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The Effect of Nocturnal Patient Care Interventions on Patient Sleep and Satisfaction With Nursing Care in Neurosurgery Intensive Care Unit Gu¨lay Altun Ug˘ras$, Sultan Babayigit, Keziban Tosun, Gu¨ler Aksoy, Yu¨ksel Turan
ABSTRACT Background: Sleep disturbance in an intensive care unit is a common problem. One of the main factors causing sleep disturbances in an intensive care unit is nocturnal patient care interventions. Aims and objectives: This study aims to determine the impact of patient care interventions performed at night in a neurosurgical intensive care unit on patients’ sleep and their nursing care satisfaction. Methods: The descriptive study was conducted on 82 patients in a neurosurgical intensive care unit between January 2009 and March 2010. The data were collected by data collection instruments and Newcastle Satisfaction with Nursing Scales. The data were statistically analyzed by frequency, mean, standard deviation, chi-square, and MannYWhitney U test. Results: The study showed that 53.7% of the patients experienced sleep disturbances in the neurosurgical intensive care unit. Because of nursing interventions at night, 39.1% of these patients had their sleep affected, but this problem did not cause any negative impact on the patients’ satisfaction (Newcastle Satisfaction with Nursing Scales score = 88.21 T 9.83). The patients received, on average, 42.21 T 7.45 times patient care interventions at night; however, the frequency of patient care interventions at night showed no effect on sleep disturbances in this study (p 9 .05). The most frequently given patient care interventions were, respectively, vital signs monitoring, neurological assessment, and repositioning in bed. These interventions were performed commonly at 6 A.M., 12 A.M., and 7 P.M. Conclusion: In this study, despite the patients reporting sleep disturbances in the neurosurgical intensive care unit because of nocturnal patient care interventions that prevented them from sleeping, the patients’ satisfaction on the given nursing care was not negatively impacted. To reduce sleep disturbances because of nursing care initiatives and promote uninterrupted sleep in the intensive care unit, it can be useful to develop new protocols regulating night care activities. Keywords: intensive care unit, nocturnal patient care interventions, nursing care satisfaction, sleep disturbances
Questions or comments about this article may be directed to Gu¨lay Altun Ug˘ras$, PhD RN, at [email protected]. She is an Assistant Professor, Health School of Surgical Nursing Department, Mersin University, Mersin, Turkey. Sultan Babayigit, RN, is a Registered Nurse, Istanbul Cerrahpas$a Medical Faculty, Neurosurgery Intensive Care Unit, Istanbul University, Istanbul, Turkey. Keziban Tosun, RN, is Head Nurse, Cerrahpas $a Medical Faculty, Neurosurgery Department, Istanbul University, Istanbul, Turkey. Gu¨ler Aksoy, PhD, is Professor, Nursing High School, Department of Surgical Nursing, Halic University, Istanbul, Turkey. Yu¨ksel Turan, RN, is a Registered Nurse, Istanbul Cerrahpas $a Medical Faculty, Neurosurgery Intensive Care Unit, Istanbul University, Istanbul, Turkey. The work was performed at the Intensive Care Unit, Department of Neurosurgery, Istanbul University Cerrahpas $a School of Medicine. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jnnonline.com). Copyright B 2015 American Association of Neuroscience Nurses DOI: 10.1097/JNN.0000000000000122
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leep is essential to generate the energy to recovery from illness (DeKeyser, 2003; Dennis, Lee, Woodard, Szalaj, & Walker, 2010; Fontana & Pittiglio, 2010). During sleep, protein synthesis and cell division are organized and result in a restorative process (Dennis et al., 2010). Sleep disturbance in intensive care units (ICUs) is a common and known problem (Bourne & Mills, 2004; DeKeyser, 2003; Fontana & Pittiglio, 2010). ICU patients may have difficulty in falling asleep; experience diminished rapid eye movement sleep and changes in their circadian rhythms; wake up more often than normal or be awakened because of noise, anxiety, pain, frequent treatments, and nursing care interventions and monitoring activities (Boyko, Krding, & Jennum, 2012; Cmiel, Karr, Gasser, Oliphant, & Neveau, 2004; DeKeyser, 2003). The negative effects of lack of sleep on ICU patients’ bodies can start to be observed within as little as 24Y48 hours. The rise in stress level increases the serum cortisol level. This causes a reduction
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Volume 47
in the number of lymphocytes and functional monocyte circulating in the bloodstream. As a result, natural killer cell activity and cytokine production decrease and then depression occur in the immune system (DeKeyser, 2003; Dennis et al., 2010). Additional negative responses include changes in respiration and ventilation (lack of separation from mechanical ventilation), vasoconstriction in peripheral blood vessels, gastrointestinal movement change, chemical variances in blood and urine, delayed wound healing, increased skeletal and muscular tension, thermoregulatory impairment, decreased glucose tolerance, increased insulin resistance, and ICU psychosis (Dennis et al., 2010; Fontana & Pittiglio, 2010; Tamburi, DiBrienza, Zozula, & Redeker, 2004). Frequent awakenings and sleep problems cause fatigue during the day. This results in development of symptoms such as anxiety, low mood or malaise, lack of concentration, and lower quality of life (Johansson, Ole´nia, & Fridlund, 2005; Tamburi et al., 2004). In addition to the development of delirium, it may lead to a prolonged ICU stay and an increase in mortality (Boyko et al., 2012; Tembo & Parker, 2009). During the night hours when the physiological tendency to sleep is at its highest level, the implementation of frequent care interventions can lead to a high risk of patient developing sleep deprivation (Tamburi et al., 2004). In the ICU, nursing interventions are usually performed at least once and sometimes even more in an hour. The average duration of sleepYwake cycle ranges from 90 to 120 minutes. Frequently performed interventions often leave patients with very little opportunity to relax and prevent them from having enough sleep (Dennis et al., 2010; Fontana & Pittiglio, 2010; Frisk & Nordstro¨m, 2003). Despite all the negative effects of nocturnal patient care on sleep, the main purpose of the nursing care given at night is to implement interventions to promote patient sleep and comfort (Johansson et al., 2005). Patients cannot control most of the environmental factors, such as sound, light, and comfort of the bed, which negatively affect their sleep. However, it is possible to limit these effects on patients of the hospital environment and routines. Grouping nocturnal care interventions allows uninterrupted periods to promote patient sleep (Cmiel et al., 2004; Tamburi et al., 2004; Tembo & Parker, 2009), which is required to maintain patients’ circadian rhythms (Fontana & Pittiglio, 2010). Despite all the negative effects of nocturnal patient care on sleep, the main purpose of the nursing care given at night is to design interventions to promote patient sleep (Johansson et al., 2005). Patients cannot control many environmental factors such as sound, light, and comfort of the bed that negatively affect their sleep. However, it is possible to limit the effect of hospital environment and routines to patients. Grouping
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This article examines the seeming contradiction between the negative effects of nocturnal patient care on sleep and the nursing interventions designed to promote better sleep. nocturnal care interventions allows uninterrupted periods to promote patient sleep (Cmiel et al., 2004; Tamburi et al., 2004; Tembo & Parker, 2009) and is required to maintain patients’ circadian rhythms (Fontana & Pittiglio, 2010). Determination of sleep disturbances in critical care enables the development of protocols and interventions to promote sleep (Tamburi et al., 2004). Although patient care activities focus on assessment and meeting patients’ needs, factors such as purpose, frequency, and time of the care interventions can affect some of the patients’ needs (eating and drinking, sleep, excretion, dressing, etc.) and nursing care satisfaction (Rhodes, Miles, & Pearson, 2006). It is important to determine patient satisfaction to meet and evaluate patient’s needs and then identify the appropriate nursing interventions (Akin & Erdogan, 2007). Although various studies in the literature have been conducted to identify nursing care interventions (C ¸ elik, ¨ Oztekin, Akyolcu, & Is$sever, 2005; Le et al., 2012; Tamburi et al., 2004) and patient satisfaction (Akin & Erdogan, 2007; McColl, Thomas, & Bond, 1996; Thomas, McColl, Priest, Bond, & Boys, 1996) during night shifts, the number of studies about the effect of nursing interventions applied in ICU at night on patients’ sleep and nursing care satisfaction was found to be insufficient that raises the need for further investigation. On the basis of this knowledge, this study was designed to determine the impact of nursing interventions applied at night on patients’ sleep and nursing care satisfaction in the neurosurgery ICU (NICU) and to identify the type and time of the interventions. Thus, it will be beneficial for nurses working in ICU to plan their intervention schedules to allow patients enough rest and maintain their circadian rhythms. The study sought to answer the following questions: 1. Do nursing interventions applied at night and their frequency affect patients’ sleep? 2. What times are nursing interventions applied intensively? 3. What type and times of the nursing interventions are applied more often?
