Running head: SLEEP QUALITY OF HOSPITALIZED PATIENTS

A Need for Improved Sleep Quality of Hospitalized Patients

Karen Hatch
University of Arizona

SLEEP QUALITY OF HOSPITALIZED PATIENTS

A Need for Improved Sleep Quality of Hospitalized Patients

Proper sleep and rest is an important part of maintaining adequate health. The average
adult needs between 7- 8 hours of sleep a night (Gellerstedt, Medin, & Karlsson, 2014);
however, ill patients often require more rest and sleep than healthy adults (Stockert, 2013). Sleep
provides healing and restoration that is particularly important for those recovering from illness
and injury (Stockert, 2013). Despite the well documented need for sleep in the critically ill
patient to promote healing, physical and emotional wellness, mood, and pain control many
environmental aspects of the hospital and current hospital protocol are not conducive for proper
sleep hygiene and fail to promote adequate sleep for patients during hospitalization (Gellerstedt,
2014). Although there are certain medications that can help reduce sleep latency and promote
prolonged sleep duration these medications often have undesired and dangerous side effects
including respiratory depression and many potential drug interactions (Lehne, 2013). Despite the
use of some of these drugs, such as sedative-hypnotics, analgesics, and antidepressants that assist
with sleep promotion, many hospitalized patients experience significantly less than the
recommended amount of sleep for a healthy adult and sleep is often fragmented (Bernhofer,
Higgins, Daly, Burant, & Hornick, 2013).
To advance understanding of the patients experiences of sleep in the hospital setting and
to assist in identifying aspects of the hospital environment, current protocol, and health care
provider practices with implications to improve quality and quantity of sleep for inpatients, the
author reviewed several studies addressing these matters. The author conducted the literary
review using five research articles published in five separate nursing peer reviewed journals. The
following five research articles have been published within the past five years and are presented
from most to least current.

SLEEP QUALITY OF HOSPITALIZED PATIENTS

Literature Review Results

Patients Experiences of Sleep in Hospital: A Qualitative Interview Study
The Gellerstedt et al. study was conducted using a qualitative descriptive design with the
aim of exploring and describing patients experiences of sleeping in the hospital (2014). The
study is based on qualitative semi-structured interviews conducted between the primary
researcher and ten patients (Gellerstedt et al., 2014). Patients were recruited from three wards at
a university hospital in central Sweden (Gellerstedt et al., 2014). Interviews began with an open
question, Could you tell us about your experiences of sleeping in the hospital? to encourage
patients to share their experiences openly with the interviewer (Gellerstedt et al., 2014). The
interviewer then followed up with two semi-structured questions, the first focused on the
relationship between sleep and health and the second encouraged the interviewees to share their
suggestions for how patients sleep should be managed while in the hospital (Gellerstedt et al.,
2014). All interviews were recorded and transcribed and responses were then analyzed by
qualitative content analysis (Gellerstedt et al., 2014). Four themes emerged: bedside manner,
physical factors, being involved, and integrity (Gellerstedt et al., 2014).
Beside manner describes the interactions that took place between patients and nurses and
includes both verbal and non-verbal communication (Gellerstedt et al., 2014). Positive body
language and communication promoted feelings of security and helped patients to feel relaxed
thus facilitating better sleep (Gellerstedt et al., 2014). The opposite was true when nurses
demonstrated a lack of caring at the bedside and their verbal and non-verbal communication
produced feelings of abandonment and insecurity that negatively affected sleep (Gellerstedt et
al., 2014). Physical factors included environmental features of the hospital, patients perceived
conditions, and the influence of drugs and treatment (Gellerstedt et al., 2014). Environmental

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factors reported by patients included uncomfortable beds, pillows, and bed clothes, misplaced
lighting, and certain disturbing sounds (Gellerstedt et al., 2014). The third theme identified in the
Gellerstedt et al. study, being involved, refers to the patients influence on and involvement in
their own care. The patients verbalized a desire for the opportunity to continue with sleep
routines that more closely resembled those which they were accustomed to at home (Gellerstedt
et al., 2014). Integrity, the fourth and final theme addressed aspects of patient privacy and how
the experiences of interaction with other patients impacted their sleep (Gellerstedt et al., 2014).
Patients desired to be cared for in single rooms because it strengthened their integrity and kept
them from feelings of concern over disrupting other patients (Gellerstedt et al., 2014).
Although the qualitative design of the Gellerstedt et at. study and the studys semistructured interviews proved to be an effective method for exploring and describing patients
experiences sleeping in the hospital the information collected may be limited due to the use of
only three questions (2014). Preliminary analysis was subject to review from multiple authors
and categories, codes, and themes were found to be consistent or were discussed by authors until
a consensus was reached (Gellerstedt et al., 2014). This procedure was conducted to ensure that
the interpretations were reliable and rigorous and provide strength to Gellerstedt et al. study.
The Experience of Sleep Deprivation in Intensive Care Patients: Findings from a Larger
Hermeneutic Phenomenological Study
This qualitative phenomenological study looks at sleep deprivation in critically ill
patients in the intensive care unit (ICU) at a large regional hospital in New South Wales,
Australia (Tembo, Parker, & Higgins, 2013). Twelve participants between the ages of 20 and 76
years who were hospitalized in the ICU for a duration of time ranging from 3-36 days were
recruited for this study (Tembo et al., 2013). The purpose of the Tembo et al. study was to

