamburri et al., 2004) and pre-classified as patient assessment/vital signs, care of hygiene, repositioning, oxygen delivery, airway suctioning, breathing exercise, enteral nutrition, medication and fluid therapy, blood sampling, and other nursing care. If care activity did not require touching the patient, for example, changing a fluid container, it was not © 2015 Wiley Publishing Asia Pty Ltd.
356
considered disturbing the patient and therefore not recorded as a nursing activity. Nurses documented in the electronic patient care record all care activities as they were performed, during the PSG recording. The number of mechanically ventilated or loudly delirious patients in the room and admissions during the night were also recorded. Patient demographic and medical information collected from the medical record included age, gender, reason for current ICU admission, length of ICU stay, and medications given on the night of the study. Additionally, three measures of the severity of illness were collected from the patients’ records for the description of the participants and exploration of possible correlations. The measures were Acute Physiology and Chronic Health Evaluation II (APACHE II) (Knaus et al., 1985) and Simplified Acute Physiology Score II (SAPS II) (Le Gall et al., 1993) documented within the first 24 h of admission, and Sequential Organ Failure Assessment (SOFA) score (Arts et al., 2005) documented at midnight during the PSG recording. Higher score values represent more severe illness.
Analysis The PSG data were scored manually in 30-s epochs according to the American Academy of Sleep Medicine (AASM) scoring criteria (Iber et al., 2007) by the clinical neurophysiologist (IV) blinded to the patients’ clinical background. The TST, percentage of each sleep stage, number of arousals lasting over 3 s, awakenings lasting for at least one 30-s epoch per hour, and fragmentation index (FI) were calculated for each patient. Nursing care activities were clustered into one if they were performed within a 5-min time frame. The number of nursing care activities per hour and the times between them were calculated. Patients’ wake or sleep stage prior to nursing care activities was analyzed from the PSG recording to identify the cases where patients were woken for nursing care activities. The nurses’ documentations of the cause for awakening (spontaneous, noise, light, or touch) were checked for confirmation of whether the patient had woken for touch, that is, nursing care activity, or something else. The data were summarized statistically and are expressed as number (percentage) or median (interquartile range; IQR). The normality of the distribution of study parameters was analyzed by the Kolmogorov–Smirnov test of normality. The correlations between patient characteristics, the amount of care activities, and sleep indices were studied with a nonparametric Spearman correlation coefficient test. A P-value below 0.05 was considered statistically significant.
Ethical considerations The study protocol was approved by the Ethics Committee of the Hospital District of Southwest Finland, and the purpose and protocol of the study were explained to all patients who met the inclusion criteria. Patients were informed of the anonymity within data collection and voluntary nature of participation, and that they could withdraw from the study any time without negative consequences. Written informed consent © 2015 Wiley Publishing Asia Pty Ltd.
M. Ritmala-Castren et al.
was obtained on the day of the planned recording from each participating patient or the next-of-kin if the patient was unable to sign the consent due to the physical limitations of his/her condition.
RESULTS A total of 187 h of PSG recording time was obtained from 21 patients, ranging from 7.3 to 10.3 h/patient. Nursing care activities were recorded on only 19 patients as two nurses had not recorded any activities on their patients.
Patients The participating patients were not extremely ill, judging by the illness severity scores (Table 1). Patients’ SOFA (rho = 0.59, P = 0.005) and SAPS (rho = 0.52, P = 0.015) scores increased with patients’ age. Nineteen patients were treated for pain with an opiate, and six patients received one dose of a sedative or a sleep medication during the recording. There were three new admissions in the room during the 21 recordings. No disturbances from delirious patients were noted. There were mechanically ventilated patients in each room during the study night.
Sleep characteristics The median TST was 6.5 h (2.8, 8.1) ranging from 0 to 10.3 h (Table 2). Seven patients slept longer than 7.5 h, and five patients slept less than 2 h. The percentage of light sleep, stages N1 and N2, was 78%.The amount of deep sleep ranged from none in 13 patients to 42% in one patient who slept the total of 10.3 h. The amount of REM sleep ranged from none in 10 patients to 65% in one patient who slept 7.7 h. Only five patients had at least small periods of all four sleep stages during the study night. The amount of arousals and awakenings varied from two to 73 per hour (MD 27 (15, 39)). Patients who slept longer had less fragmented sleep (rho = −638, P = 0.002). No similarities were found among the patients who slept over 7.5 h or had the highest FI’s regarding the use of analgesic or sedative medication, noradrenalin, or whether the admission was surgical or medical. Patients with higher APACHE II scores had less awakenings (rho = −0.64, P = 0.002) indicating that more severely ill patients’ sleep was less fragmented.
Nursing care activities Nurses recorded a total of 144 individual nursing care activities which involved touching the patient, for 19 patients. After clustering the nursing care activities performed within a 5-minute time frame (17 clusters), activities were performed 120 times, with a median of 0.6 (0.5, 0.9) per hour for each patient. Care activities were performed rather evenly throughout the night (Fig. 1). The amount of nursing care activities increased with patients’ age (rho = 0.59, P = 0.008). The most common nursing care activities were changing the patients’ position and obtaining a blood sample (Table 3).
ICU patients’ sleep and nursing care
357
Table 1. Baseline characteristics of study participants (n = 21) Variable Gender Male Female Age (years) ICU stay (days) Admitting reason Medical Respiratory insufficiency Other Surgical Cardiac Abdominal Urinary tract Other Vasoactive medication SOFA APACHE II SAPS II
n
Median
IQR
Minimum
Maximum
18 3
– – 65 3
– – 58, 72 2, 7
– – 19 1
– – 84 31
7 4 3 14 6 4 3 1 5
– – –
– – –
– – –
– – –
– – – –
– – – –
– – – –
– – – –
6 16 32
4, 7 12, 21 23, 41
2 7 10
11 27 58
IQR, interquartile range; ICU, intensive care unit; SOFA, sequential organ failure assessment (range 0–24); APACHE acute physiology and chronic health evaluation (range 0–71); SAPS, simplified acute physiology score (range 0–163).
Table 2.
The characteristics of patients’ (n = 21) sleep
Sleep characteristic TST (min) N1/TST (%) N2/TST (%) N3/TST (%) REM/TST (%) SE (%) Arousals/hr of sleep (n) Awakenings/hr of sleep (n) FI (n)
Median
Interquartile range
Minimum
Maximum
Normal values†
387 27 32 0 1 76 12 5 27
170, 486 19, 97 2, 67 0, 8 0, 8 35, 87 2, 20 2, 13 15, 39
0 1 0 0 0 0 0 0 2
621 100 88 42 65 99 69 53 73
450–510 2–5 45–55 13–23 20–25 –