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4. Does the frequency of nursing interventions affect patients’ satisfaction?
Methods Design and Consent The research was planned as a descriptive study to determine the effect of the nursing interventions applied at night on the patients’ sleep and nursing care satisfaction in the NICU. Written permission was requested from the hospital’s neurosurgery department, where the research was conducted in the NICU, and from the research ethics committee. In addition, oral and written consent was obtained from all the NICU nurses and patients before the research.
Study Settings and Sample The study population consisted of 110 patients hospitalized between January 2009 and March 2010 in the Department of Neurosurgery Intensive Care Unit, Istanbul University Cerrahpasa Medical Faculty Hospital. However, because 10 of these patients stayed only one night in NICU and 18 could not communicate sufficiently (e.g., because of Glasgow Coma Scale [GCS] score lower than 13 because of sedation medicine given, being connected to mechanical ventilator), the research was performed on 82 patients. The patients who stayed in the NICU for a minimum of two nights after surgery, were ready to be discharged, could read and write Turkish, were 18 years and over, constituted no health drawback for participating in the research (GCS score between 13 and 15), were conscious, and agreed to participate in the study were included. The patients with insufficient cognitive functions (GCS score below 13) who were given a sedative drug and connected to mechanical ventilator were excluded from the study. Although the Newcastle Satisfaction with Nursing Scales (NSNS), used for the reliability of the data obtained from the survey, recommended including at least 10 people for each item (19 10 = 190 people) in the study, it was reported that the sample number could be regulated according to the Cronbach’s alpha value based on the study conditions and scale (Akin & Erdog˘an, 2007; McColl et al., 1996; Thomas et al., 1996). In this study, the Cronbach’s alpha value was taken into consideration in determining the sample size. The Cronbach’s alpha value on the scale of 82 patients was .97.
Instruments and Procedure In this study, the data were collected using two instruments, which are available as Supplemental Digital
Content 1 at http://links.lww.com/JNN/A33. The first data collection instrument (A) was the questionnaire that was prepared by the researchers based on the literature and the opinions of one NICU physician and four clinical nurses. The questionnaire consisted of two parts. The first part of the questionnaire (A1) included the questions to determine the patients’ age, gender, the length of stay at NICU, the presence of any sleep disturbances, and the impact of ICU nursing interventions at night on their sleep. The second part (A2) was prepared for the nurses and provided a chart to mark their NICU nursing interventions applied at night (between 7 P.M. and 6 A.M.) on an hourly basis. The selection of this period was because of the nurses’ 12-hour shifts and the typical sleeping hours, when there was a high tendency to circadian sleep at patients. Tables included 15 patient-care activities typically carried out at night hours. These activities were performed by the nurse touching the patient at the bedside or with the help of medical equipment. The data used for patient care interventions at night included the applications during the patients’ second-night stay in the NICU. Because most of the patients may not have stable health conditions during the first night of their postoperative period after surgical intervention, their first night in the NICU was not used. The second data collection instrument (B) was NSNS. This scale was developed by Thomas et al. (1996) to determine patients’ experiences of and satisfaction with nursing care, based on their perspective. The Turkish validity and reliability were performed by Akin and Erdog˘an (2007). The patients, who were eligible for recruitment, were aged 18 years or older, were about to be discharged from the NICU, had spent two nights or more in the ward, were able to read and understand Turkish, were conscious, and agreed to complete the questionnaires (Akin & Erdog˘an, 2007). In this study, the second part of the ‘‘Satisfaction with Nursing Care Scale,’’ which was composed of 19 statements, was used. The first part, ‘‘Experiences of Nursing Care Scale,’’ was not preferred because it was too long for the patients in the ICU and required their clinical/intensive care experience. All statements on the ‘‘Satisfaction with Nursing Care Scale’’ are positive and scored on a 5-point Likert scale (1 = not at all satisfied, 2 = rarely satisfied; 3 = quite satisfied; 4 = very satisfied, and 5 = completely satisfied). The scale score is computed by adding the scores assigned to each question. The lowest score of the scale is 19, and the highest is 95. Score analysis is done by converting the total amount to 100 points, that is, the closer to 100 points, the higher the patient’s satisfaction with care, and the further away from 100 points, the lower the patient’s satisfaction (Akin & Erdog˘an, 2007; Thomas et al., 1996).
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Data Collection Between January 2009 and March 2010, the patients who transferred from the NICU with a capacity of eight beds to the service were given data collection instruments (A1, AB) in the NICU before they were transferred and requested to reply in their service. The patients were asked to fill in the nursing care satisfaction forms by taking into account only night-shift treatments (hours: between 7 P.M. and 6 A.M.). In addition, anonymity was requested when the patients were asked to complete the A1 and AB forms and return to the NICU secretary in sealed envelopes. The purpose of the study was explained, and the data collection tool (A2) was introduced to the NICU nurses. The nurses working at night were asked to mark on the A2 form their nursing interventions implemented at nights to the NICU patients. The A1, A2, and B tools were collected from the NICU by the researchers.
Data Analysis The collected data were analyzed using the Statistical Package for the Social Sciences for Windows 11.5 (SPSS, Chicago, IL). To interpret the data statistically, frequency, mean and standard deviation (SD), MannYWhitney U test, and chi-square (2 2) were used. The value alpha was considered .05.
Results In this study, 82 patients were monitored; 51.2% were men. The median age of the patients was 46.46 T 14.57 years. Of the 82 patients, 73.2% had been admitted to the NICU for the first time, and 91.5% were admitted because of the need for close follow-up of postsurgical procedures. Patients’ length of stay is 2.26 T 0.94 nights on average, and 89% had stayed for at least 2 days in the NICU. Figure 1 shows sleep disturbances and how nocturnal patient care interventions affect patient sleep in the NICU. In this study, 53.7% (n = 44) of the patients reported experiencing sleep disturbances, and 39.1% reported having sleep disturbances because of the nocturnal patient care interventions (Figure 1).
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Table 1 shows the effect of nocturnal patient care frequency on the patients’ sleep disturbances. The patients received nocturnal patient care, on average, 42.21 T 7.45 times/night. It was determined that the frequency of nocturnal patient care interventions did not create a statistically significant difference on patients’ sleep disturbances or on patients encountering sleep disturbances because of patient care interventions (p 9 .05; Table 1). Figure 2 illustrates the patient care interventions between the hours of 7 P.M. and 6 A.M. in the NICU. It was observed that, during nighttime (7 P.M.Y6 A.M.), the number of patient care interventions administered by nurses was highest, respectively, at 6 A.M. (6.8 T 3.0), 12 A.M. (5.6 T 2.4), and 7 P.M. (3.6 T 2.5). The number of patient care interventions by nurses per hour ranged between 2.6 T 0.9 and 6.8 T 3.0 (Figure 2). Table 2 shows the types of patient care interventions at the NICU and the hours they were frequently administered. These interventions are categorized as assessment, diagnostic testing, treatment, and hygiene. It was found out that the nurses in the NICU, under the scope of assessment, monitored patients’ vital signs, on average, 12 T 0.00 times/night (administered all hours) and performed patients’ neurological assessment 11.70 T 1.47 times/night (administered frequently all hours); for diagnostic testing, took patients’ blood samples (blood glucose testing, blood gas analysis, etc.) 3.58 T 1.68 times/night (most frequently at 7 P.M., 8 P.M., 12 A.M., 4 A.M., and 6 A.M.); as part of treatment interventions, gave catheter/wound care 2.87 T 2.63 times/night (most frequently at 7 P.M., 12 A.M., and 6 A.M.), administered treatment 1.77 T 1.19 times/night (most frequently at 8 P.M., 12 A.M., and 6 A.M.), and fed the patients (oral or nasogastric) 1.41 T 1.71 times/night (most frequently at 7 P.M., 12 A.M., 2 A.M., 4 A.M., and 6 A.M.); and for hygiene, repositioned patients in bed 4.54 T 6.35 times/ night (administered frequently all hours), gave oral care 1.43 T 0.71 times/night (most frequently at 7 P.M., 12 A.M., 2 A.M., 4 A.M., and 6 A.M.), gave eye care 1.31 T 0.65 times/night (most frequently at 7 P.M., 12 A.M., 2 A.M., and 6 A.M.), and gave a bed bath 1.01 T 0.53 times/ night (most frequently at 12 P.M., 2 A.M., and 6 A.M.; Table 2).