SLEEP QUALITY OF HOSPITALIZED PATIENTS

describe the experience of critical illness in the ICU specifically involving patients who
underwent daily sedation interruption (DSI) and how this impacted the patients while in the
hospital and after discharge. In depth face to face interviews were conducted with all twelve
participants two weeks after discharge from the ICU, followed by a second interview with eight
of the original twelve participants six to eleven months later (Tembo et al., 2013). The
researchers of the Tembo et al. study used an interview guide with open ended questions
designed to explore the patients experiences. All interviews were tape recorded, transcribed, and
analyzed thematically. Sleep deprivations emerged as a major concern for eight of the twelve
patients initially interviewed. Two of the themes, Longing for normal sleep and Being
tormented by nightmares highlighted the concerns of participants related to sleep (Tembo et al.,
2013, p.310). The Tembo et al. study demonstrates that patients experience sleep deprivation at
various stages of their illness while in the hospital and after discharge.
This study targeted a highly specific subpopulation of the ICU and the findings of this
study may not accurately represent the hospital patient population in its entirety. Further studies
should be conducted to investigate these themes and there relevance in other hospital
subpopulations. Strengths of this study include a diverse participant demographic including a
wide range of reason for hospital admission, an age range of 56 years, and a varied period of
days spent in the ICU. This study was strengthened further by the use of reflexivity throughout;
assumptions, preconception, and beliefs relating to the study were identified, monitored and
discussed as the data was collected and analyzed (Tembo et al., 2013).
Hospital Lighting Association with Sleep, Mood, and Pain in Medical Inpatients
Hospital lighting has been documented as significantly low (50-300 lux) worldwide with
nurses and other healthcare staff often adjusting lighting to subdued levels based on the

SLEEP QUALITY OF HOSPITALIZED PATIENTS

assumption that this will promote patients rest and sleep (Bernhofer, Higgins, Daly, Burant, &
Hornick, 2013). However, this practice may be inadequate for maintaining the human bodys
circadian rhythms (Bernhofer et al., 2013). The aim of the Bernhofer et al. study was to describe
light exposure, sleep-wake patterns, mood, pain, and their relationships in adult medical patients
(Bernhofer et al., 2013).
Five inpatient medical units at a large academic medical center in the Midwest U.S.
emerged as the setting for this yearlong study (Bernhofer et al., 2013). The Bernhofer et al. study
used a descriptive correlational design that produced findings from the analysis of 40 cases. The
Heitkemper and Shaver Human Response Model (HRM) was used to conduct the investigation
among relationships of person, environment, and individual adaptation (Bernhofer et al., 2013).
In this study person was the medical inpatient environment was light exposure, and
individual adaptations included sleep-wake patterns, mood, and pain (Bernhofer et al., 2013).
The measurements of these three individual adaptations and their correlation with each
participant and their sleep-wake patterns comprise the findings of this study. Light exposure and
sleep-wake patterns were measured using actigraph watches with built in light meters that each
participant wore for 72 continuous hours (Bernhofer et al., 3013). Mood was measured using the
Profile of Mood States Brief Form (POMSTM Brief) completed by the participants at the
beginning of the study and each morning during the study (Bernhofer, 2013). Participants
subjective pain levels were measured using a Numerical Rating Scale of 0 10 with 0 being no
pain and 10 signifying the worst pain imaginable (Bernhofer et al., 2013). Amounts and types of
opioid analgesics administered to the participants for pain were tracked electronically and
converted to oral morphine equivalents for comparison (Bernhofer et al., 2013). Participants
were exposed to low light levels 24 hours a day, demonstrating a lack of the natural fluctuations

