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Sleep is utterly central to our lives and our well-being. Unfortunately, when people are sick enough to be in hospital, they are in an environment which is for the most part hostile to sleep. Intensive care units (ICUs) are probably the least restful places in hospitals due to the high levels of nursing and other activities 24 hours a day, painful conditions, invasive procedures, environmental noise and anxiety. This is not a new problem, but it seems that it is a very persistent one. This paper by Çelik et al. is a welcome reminder to all those who work in this field that action is needed to minimize night-time disruptions in ICUs.

Probably the earliest mention in the nursing literature of how difficult it is to sleep in ICU was almost 30 years ago. A small US study monitored sleep using electroencephalogram and showed that the nine patients they observed in ICU only got 2.4 hours sleep over 24 hours (Hilton 1976). This was later shown also to be the case in the UK, where a similar study again of nine ICU patients showed that they had less than two hours sleep in 48 (Aurell & Elmqvist 1985). Since that time, sophisticated (and noisy) equipment has proliferated, and a series of studies has described the difficulties of creating a restful environment where intensive therapy is delivered round the clock (e.g. Gabor et al. 2003). A few have assessed the effectiveness of interventions designed to improve the sleep of ICU patients, such as reductions in noise and light levels (e.g. Walder et al. 2000) and the masking of noise (e.g. Williamson 1992).

This paper is a useful addition to the existing literature, the first that we are aware of set in an ICU in Turkey. It identifies some of the issues which might be tackled by nurses in order to improve the chances of their patients getting a decent night's sleep. The paper is, however, quite brief, leaving us with questions about some of the details of the method, data collection results and conclusion of the study which were not entirely clear.

Method

  1. Top of page
  2. Method
  3. Data collection
  4. Results
  5. Conclusion
  6. References

The rationale for undertaking this study is not made explicit – why was the main focus a comparison of the care of sedated and non-sedated patients? Presumably, there was a hypothesis about differences in the way these groups are treated during the night, for example an expectation that sedated patients would require more care and therefore undergo greater disruption, or that the sleep of sedated patients would be less respected and that they would undergo more non-urgent care.

It would have been helpful to provide justification for the size of the sample and explain the method of random selection. Sample size might have been determined by a power calculation based on the anticipated size of group differences in a primary outcome, for example the length of time patients were left undisturbed during the night-time period. Without this, we cannot be certain that enough patients have been included in the study to show a statistically significant difference between the two groups. It is not clear whether patients were selected for inclusion in the study using a formal randomization process, such as by using random-number tables, or if it was a convenience sample. Consequently, it is not possible for the reader to assume that this sample was representative of the population of patients in this ICU (although it may have been).

Data collection

  1. Top of page
  2. Method
  3. Data collection
  4. Results
  5. Conclusion
  6. References

The exact roles of the self-report diary and the retrospective chart review are a little difficult to follow. The results seem to refer to the nursing activities recorded on the charts and no mention is made of the data in the diaries. Was the self-reporting diary completely free-form, so that nurses could write down any activity that they undertook, or was it structured in some way? For example, were nurses given a list of the activities being monitored, so that they had a prompt to remind them to record specific activities?

There is no mention of the sample of nurses who completed the charts or the activity diaries (if indeed they did this). There is a possible source of bias here – for example, did 10 different nurses make recordings for sedated patients and only two for the non-sedated patients? It would be interesting to know whether similar numbers of nurses reported on each group and whether particular nurses looked after patients from both groups while others only looked after those from one of the groups.

The perennial problem of the accuracy of nurses’ reporting is not explored in any detail. If they were busy, it would be possible that they did not write down everything that they did. It would be useful to know what checks were made on the validity of the nurses’ recordings. For example, a researcher might have observed a systematically selected sub-sample of nurses for two-hour stretches and compared their own recordings of activity with those of the nurse for that period.

Results

  1. Top of page
  2. Method
  3. Data collection
  4. Results
  5. Conclusion
  6. References

It is not stated whether there were any differences between sedated and non-sedated patients that may have influenced the results. For example, if the sedated group was significantly older than the non-sedated group, might this have contributed to a greater need for mechanical ventilation? At face value, the results appear to confirm what is already known – people who are sedated are more likely to be ventilated because sedation depresses respiratory function.