FIGURE 1 Patients’ Sleep Disturbances and the Effect of Nocturnal Patient Care Interventions on the Patients’ Sleep
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TABLE 1.
Patients Encountering Sleep Disturbances According to the Frequency of Nocturnal Patient Care Interventions in the NICU Frequency of Nocturnal Patient Care
Variable
21Y42 Times/Night
Encountering sleep disturbances in the NICU
43Y64 Times/Night
n
%
n
%
Yes
29
55.8
15
50
No
23
44.2
15
50
11
36.7
19
63.3
d statistica and p value
5.8, .784
Encountering sleep disturbances because of NICU patient care interventions Yes
23
44.2
No
29
55.8
d statistica and p value Mean average of nocturnal patient care
7.5, .662 42.21 T 7.45
Note. The chi-square test (continuity correction value taken). NICU = neurosurgery intensive care unit. a d statistic: effect size.
Table 3 presents the nursing care satisfaction scores according to some of the patients’ characteristics. According to NSNS, nursing care satisfaction scores given by the patients were found to be 92.90 T 10:35. The patients’ intensive care experience, length of stay at the NICU, sleep disturbances, sleep disturbances because of the patient care interventions at the NICU, and frequency of nocturnal patient care interventions did not imply a statistically significant difference on patients’ nursing care satisfaction levels (p 9 .05; Table 3). Most of the patients (78%, n = 64) had higher satisfaction on the scale sections, such as ‘‘how quickly nurses responded to their requests,’’ ‘‘the amount of privacy they were given,’’ and ‘‘attitude at work’’; on the other hand, their satisfaction scores for ‘‘the amount of freedom they were given on the ward’’ were observed to be low (31.7%, n = 26).
Discussion This study showed that more than half of the patients at the NICU encountered sleep disturbances
and continuous nocturnal patient care interventions disturbed less than half of the patients’ sleep during nighttime when patients’ circadian sleep propensity was high. However, this did not affect the patient care satisfaction. There are different perspectives on how nocturnal patient care interventions impact patients’ sleep. In some studies (C ¸ elik et al., 2005; Le et al., 2012; Tamburi et al., 2004), it has been reported that nocturnal treatment and patient care interventions affected sleep in a negative way; however, in the other studies (Frisk & Nordstro¨m, 2003; Gabor et al., 2003; Parthasarathy & Tobin, 2004), the effect on sleep had not been found too notable and reportedly caused sleep disturbances of around 10%Y17% (Parthasarathy & Tobin, 2004). Gabor and colleagues (2003) determined that patient care activities during sleep time caused 17.7% T 5% of sleep disturbances and only accounted for 7.1% T 4.4% of the total times of waking up or being woken up. In a different study, it was reported that patient care interventions during sleep hours (10 P.M.Y 6 A.M.) were frequent and acted as the primary factor in
FIGURE 2 Frequency of Patient Care Interventions in the Neurosurgery Intensive Care Unit Between 7 P.M. AND 6 A.M.
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TABLE 2.
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Types of Patient Care Interventions and Frequently Administered Times Between 7 P.M. and 6 A.M. in the NICU Mean T SD
Patient Care Intervention Categories
Frequently Administered Times
Assessment 12 T 0.00
All hours
11.70 T 1.47
All hours
Taking blood sample (for blood glucose testing, blood gas analysis, etc.)
3.58 T 1.68
7 P.M., 8 P.M., 12 A.M., 4 A.M., 6 A.M.
Patient’s transfer to another department (for computed tomography or magnetic resonance, etc.)
0.09 T 0.28
6 A . M.
Giving catheter/wound care
2.87 T 2.63
7 P.M., 12 A.M., 6 A.M.
Administering treatments
1.77 T 1.19
8 P.M., 12 A.M., 6 A.M.
Oral or nasogastric feeding
1.41 T 1.71
8 P.M., 12 A.M., 6 A.M.
Monitoring vital signs Doing neurological assessment Diagnostic testing
Treatment
Putting on varicose vein socks
0.39 T 0.79
6 A . M.
Applying cold when body temperature is elevated
0.22 T 0.67
6 A . M.
Administering blood products (erythrocyte, plasma)
0.09 T 0.39
7 P.M.
4.54 T 6.35
All hours
Giving oral care
1.43 T 0.71
7 P.M., 12 A.M., 2 A.M., 4 A.M., 6 A.M.
Giving eye care
1.31 T 0.65
7 P.M., 12 A.M., 2 A.M., 6 A.M.
Giving a bed bathing
1.10 T 0.62
12 A.M., 2 A.M., 6 A.M.
Giving hair care
0.44 T 0.61
6 A . M.
Hygiene Positioning and repositioning in bed
Note. NICU = neurosurgery intensive care unit.
TABLE 3.
Nursing Care Satisfaction According to the Clinical Characteristics of the Sample NSNS Point, Mean T SD
d Statistica and p Value
Yes
89.45 T 13.21
4.71, .359
No
94.16 T 8.88
Variable ICU experience
Length of stay in NICU Minimum of 2 nights
92.63 T 10.02
3Y8 nights
95.11 T 13.20
2.48, .103
Sleep disturbance at NICU Yes
92.52 T 11.00
No
93.34 T 9.68
0.82, .776
Sleep disturbance at NICU because of patient care interventions Yes
92.11 T 11.44
No
93.45 T 9.59
1.34, .470
Frequency of nocturnal patient care 21Y42 times/night
92.26 T 10.51
43Y64 times/night
94.00 T 10.16
Total satisfaction score
1.74, .072 92.90 T 10.35
Note. MannYWhitney U test. NSNS = Newcastle Satisfaction with Nursing Scales; NICU = neurosurgery intensive care unit. a d statistic: effect size.