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between bright and low light required to maintain circadian rhythm (Bernhofer et al., 2013). The
rest-activity patterns of the participating patients coupled with low intra-daily stability scores
revealed restless sleep and little circadian synchronization (Bernhofer et al., 2013). The findings
of the Bernhofer et al. study showed that changes in light exposure levels were associated with
differences with mood and fatigue. Several consistent relationships were produced; an inverse
relationship existed between light levels and fatigue, with fatigue and pain positively and highly
correlated and low light exposure predicting fatigue and total mood disturbance (Bernhofer et al.,
2013).
This novel study used several measurement tools to provide data on light exposure and
sleep-wake activity and to assess mood and subjective pain levels of participants. All of these
measurement tools were either assessed extensively before use in this study or in previous
studies and demonstrated validity and reliability strengthening the findings of the Bernhofer et al
study (2013). One weakness of this study is its sample size which failed to reach statistical
significance to allow for generalizability (Bernhofer et al., 2013). Further studies should expand
upon concepts developed in this study while prioritizing the importance of recruiting a larger
patient population that will allow for greater application.
Sleep Quality of Hospitalized Patients in Surgical Units
The purpose of this study was to determine sleep quality of patients hospitalized in
surgical units and the factors that influence their sleep during this time in the hospital (Yilmaz,
Sayin, & Gurler, 2012). Randomized descriptive method was used to conduct the Yilmaz et al.
study and data were collected by means of the Pittsburg Sleep Quality Index (PSQI). The
questionnaire aimed at gathering personal information about patients and the factors influencing
their sleep (Yilmaz et al., 2013). A total of 411 patients at Sivas Cumhuriyet University Health

SLEEP QUALITY OF HOSPITALIZED PATIENTS

Services Research Hospital in Turkey completed the PSQI questionnaire (Yilmaz et al., 2013).
The sleep components scores of the patients during their last week in the hospital were compared
to their scores as reported during a preadmission period at home (Yilmaz et al., 2013). Results
from the questionnaire showed a decrease in subjective sleep quality, an increase in sleep
latency, and a decrease in total sleep (Yilmaz et al., 2013). Sleep disturbances as reported by
patients are as follows: noise and people entering and exiting the room (92.9%), sleeping hours
of the hospital (91.7%), the treatment and care given during sleep time (86.4%), the air and
temperature of the room (80.1%), room being crowded (80.0%), structure of bed and pillow
(72.3%), worries about safety (72.3%), room illumination at night (72.0%), and being hungry
(62.5%) (Yilmaz et al., 2013).
Strengths of the Yilmaz et al. study are demonstrated in the consistency of the finding
among the 411 participants and the validity and reliability of the PSQI measurement tool. Two
major limitations were identified by the researchers that conducted this study. First, the number
of participants from each department were not equivalent and therefore not equally
representative in the Yilmaz et al. study. Second, the study only examined perceived sleep
quality and failed to perform and measure any nursing interventions that may influence the
patients sleep quality (Yilmaz et al., 2013).
Benefits of Quiet Time for Neuro-intensive Care Patients
The purpose of this quasi-experimental study was to determine if implementation of a
quiet time (QT) protocol twice a day would reduce noise to EPA-recommended levels and to
determine if this in conjunction with reducing light levels and other environmental stimuli would
allow patients to sleep or rest peacefully (Dennis, Lee, Woodard, Szalaj, & Walker, 2010). The
Dennis et al. study took place in an ICU located in Raleigh, North Carolina and included 50

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neuro-ICU patients. This study consisted of a preintervention phase that allowed the
establishment of baseline measurements of light and noise and an intervention phase that ran six
consecutive months (Dennis et al., 2010). QT hours were chosen on the basis of the circadian
rhythm and ensued during the day shift from 2:00 to 4:00 pm, and during the night shift from
1:30 to 3:30 am (Dennis et al., 2010). At the onset of each QT, lights were extinguished or
dimmed in patient rooms and at the central station (Dennis et al., 2010). Telephone volumes
were decreased, nursing activities were limited as much as possible, charting and conversations
occurred at the central station furthest from patient rooms, and patient visitation was prohibited
(Dennis et al., 2010).
Day shift QT hours showed mean reduction of average noise levels by approximately 10
decibels, around 15%, at two locations: doors to patients room and head of patients bed
(Dennis et al., 2010). Reductions of noise levels at the center unit were almost as large,
decreasing by approximately 10% (Dennis et al., 2010). Noise levels also decrease during night
shift QT by a statistically significant level (Dennis et al., 2010). Light levels measured during
dayshift QT averaged only 15-25% of those recorded both before and after QT hours (Dennis et
al., 2010). Reduction in light levels during night shift QT however, did not prove to be
statistically significant (Dennis et al., 2010). Dayshift QT intervention successfully produced
statistically lower levels of both noise and light consistently (Dennis et al., 2010). Results of the
Dennis et al. study suggest success of the QT intervention during day shift for the time period of
2:00 to 4:00pm when patients circadian rhythms would promote sleep (Dennis et al., 2010).
During the QT hours, patients were four times more likely to be observed sleeping than in the
half hour before (Dennis et al., 2010). Strengths of the Dennis et al. study are found in the
consistency of the results in comparison with results of similar studies and that reduction of light