In Fig. 1, it would have been useful if a distinction had been made between those activities which might disrupt sleep, such as suctioning and neurological assessment, and those which do not, for example monitoring central venous pressure. Some of the activities may or may not be disruptive but not enough information is given for the reader to decide. For example, whether ‘medicine application’ is likely to disrupt sleep depends upon the medication, route of administration and the state of the patient. Some activities which normally interfere with sleep may, in certain circumstances, be sleep promoting, such as administering analgesics to prevent breakthrough pain, or suctioning a patient with some respiratory distress and who is awake.

Some of the findings are surprising and are worthy of further discussion. Figure 1 appears to show that during the three nights a maximum of only 6.7% of patients were repositioned during the 12-hour period from 1900 to 0700 hours. Unless the patients were all on very expensive ‘turning’ beds, this figure should be near 100%. This would suggest one of three things: the unit in the study was unusually well resourced; patient positioning was not taken seriously; or that the data collection method did not pick up this common, disruptive but important nursing activity. Knowing which of these possibilities reflects reality would help other units to incorporate this work into their own protocols. This issue is again illustrated by the seemingly low number of patients who were fed orally or nasogastrically during the 12-hour night shift. Is it the unit which is unusual or the study not picking up the activities? It would be interesting to hear the authors’ views on these issues.

Figure 2 is difficult to read as the key is very small. It would have been interesting to have simplified this by prioritizing activities into, for example, essential and non-essential or urgent and non-urgent to see whether certain types of activity were reduced during the night. As it stands, Fig. 2 shows peaks in overall activity at midnight, 2 a.m. and 4 a.m. This is plainly not conducive to sleep, and is worthy of further consideration.

The differences between the groups in terms of mechanical ventilation control and endo-tracheal suction are mentioned as statistically significant, but no further explication is provided. Is this difference used as a confirmation that the data collection method is working, or can some clinical significance be inferred? As there is no indication of sleep quality, we cannot infer that either group slept better than the other.

Finally, it is interesting that all nursing activities are accounted for in the figures and that no activities come under the banner of ‘other’. For example, did none of the patients have their ventilation tubing changed or have DVT prophylactic stockings put on or taken off, two common night-time tasks?

Conclusion

  1. Top of page
  2. Method
  3. Data collection
  4. Results
  5. Conclusion
  6. References

We would question the conclusion that during the night shift nurses focus on those activities ‘which will maximize what is seen to be physiological stability?’ The peak of certain types of care during the early hours, in particular bedbath, decubitus ulcer care and catheter change, suggests a different interpretation: that these low priority, messy, or potentially time-consuming tasks are being fitted in when the unit is quiet. It is often difficult for nurses to find the time to do these jobs during the day when patients are being bombarded by various people and interventions. Intensivists, surgeons, physiotherapists, dieticians, pharmacists, phlebotomists and respiratory technicians may all need to visit and the patient may need to undergo procedures on and off the unit. During all of these activities, their relatives will be waiting outside, tense and anxious. Is it any surprise that a nurse may feel reluctant to give the patient a bedbath or change a dressing during the day when someone can do it at night without interrupting the patient's day and risk causing the relatives further distress?

In conclusion, we suggest that a longer version of this paper with more methodological detail and in-depth discussion of the clinical significance of the results would have increased its usefulness. As is usually the case, this piece of research highlights more issues than it resolves and provides clues for where to go next in this very important area. To devise a working sleep protocol, the care given during the whole 24-hour period needs to be considered as those activities sidelined in the day will inevitably surface during the night. A distinction needs to be made between essential and non-essential (or urgent and non-urgent) activities, and those activities which are disruptive to sleep need to be separated from those which are not. For patients to get better sleep, these findings need to be used to provide an integrated plan that co-ordinates the work of all members of the caring team, from cleaners to consultants, and takes account of the needs of the patient and their family. Nurses are in the key position to do this.

References

  1. Top of page
  2. Method
  3. Data collection
  4. Results
  5. Conclusion
  6. References
  • Aurell J & Elmqvist D (1985) Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving post-operative care. British Medical Journal 290, 10291032.
  • Gabor JY, Cooper AB, Crombach SA, Lee B, Kadikar N, Bettger HE & Hanly PJ (2003) Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. American Journal of Respiratory Critical Care Medicine 167, 708715.
  • Hilton BA (1976) Quantity and quality of patients’ sleep and sleep disturbing factors in a respiratory intensive care unit. Journal of Advanced Nursing 1, 435468.
  • Walder B, Francioli D, Meyer J-J, Lançon M & Romand J-A (2000) Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels. Critical Care Medicine 28, 22422247.
  • Williamson J (1992) The effect of ocean sounds on sleep after coronary artery bypass graft surgery. American Journal of Critical Care 1, 9197.