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sleep disturbances (Le et al., 2012). In this study, similar to the results of Le and colleagues (2012), most of the patients experiencing sleep disturbances pointed to patient care interventions as the cause. This number was higher than the results found by Gabor and colleagues as well as the percentage in the literature (10%Y17%). In addition, it accounted for sleep disturbances in more patients. C ¸ elik and colleagues (2005) reported that nurses interacted with each patient, on average, 51 times to practice patient care activities. In the same study, nurses stated that patients’ sleep was disturbed frequently for diagnosis and patient care activities and patients did not get enough sleep in ICU. In our study, the average number of interactions with each patient was lower than the results of C¸elik and colleagues, but it was close (42.6) to Tamburi and colleagues’ (2004) result. In our study, as similar to the two studies before, patient care interventions had been continuous throughout the night, and most of the patients who experienced sleep disturbances reported that their sleep disturbances were because of the patient care interventions. However, in this study, the frequency of nocturnal patient care interventions did not show a statistically significant difference in patients experiencing sleep disturbances because of patient care interventions. The times when the most frequent patient care interventions were administered were at 6 A.M., 12 A.M., and 7 P.M. The reason that the frequency of patient care interventions did not have an impact on sleep disturbances might be because of the fact that these hours coincided with the times when the patients were mostly awake. The 10 most frequent patient care activities were, respectively, (a) monitoring vital signs, (b) performing a neurological assessment, (c) repositioning in bed, (d) taking a blood sample, (e) giving catheter/wound care, (f) administering treatments, (g) feeding, (h) giving oral care, (i) giving eye care, and (j) bathing. When the hours for intense patient care interventions were considered, it was observed that these hours coincide with the nurses’ shift change hours. The interventions frequently taking place at these hours were patient assessment before and after the shift change (monitoring vital signs, performing a neurological assessment), treatment (administering treatment, taking blood samples), and hygiene interventions (positioning in bed, giving catheter/wound care, giving oral care, giving eye care, bathing). At the NICU where the study was conducted, continuous hourly monitoring of vital signs and making neurological assessments throughout the night were common procedures for early diagnosis of intracranial pressure increase risk on neurosurgical patients during the postoperative period. In some studies conducted at different ICUs, monitoring vital signs was found to be less disturbing than the other factors such as environment
(noise, lighting), nursing interventions such as bed bathing, and diagnostic tests (chest x-ray; Altun Ug˘ras$ ¨ ztekin, 2007; Freedman, Kotzer, & Schwab, 1999). &O On the other hand, hourly neurological assessments were reported as the most disturbing patient care in¨ ztekin, 2007; Mons6n & tervention (Altun Ug˘ras$ & O Ed6ll-Gustafsson, 2005). In the study, in terms of the frequency of patient care interventions, which were reported to be less frequent, it can be said that the short duration of stay and the need-based realization of patient care interventions at the NICU might have had an impact on this. The patients were more affected by the time of the patient care interventions rather than their frequency. In the literature, it is reported that patient care interventions are (Erkal, 1994) commonly administered between 2 A.M. and 5 A.M. to conscious patients (C ¸ elik et al., 2005) and particularly disrupt rapid eye movement sleep (Lusk & Lash, 2005). Tamburi and colleagues (2004) stated that 62% of in-bed bathing was carried out between 9 P.M. and 6 A.M. In this study, too, this was carried out during nighttime hours and disturbed patients’ sleep. Undertaking hygiene interventions (in-bed bathing, oral care, eye care, etc.) during the daytime, when patients are awake, would create an opportunity for undisturbed sleep at night. In the study, it was observed that the patients were satisfied with nocturnal patient care interventions, and the patients’ NICU experience, length of stay at the NICU, encountering sleep disturbances in the NICU, and encountering sleep disturbances because of nocturnal patient care interventions did not have a negative effect on patient care satisfaction. It had been noted that the patients had high level of satisfaction in terms of ‘‘how quickly nurses responded to their requests,’’ ‘‘the amount of privacy they were given,’’ and ‘‘attitude at work,’’ whereas the satisfaction level for ‘‘the amount of freedom they were given on the ward’’ was low. In Johansson and colleagues’ (2005) study in which a nocturnal patient care instrument was developed and measured nocturnal patient care, it was reported that 55% of patients had a positive perception of nocturnal patient care. In the same study, patients’ satisfaction regarding ‘‘night rest’’ was low (Johansson et al., 2005). In this study, although nocturnal patient care interventions in the NICU kept patients awake and caused patients reporting sleep disturbances, patients’ satisfaction was not impacted negatively by the administered patient care. When the NSNS items with high satisfaction points were taken into consideration, nurses almost never leaving the patients alone on their own and their attitude while attending to them might have resulted in patients feeling safe in a foreign hospital environment. In the past studies, patients had reported feeling uncomfortable with being naked in ICU
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(Hweidi, 2007; So & Chan, 2004) and their sleep being affected because of this feeling (Altun Ug˘ras$ ¨ ztekin, 2007). ‘‘Respecting their privacy’’ might &O have strengthened patients’ confidence in the nurses. Although sleep, as one of the basic necessities, was affected, patients’ satisfaction of nursing care suggests that the sense of confidence surpassed the sense of comfort.
Limitations There are some limitations to this study. The first one is that sleep was not evaluated with clinical sleep studies (such as polysomnography) providing an objective assessment. Instead, it was subjectively assessed by the patient responses. The second limitation is that the NICU nurses were asked to record the care they gave to the patients; this may cause deviation (bias) in the results. In addition, focusing only on the effect of nursing care given at night on sleep can be considered as the third limitation in the study because sleep does not only depend on this factor; other factors such as light, noise, bed comfort, pain, anxiety, and so forth should be taken into account. The fourth limitation is that the information regarding nursing care activities reflects the second evening after surgical intervention. In other limitations, the mean length of the patients’ stay in the NICU was only 2 days. This time may be shorter for patients to experience sleep disturbances and affect their care satisfaction.
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lighting, noise, bed comfort, pain, anxiety, etc.) on sleep patterns and total quality sleep time; combining or grouping nursing care activities performed at night, creating uninterrupted sleep periods for patients, and examining the frequency of ICU patients’ sleep disturbances and their sleep quality; and investigating sleep patterns and nursing care satisfaction for the patients hospitalized in the ICU for a long time.
Summary Sleep disturbance is a common problem in the ICU. In this study, more than half of the patients in the NICU experienced sleep disturbances. However, it was observed that nocturnal patient care interventions at night affected less than half of the patients’ sleep. Although sleep, as one of the fundamental patient requirements, was affected, the patients’ satisfaction with nursing care at night was still high. To reduce sleep disturbances because of nursing care initiatives and to promote uninterrupted sleep in the ICU, it may be useful to develop new protocols regulating night care activities.
Acknowledgments We thank Atilla Bozdog˘an, Statistician, for supporting the statistical analysis reports and all the intensive care nurses and the patients participating in our study.
Recommendations To reduce patients’ sleep disturbances in the NICU because of nursing activities, nurses should:
coordinate nursing care to allow patients to sleep undisturbed for up to 90Y120 minutes, combining or grouping nursing care activities to achieve this (e.g., if the patient awakens and requests pain medication, use that time to check vital signs, if needed, and conduct any necessary neurological assessment); enhance uninterrupted sleep at night and develop protocols that will regulate care activities; and maintain patients’ normal sleep patterns and carry out assessment, treatment, and especially, hygiene interventions and routine applications during the patient’s awake periods.
For future studies, the following may be recommended: evaluating sleep with a polysomnographic method to provide objective data, determining ICU patients’ sleep disturbances and their factors, and investigating the effects of these factors (nursing activities,
References Akin, S., & Erdog˘an, S. (2007). The Turkish version of the Newcastle satisfaction with nursing care scale used on medical and surgical patients. Journal of Clinical Nursing, 16, 646Y653. doi:10.1111/j.1365-2702.2006.01583.x ¨ ztekin, D. (2007). Patient perception of Altun Ug˘ras$, G., & O environmental and nursing factors contributing to sleep disturbances in a neurosurgical intensive care unit. Tohoku Journal of Experimental Medicine, 212, 207Y339. Bourne, R. S., & Mills, G. H. (2004). Sleep disruption in critically ill patientsVPharmacological considerations. Anaesthesia, 59, 374Y384. Boyko, Y., Krding, H., & Jennum, P. (2012). Sleep disturbances in critically ill patients in ICU: How much do we know? Acta Anaesthesiol Scan, 56, 950Y958. doi:10.1111/ j.1399-6576.2012.02672.x ¨ ztekin, D., Akyolcu, N., & Is$sever, H. (2005). The C¸elik, S., O patient care activities applied at the nightshift in intensive care unit. Journal of Clinical Nursing, 14, 102Y106. doi:10.1111/j.1365-2702.2004.01010.x Cmiel, C. A., Karr, D. M., Gasser, D. M., Oliphant, L. M., & Neveau, A. J. (2004). Noise control: A nursing team’s approach to sleep promotion. American Journal of Nursing, 104, 40Y48. DeKeyser, F. (2003). Psychoneuroimmunology in critically ill patients. AACN Clinical, 14, 25Y32.