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10

and noise reached statistical significance at the .025 level. One weakness of the Dennis et al.
study is that some noises could not be controlled such as overhead paging of a code blue or rapid
response due to the nature of the ICU and the hospital in general.
Summary
The findings of these studies suggest a need for models of care that aim to support
restful sleep and prevent or alleviate sleep deprivation in hospitalized patients. Nursing
procedures are often performed with little regard to the patients sleep cycle and daily schedules
of routine care are based on standard hospital protocol and not individual patients needs. Sleep
promotion should be an important part of every nursing care plan that is assessed and modified
throughout patient hospitalization and should incorporate patients specific sleep needs and
practices.
A number of factors have an influence on patients ability to sleep while in the hospital.
Findings show that not only physical factors but also psychological factors such as bedside
manner affect patients ability to sleep (Gellerstedt et al., 2014). Several of these studies support
the claim that hospital environments are not conducive to restful sleep and suggest implications
for a variety of physical changes to the hospital building itself to allow for private patient rooms,
promote optimal lighting, and increased insulation for noise control. Other areas of
environmental improvement may include changes to current equipment and supplies such as
beds, pillows, and sleepwear. Further studies of both qualitative and quantitative design are
needed to confirm and build on the content and themes developed in these five studies and to
focus on developing and implementing specific interventions for promotion of patients sleep.
These studies also suggest a deficit in nursing awareness and education concerning proper sleep
hygiene. Future studies should include hospital staff education programs that address these

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matters and raise staff awareness of factors which affect patient sleep and include implications
for patient sleep promotion. Improved patient sleep is an important part of holistic patient care
that has the potential to improve patient health and well-being both physically and
psychologically and must be recognized and addressed by the entire healthcare community.
Through research and practice changes can be made to improve patient sleep and reduce the
incidence and duration of insomnia that will allow for health promotion of inpatients throughout
the hospital.

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References
Bernhofer, E., I., Higgins, P., A., Daly, B., J., Burant, C., J., & Hornick, T., R. (2014). Hospital
lighting and its association with sleep, mood and pain in medical inpatients. Journal of
Advanced Nursing, 70(5), 1164-1173. doi:10.1111/jan.12282
Dennis, C. M., Lee, R., Woodard, E. K., Szalaj, J. J., & Walker, C. A. (2010). Benefits of quiet
time for neuro-intensive care patients. The Journal of Neuroscience Nursing: Journal of
the American Association of Neuroscience Nurses, 42(4), 217-224. Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE%7CA234418357&v=2.1&u=uarizona_main&
it=r&p=AONE&sw=w&asid=b70aa03968e4dbf8afbf06f6d6a8e00c
Gellerstedt, L., Medin, J., & Karlsson, M., Rydell. (2014). Patients experiences of sleep in
hospital: A qualitative interview study. Journal of Research in Nursing, 19(3), 176-188.
doi:10.1177/1744987113490415
Lehne, R. A. (2013). Pharmacology for nursing care. St. Louis, MO: Elsevier.
Stockert, P. A. (2013). Sleep. In P. Potter, A. Perry, P. Stockert, & A. Hall (Eds.), Fundamentals
of nursing (8th ed., pp. 939-961). St. Louis, MO: Elsevier.
Tembo, A. C., Parker, V., & Higgins, I. (2013). The experience of sleep deprivation in intensive
care patients: Findings from a larger hermeneutic phenomenological study. Intensive &
Critical Care Nursing: The Official Journal of the British Association of Critical Care
Nurses, 29(6), 310-316. doi:10.1016/j.iccn.2013.05.003
Yilmaz, M., Sayin, Y., & Gurler, H. (2012). Sleep quality of hospitalized patients in surgical
units. Nursing Forum, 47(3), 183-192. doi:10.1111/j.1744-6198.2012.00268.x