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Dennis, C. M., Lee, R., Woodard, E. K., Szalaj, J. J., & Walker, C. A. (2010). Benefits of quiet time for neuro-intensive care patients. Journal of Neuroscience Nursing, 42, 217Y224. Erkal, S. (1994). Kardiyo-vasku¨ler cerrahi yog˘un bakim u¨nitelerinde ilk 24 saatte hems$irelik bakimi i0in harcanan su¨renin belirlenmesine ilis$kin bir 0alis$ma. Doktora Tezi, Istanbul Zniversitesi Sag˘lik Bilimleri Enstitu¨su¨ Cerrahi HastalNklarN Hems$irelig˘i Anabilim DalN, Istanbul. Fontana, C. J., & Pittiglio, L. I. (2010). Sleep deprivation among critical care patients. Critical Care Nursing Quarterly, 33, 75Y81. doi:10.1097/CNQ.0b013e3181c8e030 Freedman, N. S., Kotzer, N., & Schwab, R. J. (1999). Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. American Journal of Respiratory and Critical Care Medicine, 159, 1155Y1162. doi:10.1164/ ajrccm.159.4.9806141 Frisk, U., & Nordstro¨m, G. (2003). Patients’ sleep in an intensive care unitVPatients’ and nurses’ perception. Intensive and Critical Care Nursing, 19, 342Y349. doi:10.1016/S0964-3397 (03)00076-4 Gabor, J. Y., Cooper, A. B., Crombach, S. A., Lee, B., Kadikar, N., Bettger, H. E., & Hanly, P. J. (2003). Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. American Journal of Respiratory and Critical Care Medicine, 167, 708Y715. doi:10.1164/rccm.2201090 Hweidi, I. M. (2007). Jordanian patients’ perception of stressors in critical care units: A questionnaire survey. International Journal of Nursing Studies, 44, 227Y235. doi:10.1016/j.ijnurstu .2005.11.025 Johansson, P., Ole´nia, M., & Fridlund, B. (2005). Nurses’ assessments and patients’ perceptions: Development of the night nursing care instrument (NNCI), measuring nursing care at night. International Journal of Nursing Studies, 42, 569Y578. doi:10.1016/j.ijnurstu.2004.09.004
Le, A., Friese, R. S., Hsu, C. H., Wynne, J. L., Rhee, P., & O’Keeffe, T. (2012). Sleep disruptions and nocturnal nursing interventions in the intensive care unit. Journal of Surgical Research, 177, 310Y314. doi:10.1016/j.jss.2012.05.038 Lusk, B., & Lash, A. A. (2005). The stress response, psychoneuroimmunology, and stress among ICU patients. Dimensions of Critical Care Nursing, 24, 25Y31. McColl, E., Thomas, L., & Bond, S. (1996). A study to determine patient satisfaction with nursing care. Nursing Standard, 52, 34Y38. Mons6n, M. G., & Ed6ll-Gustafsson, U. M. (2005). Noise and sleep disturbance factors before and after implementation of a behavioral modification program. Intensive and Critical Care Nursing, 21, 208Y219. doi:10.1016/j.iccn.2004.12.002 Parthasarathy, S., & Tobin, M. J. (2004). Sleep in the intensive care unit. Intensive Care Medicine, 30, 197Y206. Rhodes, L., Miles, G., & Pearson, A. (2006). Patient subjective experience and satisfaction during the perioperative period in the day surgery setting: A systematic review. International Journal of Practice, 12, 178Y92. doi:10.1111/j.1440172X.2006.00575.x So, H. M., & Chan, D. S. (2004). Perception of stressors by patients and nurses of critical care units in Hong Kong. International Journal of Nursing Studies, 41, 77Y84. Tamburi, L. M., DiBrienza, R., Zozula, R., & Redeker, N. S. (2004). Nocturnal care interventions with patients in critical care units. American Journal of Critical Care, 13, 102Y112. Tembo, A. C., & Parker, V. (2009). Factors that impact on sleep in intensive care patients. Intensive and Critical Care Nursing, 25, 314Y322. doi:10.1016/j.iccn.2009.07.002 Thomas, L. H., McColl, E., Priest, J., Bond, S., & Boys, J. R. (1996). Newcastle satisfaction with nursing scales: An instrument for quality assessments of nursing care. Quality in Health Care, 5, 67Y72.
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Journal of Neuroscience Nursing
The Effect of Nocturnal Patient Care Interventions on Patient Sleep and Satisfaction With Nursing Care in Neurosurgery Intensive Care Unit Gu¨lay Altun Ug˘ras$, Sultan Babayigit, Keziban Tosun, Gu¨ler Aksoy, Yu¨ksel Turan
ABSTRACT Background: Sleep disturbance in an intensive care unit is a common problem. One of the main factors causing sleep disturbances in an intensive care unit is nocturnal patient care interventions. Aims and objectives: This study aims to determine the impact of patient care interventions performed at night in a neurosurgical intensive care unit on patients’ sleep and their nursing care satisfaction. Methods: The descriptive study was conducted on 82 patients in a neurosurgical intensive care unit between January 2009 and March 2010. The data were collected by data collection instruments and Newcastle Satisfaction with Nursing Scales. The data were statistically analyzed by frequency, mean, standard deviation, chi-square, and MannYWhitney U test. Results: The study showed that 53.7% of the patients experienced sleep disturbances in the neurosurgical intensive care unit. Because of nursing interventions at night, 39.1% of these patients had their sleep affected, but this problem did not cause any negative impact on the patients’ satisfaction (Newcastle Satisfaction with Nursing Scales score = 88.21 T 9.83). The patients received, on average, 42.21 T 7.45 times patient care interventions at night; however, the frequency of patient care interventions at night showed no effect on sleep disturbances in this study (p 9 .05). The most frequently given patient care interventions were, respectively, vital signs monitoring, neurological assessment, and repositioning in bed. These interventions were performed commonly at 6 A.M., 12 A.M., and 7 P.M. Conclusion: In this study, despite the patients reporting sleep disturbances in the neurosurgical intensive care unit because of nocturnal patient care interventions that prevented them from sleeping, the patients’ satisfaction on the given nursing care was not negatively impacted. To reduce sleep disturbances because of nursing care initiatives and promote uninterrupted sleep in the intensive care unit, it can be useful to develop new protocols regulating night care activities. Keywords: intensive care unit, nocturnal patient care interventions, nursing care satisfaction, sleep disturbances
Questions or comments about this article may be directed to Gu¨lay Altun Ug˘ras$, PhD RN, at [email protected]. She is an Assistant Professor, Health School of Surgical Nursing Department, Mersin University, Mersin, Turkey. Sultan Babayigit, RN, is a Registered Nurse, Istanbul Cerrahpas$a Medical Faculty, Neurosurgery Intensive Care Unit, Istanbul University, Istanbul, Turkey. Keziban Tosun, RN, is Head Nurse, Cerrahpas $a Medical Faculty, Neurosurgery Department, Istanbul University, Istanbul, Turkey. Gu¨ler Aksoy, PhD, is Professor, Nursing High School, Department of Surgical Nursing, Halic University, Istanbul, Turkey. Yu¨ksel Turan, RN, is a Registered Nurse, Istanbul Cerrahpas $a Medical Faculty, Neurosurgery Intensive Care Unit, Istanbul University, Istanbul, Turkey. The work was performed at the Intensive Care Unit, Department of Neurosurgery, Istanbul University Cerrahpas $a School of Medicine. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jnnonline.com). Copyright B 2015 American Association of Neuroscience Nurses DOI: 10.1097/JNN.0000000000000122
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leep is essential to generate the energy to recovery from illness (DeKeyser, 2003; Dennis, Lee, Woodard, Szalaj, & Walker, 2010; Fontana & Pittiglio, 2010). During sleep, protein synthesis and cell division are organized and result in a restorative process (Dennis et al., 2010). Sleep disturbance in intensive care units (ICUs) is a common and known problem (Bourne & Mills, 2004; DeKeyser, 2003; Fontana & Pittiglio, 2010). ICU patients may have difficulty in falling asleep; experience diminished rapid eye movement sleep and changes in their circadian rhythms; wake up more often than normal or be awakened because of noise, anxiety, pain, frequent treatments, and nursing care interventions and monitoring activities (Boyko, Krding, & Jennum, 2012; Cmiel, Karr, Gasser, Oliphant, & Neveau, 2004; DeKeyser, 2003). The negative effects of lack of sleep on ICU patients’ bodies can start to be observed within as little as 24Y48 hours. The rise in stress level increases the serum cortisol level. This causes a reduction
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Volume 47
in the number of lymphocytes and functional monocyte circulating in the bloodstream. As a result, natural killer cell activity and cytokine production decrease and then depression occur in the immune system (DeKeyser, 2003; Dennis et al., 2010). Additional negative responses include changes in respiration and ventilation (lack of separation from mechanical ventilation), vasoconstriction in peripheral blood vessels, gastrointestinal movement change, chemical variances in blood and urine, delayed wound healing, increased skeletal and muscular tension, thermoregulatory impairment, decreased glucose tolerance, increased insulin resistance, and ICU psychosis (Dennis et al., 2010; Fontana & Pittiglio, 2010; Tamburi, DiBrienza, Zozula, & Redeker, 2004). Frequent awakenings and sleep problems cause fatigue during the day. This results in development of symptoms such as anxiety, low mood or malaise, lack of concentration, and lower quality of life (Johansson, Ole´nia, & Fridlund, 2005; Tamburi et al., 2004). In addition to the development of delirium, it may lead to a prolonged ICU stay and an increase in mortality (Boyko et al., 2012; Tembo & Parker, 2009). During the night hours when the physiological tendency to sleep is at its highest level, the implementation of frequent care interventions can lead to a high risk of patient developing sleep deprivation (Tamburi et al., 2004). In the ICU, nursing interventions are usually performed at least once and sometimes even more in an hour. The average duration of sleepYwake cycle ranges from 90 to 120 minutes. Frequently performed interventions often leave patients with very little opportunity to relax and prevent them from having enough sleep (Dennis et al., 2010; Fontana & Pittiglio, 2010; Frisk & Nordstro¨m, 2003). Despite all the negative effects of nocturnal patient care on sleep, the main purpose of the nursing care given at night is to implement interventions to promote patient sleep and comfort (Johansson et al., 2005). Patients cannot control most of the environmental factors, such as sound, light, and comfort of the bed, which negatively affect their sleep. However, it is possible to limit these effects on patients of the hospital environment and routines. Grouping nocturnal care interventions allows uninterrupted periods to promote patient sleep (Cmiel et al., 2004; Tamburi et al., 2004; Tembo & Parker, 2009), which is required to maintain patients’ circadian rhythms (Fontana & Pittiglio, 2010). Despite all the negative effects of nocturnal patient care on sleep, the main purpose of the nursing care given at night is to design interventions to promote patient sleep (Johansson et al., 2005). Patients cannot control many environmental factors such as sound, light, and comfort of the bed that negatively affect their sleep. However, it is possible to limit the effect of hospital environment and routines to patients. Grouping
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This article examines the seeming contradiction between the negative effects of nocturnal patient care on sleep and the nursing interventions designed to promote better sleep. nocturnal care interventions allows uninterrupted periods to promote patient sleep (Cmiel et al., 2004; Tamburi et al., 2004; Tembo & Parker, 2009) and is required to maintain patients’ circadian rhythms (Fontana & Pittiglio, 2010). Determination of sleep disturbances in critical care enables the development of protocols and interventions to promote sleep (Tamburi et al., 2004). Although patient care activities focus on assessment and meeting patients’ needs, factors such as purpose, frequency, and time of the care interventions can affect some of the patients’ needs (eating and drinking, sleep, excretion, dressing, etc.) and nursing care satisfaction (Rhodes, Miles, & Pearson, 2006). It is important to determine patient satisfaction to meet and evaluate patient’s needs and then identify the appropriate nursing interventions (Akin & Erdogan, 2007). Although various studies in the literature have been conducted to identify nursing care interventions (C ¸ elik, ¨ Oztekin, Akyolcu, & Is$sever, 2005; Le et al., 2012; Tamburi et al., 2004) and patient satisfaction (Akin & Erdogan, 2007; McColl, Thomas, & Bond, 1996; Thomas, McColl, Priest, Bond, & Boys, 1996) during night shifts, the number of studies about the effect of nursing interventions applied in ICU at night on patients’ sleep and nursing care satisfaction was found to be insufficient that raises the need for further investigation. On the basis of this knowledge, this study was designed to determine the impact of nursing interventions applied at night on patients’ sleep and nursing care satisfaction in the neurosurgery ICU (NICU) and to identify the type and time of the interventions. Thus, it will be beneficial for nurses working in ICU to plan their intervention schedules to allow patients enough rest and maintain their circadian rhythms. The study sought to answer the following questions: 1. Do nursing interventions applied at night and their frequency affect patients’ sleep? 2. What times are nursing interventions applied intensively? 3. What type and times of the nursing interventions are applied more often?
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4. Does the frequency of nursing interventions affect patients’ satisfaction?
Methods Design and Consent The research was planned as a descriptive study to determine the effect of the nursing interventions applied at night on the patients’ sleep and nursing care satisfaction in the NICU. Written permission was requested from the hospital’s neurosurgery department, where the research was conducted in the NICU, and from the research ethics committee. In addition, oral and written consent was obtained from all the NICU nurses and patients before the research.
Study Settings and Sample The study population consisted of 110 patients hospitalized between January 2009 and March 2010 in the Department of Neurosurgery Intensive Care Unit, Istanbul University Cerrahpasa Medical Faculty Hospital. However, because 10 of these patients stayed only one night in NICU and 18 could not communicate sufficiently (e.g., because of Glasgow Coma Scale [GCS] score lower than 13 because of sedation medicine given, being connected to mechanical ventilator), the research was performed on 82 patients. The patients who stayed in the NICU for a minimum of two nights after surgery, were ready to be discharged, could read and write Turkish, were 18 years and over, constituted no health drawback for participating in the research (GCS score between 13 and 15), were conscious, and agreed to participate in the study were included. The patients with insufficient cognitive functions (GCS score below 13) who were given a sedative drug and connected to mechanical ventilator were excluded from the study. Although the Newcastle Satisfaction with Nursing Scales (NSNS), used for the reliability of the data obtained from the survey, recommended including at least 10 people for each item (19 10 = 190 people) in the study, it was reported that the sample number could be regulated according to the Cronbach’s alpha value based on the study conditions and scale (Akin & Erdog˘an, 2007; McColl et al., 1996; Thomas et al., 1996). In this study, the Cronbach’s alpha value was taken into consideration in determining the sample size. The Cronbach’s alpha value on the scale of 82 patients was .97.
Instruments and Procedure In this study, the data were collected using two instruments, which are available as Supplemental Digital
Content 1 at http://links.lww.com/JNN/A33. The first data collection instrument (A) was the questionnaire that was prepared by the researchers based on the literature and the opinions of one NICU physician and four clinical nurses. The questionnaire consisted of two parts. The first part of the questionnaire (A1) included the questions to determine the patients’ age, gender, the length of stay at NICU, the presence of any sleep disturbances, and the impact of ICU nursing interventions at night on their sleep. The second part (A2) was prepared for the nurses and provided a chart to mark their NICU nursing interventions applied at night (between 7 P.M. and 6 A.M.) on an hourly basis. The selection of this period was because of the nurses’ 12-hour shifts and the typical sleeping hours, when there was a high tendency to circadian sleep at patients. Tables included 15 patient-care activities typically carried out at night hours. These activities were performed by the nurse touching the patient at the bedside or with the help of medical equipment. The data used for patient care interventions at night included the applications during the patients’ second-night stay in the NICU. Because most of the patients may not have stable health conditions during the first night of their postoperative period after surgical intervention, their first night in the NICU was not used. The second data collection instrument (B) was NSNS. This scale was developed by Thomas et al. (1996) to determine patients’ experiences of and satisfaction with nursing care, based on their perspective. The Turkish validity and reliability were performed by Akin and Erdog˘an (2007). The patients, who were eligible for recruitment, were aged 18 years or older, were about to be discharged from the NICU, had spent two nights or more in the ward, were able to read and understand Turkish, were conscious, and agreed to complete the questionnaires (Akin & Erdog˘an, 2007). In this study, the second part of the ‘‘Satisfaction with Nursing Care Scale,’’ which was composed of 19 statements, was used. The first part, ‘‘Experiences of Nursing Care Scale,’’ was not preferred because it was too long for the patients in the ICU and required their clinical/intensive care experience. All statements on the ‘‘Satisfaction with Nursing Care Scale’’ are positive and scored on a 5-point Likert scale (1 = not at all satisfied, 2 = rarely satisfied; 3 = quite satisfied; 4 = very satisfied, and 5 = completely satisfied). The scale score is computed by adding the scores assigned to each question. The lowest score of the scale is 19, and the highest is 95. Score analysis is done by converting the total amount to 100 points, that is, the closer to 100 points, the higher the patient’s satisfaction with care, and the further away from 100 points, the lower the patient’s satisfaction (Akin & Erdog˘an, 2007; Thomas et al., 1996).
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Data Collection Between January 2009 and March 2010, the patients who transferred from the NICU with a capacity of eight beds to the service were given data collection instruments (A1, AB) in the NICU before they were transferred and requested to reply in their service. The patients were asked to fill in the nursing care satisfaction forms by taking into account only night-shift treatments (hours: between 7 P.M. and 6 A.M.). In addition, anonymity was requested when the patients were asked to complete the A1 and AB forms and return to the NICU secretary in sealed envelopes. The purpose of the study was explained, and the data collection tool (A2) was introduced to the NICU nurses. The nurses working at night were asked to mark on the A2 form their nursing interventions implemented at nights to the NICU patients. The A1, A2, and B tools were collected from the NICU by the researchers.
Data Analysis The collected data were analyzed using the Statistical Package for the Social Sciences for Windows 11.5 (SPSS, Chicago, IL). To interpret the data statistically, frequency, mean and standard deviation (SD), MannYWhitney U test, and chi-square (2 2) were used. The value alpha was considered .05.
Results In this study, 82 patients were monitored; 51.2% were men. The median age of the patients was 46.46 T 14.57 years. Of the 82 patients, 73.2% had been admitted to the NICU for the first time, and 91.5% were admitted because of the need for close follow-up of postsurgical procedures. Patients’ length of stay is 2.26 T 0.94 nights on average, and 89% had stayed for at least 2 days in the NICU. Figure 1 shows sleep disturbances and how nocturnal patient care interventions affect patient sleep in the NICU. In this study, 53.7% (n = 44) of the patients reported experiencing sleep disturbances, and 39.1% reported having sleep disturbances because of the nocturnal patient care interventions (Figure 1).
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Table 1 shows the effect of nocturnal patient care frequency on the patients’ sleep disturbances. The patients received nocturnal patient care, on average, 42.21 T 7.45 times/night. It was determined that the frequency of nocturnal patient care interventions did not create a statistically significant difference on patients’ sleep disturbances or on patients encountering sleep disturbances because of patient care interventions (p 9 .05; Table 1). Figure 2 illustrates the patient care interventions between the hours of 7 P.M. and 6 A.M. in the NICU. It was observed that, during nighttime (7 P.M.Y6 A.M.), the number of patient care interventions administered by nurses was highest, respectively, at 6 A.M. (6.8 T 3.0), 12 A.M. (5.6 T 2.4), and 7 P.M. (3.6 T 2.5). The number of patient care interventions by nurses per hour ranged between 2.6 T 0.9 and 6.8 T 3.0 (Figure 2). Table 2 shows the types of patient care interventions at the NICU and the hours they were frequently administered. These interventions are categorized as assessment, diagnostic testing, treatment, and hygiene. It was found out that the nurses in the NICU, under the scope of assessment, monitored patients’ vital signs, on average, 12 T 0.00 times/night (administered all hours) and performed patients’ neurological assessment 11.70 T 1.47 times/night (administered frequently all hours); for diagnostic testing, took patients’ blood samples (blood glucose testing, blood gas analysis, etc.) 3.58 T 1.68 times/night (most frequently at 7 P.M., 8 P.M., 12 A.M., 4 A.M., and 6 A.M.); as part of treatment interventions, gave catheter/wound care 2.87 T 2.63 times/night (most frequently at 7 P.M., 12 A.M., and 6 A.M.), administered treatment 1.77 T 1.19 times/night (most frequently at 8 P.M., 12 A.M., and 6 A.M.), and fed the patients (oral or nasogastric) 1.41 T 1.71 times/night (most frequently at 7 P.M., 12 A.M., 2 A.M., 4 A.M., and 6 A.M.); and for hygiene, repositioned patients in bed 4.54 T 6.35 times/ night (administered frequently all hours), gave oral care 1.43 T 0.71 times/night (most frequently at 7 P.M., 12 A.M., 2 A.M., 4 A.M., and 6 A.M.), gave eye care 1.31 T 0.65 times/night (most frequently at 7 P.M., 12 A.M., 2 A.M., and 6 A.M.), and gave a bed bath 1.01 T 0.53 times/ night (most frequently at 12 P.M., 2 A.M., and 6 A.M.; Table 2).
FIGURE 1 Patients’ Sleep Disturbances and the Effect of Nocturnal Patient Care Interventions on the Patients’ Sleep
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TABLE 1.
Patients Encountering Sleep Disturbances According to the Frequency of Nocturnal Patient Care Interventions in the NICU Frequency of Nocturnal Patient Care
Variable
21Y42 Times/Night
Encountering sleep disturbances in the NICU
43Y64 Times/Night
n
%
n
%
Yes
29
55.8
15
50
No
23
44.2
15
50
11
36.7
19
63.3
d statistica and p value
5.8, .784
Encountering sleep disturbances because of NICU patient care interventions Yes
23
44.2
No
29
55.8
d statistica and p value Mean average of nocturnal patient care
7.5, .662 42.21 T 7.45
Note. The chi-square test (continuity correction value taken). NICU = neurosurgery intensive care unit. a d statistic: effect size.
Table 3 presents the nursing care satisfaction scores according to some of the patients’ characteristics. According to NSNS, nursing care satisfaction scores given by the patients were found to be 92.90 T 10:35. The patients’ intensive care experience, length of stay at the NICU, sleep disturbances, sleep disturbances because of the patient care interventions at the NICU, and frequency of nocturnal patient care interventions did not imply a statistically significant difference on patients’ nursing care satisfaction levels (p 9 .05; Table 3). Most of the patients (78%, n = 64) had higher satisfaction on the scale sections, such as ‘‘how quickly nurses responded to their requests,’’ ‘‘the amount of privacy they were given,’’ and ‘‘attitude at work’’; on the other hand, their satisfaction scores for ‘‘the amount of freedom they were given on the ward’’ were observed to be low (31.7%, n = 26).
Discussion This study showed that more than half of the patients at the NICU encountered sleep disturbances
and continuous nocturnal patient care interventions disturbed less than half of the patients’ sleep during nighttime when patients’ circadian sleep propensity was high. However, this did not affect the patient care satisfaction. There are different perspectives on how nocturnal patient care interventions impact patients’ sleep. In some studies (C ¸ elik et al., 2005; Le et al., 2012; Tamburi et al., 2004), it has been reported that nocturnal treatment and patient care interventions affected sleep in a negative way; however, in the other studies (Frisk & Nordstro¨m, 2003; Gabor et al., 2003; Parthasarathy & Tobin, 2004), the effect on sleep had not been found too notable and reportedly caused sleep disturbances of around 10%Y17% (Parthasarathy & Tobin, 2004). Gabor and colleagues (2003) determined that patient care activities during sleep time caused 17.7% T 5% of sleep disturbances and only accounted for 7.1% T 4.4% of the total times of waking up or being woken up. In a different study, it was reported that patient care interventions during sleep hours (10 P.M.Y 6 A.M.) were frequent and acted as the primary factor in
FIGURE 2 Frequency of Patient Care Interventions in the Neurosurgery Intensive Care Unit Between 7 P.M. AND 6 A.M.
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TABLE 2.
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Types of Patient Care Interventions and Frequently Administered Times Between 7 P.M. and 6 A.M. in the NICU Mean T SD
Patient Care Intervention Categories
Frequently Administered Times
Assessment 12 T 0.00
All hours
11.70 T 1.47
All hours
Taking blood sample (for blood glucose testing, blood gas analysis, etc.)
3.58 T 1.68
7 P.M., 8 P.M., 12 A.M., 4 A.M., 6 A.M.
Patient’s transfer to another department (for computed tomography or magnetic resonance, etc.)
0.09 T 0.28
6 A . M.
Giving catheter/wound care
2.87 T 2.63
7 P.M., 12 A.M., 6 A.M.
Administering treatments
1.77 T 1.19
8 P.M., 12 A.M., 6 A.M.
Oral or nasogastric feeding
1.41 T 1.71
8 P.M., 12 A.M., 6 A.M.
Monitoring vital signs Doing neurological assessment Diagnostic testing
Treatment
Putting on varicose vein socks
0.39 T 0.79
6 A . M.
Applying cold when body temperature is elevated
0.22 T 0.67
6 A . M.
Administering blood products (erythrocyte, plasma)
0.09 T 0.39
7 P.M.
4.54 T 6.35
All hours
Giving oral care
1.43 T 0.71
7 P.M., 12 A.M., 2 A.M., 4 A.M., 6 A.M.
Giving eye care
1.31 T 0.65
7 P.M., 12 A.M., 2 A.M., 6 A.M.
Giving a bed bathing
1.10 T 0.62
12 A.M., 2 A.M., 6 A.M.
Giving hair care
0.44 T 0.61
6 A . M.
Hygiene Positioning and repositioning in bed
Note. NICU = neurosurgery intensive care unit.
TABLE 3.
Nursing Care Satisfaction According to the Clinical Characteristics of the Sample NSNS Point, Mean T SD
d Statistica and p Value
Yes
89.45 T 13.21
4.71, .359
No
94.16 T 8.88
Variable ICU experience
Length of stay in NICU Minimum of 2 nights
92.63 T 10.02
3Y8 nights
95.11 T 13.20
2.48, .103
Sleep disturbance at NICU Yes
92.52 T 11.00
No
93.34 T 9.68
0.82, .776
Sleep disturbance at NICU because of patient care interventions Yes
92.11 T 11.44
No
93.45 T 9.59
1.34, .470
Frequency of nocturnal patient care 21Y42 times/night
92.26 T 10.51
43Y64 times/night
94.00 T 10.16
Total satisfaction score
1.74, .072 92.90 T 10.35
Note. MannYWhitney U test. NSNS = Newcastle Satisfaction with Nursing Scales; NICU = neurosurgery intensive care unit. a d statistic: effect size.
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sleep disturbances (Le et al., 2012). In this study, similar to the results of Le and colleagues (2012), most of the patients experiencing sleep disturbances pointed to patient care interventions as the cause. This number was higher than the results found by Gabor and colleagues as well as the percentage in the literature (10%Y17%). In addition, it accounted for sleep disturbances in more patients. C ¸ elik and colleagues (2005) reported that nurses interacted with each patient, on average, 51 times to practice patient care activities. In the same study, nurses stated that patients’ sleep was disturbed frequently for diagnosis and patient care activities and patients did not get enough sleep in ICU. In our study, the average number of interactions with each patient was lower than the results of C¸elik and colleagues, but it was close (42.6) to Tamburi and colleagues’ (2004) result. In our study, as similar to the two studies before, patient care interventions had been continuous throughout the night, and most of the patients who experienced sleep disturbances reported that their sleep disturbances were because of the patient care interventions. However, in this study, the frequency of nocturnal patient care interventions did not show a statistically significant difference in patients experiencing sleep disturbances because of patient care interventions. The times when the most frequent patient care interventions were administered were at 6 A.M., 12 A.M., and 7 P.M. The reason that the frequency of patient care interventions did not have an impact on sleep disturbances might be because of the fact that these hours coincided with the times when the patients were mostly awake. The 10 most frequent patient care activities were, respectively, (a) monitoring vital signs, (b) performing a neurological assessment, (c) repositioning in bed, (d) taking a blood sample, (e) giving catheter/wound care, (f) administering treatments, (g) feeding, (h) giving oral care, (i) giving eye care, and (j) bathing. When the hours for intense patient care interventions were considered, it was observed that these hours coincide with the nurses’ shift change hours. The interventions frequently taking place at these hours were patient assessment before and after the shift change (monitoring vital signs, performing a neurological assessment), treatment (administering treatment, taking blood samples), and hygiene interventions (positioning in bed, giving catheter/wound care, giving oral care, giving eye care, bathing). At the NICU where the study was conducted, continuous hourly monitoring of vital signs and making neurological assessments throughout the night were common procedures for early diagnosis of intracranial pressure increase risk on neurosurgical patients during the postoperative period. In some studies conducted at different ICUs, monitoring vital signs was found to be less disturbing than the other factors such as environment
(noise, lighting), nursing interventions such as bed bathing, and diagnostic tests (chest x-ray; Altun Ug˘ras$ ¨ ztekin, 2007; Freedman, Kotzer, & Schwab, 1999). &O On the other hand, hourly neurological assessments were reported as the most disturbing patient care in¨ ztekin, 2007; Mons6n & tervention (Altun Ug˘ras$ & O Ed6ll-Gustafsson, 2005). In the study, in terms of the frequency of patient care interventions, which were reported to be less frequent, it can be said that the short duration of stay and the need-based realization of patient care interventions at the NICU might have had an impact on this. The patients were more affected by the time of the patient care interventions rather than their frequency. In the literature, it is reported that patient care interventions are (Erkal, 1994) commonly administered between 2 A.M. and 5 A.M. to conscious patients (C ¸ elik et al., 2005) and particularly disrupt rapid eye movement sleep (Lusk & Lash, 2005). Tamburi and colleagues (2004) stated that 62% of in-bed bathing was carried out between 9 P.M. and 6 A.M. In this study, too, this was carried out during nighttime hours and disturbed patients’ sleep. Undertaking hygiene interventions (in-bed bathing, oral care, eye care, etc.) during the daytime, when patients are awake, would create an opportunity for undisturbed sleep at night. In the study, it was observed that the patients were satisfied with nocturnal patient care interventions, and the patients’ NICU experience, length of stay at the NICU, encountering sleep disturbances in the NICU, and encountering sleep disturbances because of nocturnal patient care interventions did not have a negative effect on patient care satisfaction. It had been noted that the patients had high level of satisfaction in terms of ‘‘how quickly nurses responded to their requests,’’ ‘‘the amount of privacy they were given,’’ and ‘‘attitude at work,’’ whereas the satisfaction level for ‘‘the amount of freedom they were given on the ward’’ was low. In Johansson and colleagues’ (2005) study in which a nocturnal patient care instrument was developed and measured nocturnal patient care, it was reported that 55% of patients had a positive perception of nocturnal patient care. In the same study, patients’ satisfaction regarding ‘‘night rest’’ was low (Johansson et al., 2005). In this study, although nocturnal patient care interventions in the NICU kept patients awake and caused patients reporting sleep disturbances, patients’ satisfaction was not impacted negatively by the administered patient care. When the NSNS items with high satisfaction points were taken into consideration, nurses almost never leaving the patients alone on their own and their attitude while attending to them might have resulted in patients feeling safe in a foreign hospital environment. In the past studies, patients had reported feeling uncomfortable with being naked in ICU
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 47
(Hweidi, 2007; So & Chan, 2004) and their sleep being affected because of this feeling (Altun Ug˘ras$ ¨ ztekin, 2007). ‘‘Respecting their privacy’’ might &O have strengthened patients’ confidence in the nurses. Although sleep, as one of the basic necessities, was affected, patients’ satisfaction of nursing care suggests that the sense of confidence surpassed the sense of comfort.
Limitations There are some limitations to this study. The first one is that sleep was not evaluated with clinical sleep studies (such as polysomnography) providing an objective assessment. Instead, it was subjectively assessed by the patient responses. The second limitation is that the NICU nurses were asked to record the care they gave to the patients; this may cause deviation (bias) in the results. In addition, focusing only on the effect of nursing care given at night on sleep can be considered as the third limitation in the study because sleep does not only depend on this factor; other factors such as light, noise, bed comfort, pain, anxiety, and so forth should be taken into account. The fourth limitation is that the information regarding nursing care activities reflects the second evening after surgical intervention. In other limitations, the mean length of the patients’ stay in the NICU was only 2 days. This time may be shorter for patients to experience sleep disturbances and affect their care satisfaction.
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lighting, noise, bed comfort, pain, anxiety, etc.) on sleep patterns and total quality sleep time; combining or grouping nursing care activities performed at night, creating uninterrupted sleep periods for patients, and examining the frequency of ICU patients’ sleep disturbances and their sleep quality; and investigating sleep patterns and nursing care satisfaction for the patients hospitalized in the ICU for a long time.
Summary Sleep disturbance is a common problem in the ICU. In this study, more than half of the patients in the NICU experienced sleep disturbances. However, it was observed that nocturnal patient care interventions at night affected less than half of the patients’ sleep. Although sleep, as one of the fundamental patient requirements, was affected, the patients’ satisfaction with nursing care at night was still high. To reduce sleep disturbances because of nursing care initiatives and to promote uninterrupted sleep in the ICU, it may be useful to develop new protocols regulating night care activities.
Acknowledgments We thank Atilla Bozdog˘an, Statistician, for supporting the statistical analysis reports and all the intensive care nurses and the patients participating in our study.
Recommendations To reduce patients’ sleep disturbances in the NICU because of nursing activities, nurses should:
coordinate nursing care to allow patients to sleep undisturbed for up to 90Y120 minutes, combining or grouping nursing care activities to achieve this (e.g., if the patient awakens and requests pain medication, use that time to check vital signs, if needed, and conduct any necessary neurological assessment); enhance uninterrupted sleep at night and develop protocols that will regulate care activities; and maintain patients’ normal sleep patterns and carry out assessment, treatment, and especially, hygiene interventions and routine applications during the patient’s awake periods.
For future studies, the following may be recommended: evaluating sleep with a polysomnographic method to provide objective data, determining ICU patients’ sleep disturbances and their factors, and investigating the effects of these factors (nursing activities,
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