Dobson, Linda, BSN, RN; Stutzman, Sonja E., PhD; Hicks, Amber D., MBA; Olson, DaiWai M., PhD, RN

SLEEP IS A UNIQUELY personal experience. While all humans sleep, each does so differently. Variables such as light, sound, temperature, clothing, coverings, and positioning are all specific to individual comfort levels, habits, and lifestyles.1 As such, it is unlikely that one single intervention would have the same impact on sleep across a diverse population within a hospital setting.2

Sleep hygiene has been defined as “practicing behaviors that facilitate sleep and avoiding behaviors that interfere with sleep.”3 Poor sleep hygiene is one of the primary factors contributing to sleep deprivation in hospitalized patients.4 Lack of sleep can have significant consequences that affect the overall health and well-being of patients, and improved sleep hygiene may reduce sleep deprivation.1,5

Patients whose pulmonary status is compromised, such as those with cystic fibrosis (CF) or pulmonary hypertension (PH), are susceptible to sleep deprivation due to an above-average amount of time spent in and out of the hospital.6 Their signs and symptoms often exacerbate poor sleep quality. This article assesses the effectiveness of patient-directed interventions in improving sleep for patients with CF and PH.

Sleep hygiene and sleep quality

Many of the habits and practices that are conducive to a good night's sleep are also essential for preserving the patient's overall health. Sleep deprivation in hospitalized patients may result in delayed wound healing, longer length of stay (LOS), and extended recovery times.2 The consequences of poor sleep hygiene can include the worsening of pain, cardiorespiratory status, and/or psychiatric health.5 Sleep deprivation can also weaken a hospitalized patient's immune system, increasing LOS and medical costs.

The factors that impact sleep can be categorized as physiological, environmental, and psychological.

The physiological factors impacting sleep may include obstructive sleep apnea, infection, pain, poor nutritional status, fluid and electrolyte imbalances, metabolic and endocrine disorders, malignancies, and numerous other disease-related factors depending on the patient and the disease process. The environmental factors that impact sleep include noise, lighting, room temperature, and staff interruptions. The most common psychological factors affecting sleep are anxiety and depression.5,7-9 Improved sleep quality may also prevent or decrease depressive symptoms, as sleep disturbances have been associated with depression.10

The many benefits of quality sleep include improvements in memory, insight formation, learning, and creativity.11 Additionally, sleep is important for tissue growth, restoration, and repair.11 It can also help decrease pain sensitivity and increase the analgesic effects of medications.12

As personal tracking devices have become less expensive, easy to wear, and integrated with smartphone technology, activity and sleep monitoring has become a social fad. Although this technology has seen tremendous growth, it is not yet used consistently among patient populations due to several barriers, including cross-contamination between patients, inadequate testing of device reliability, cost, and discomfort.

The importance of quality sleep is often overlooked in hospital settings, where sleep hygiene is impacted by noise, temperature variations, lighting, and staff interruptions.13 Patients at the University of Texas Southwestern Medical Center voiced concerns that a lack of sleep affects their healing process, causing them to feel worse. Although various nonpharmacologic interventions can be utilized in hospital settings, no standardized practices are currently in place to address interventions and improve sleep quality.14-16

Table

Study variables and participants

As part of a nonrandomized, prospective pilot study approved by the Institutional Review Board, researchers examined the effectiveness of patient-initiated sleep preferences in 15 hospitalized participants, implementing a personalized sleep hygiene program. The study incorporated biomotion sensors and measured sleep quality using the Pittsburg Sleep Quality Index (PSQI) and the Richard-Campbell Sleep Questionnaire (RCSQ). The goal was to improve sleep hygiene by introducing a list of preferences to the target group of patients with CF or PH in the pulmonary/medical-surgical unit.

Patients were considered eligible if they were age 18 or older, able to provide informed consent, and admitted with a CF or PH diagnosis and an expected LOS of at least 4 days. Participants not expected to be hospitalized longer than 4 nights, non-English speakers, prisoners, and pregnant women were excluded. In total, 15 patients consented to this pilot study, which tested the sleep hygiene programs' feasibility.

Procedures and measurement tools

Patients completed baseline PSQI testing, reviewed a sleep intervention list, and received education about the importance of good sleep hygiene and the consequences of poor sleep quality. Sleep hygiene interventions, such as noise reduction, lighting and temperature control, and pain management, were implemented. The interventions were selected by patients on an individual basis according to their preferences (see Potential interventions to promote sleep). Biomotion sensor data were tracked, and patients completed an RCSQ each morning for 4 days.

PSQI is a well-respected self-reporting questionnaire used to assess up to 1 month of sleep quality. It consists of 19 items and produces one global score based on seven components:

• subjective sleep quality
• sleep latency
• sleep duration
• habitual sleep efficiency
• sleep disturbances
• use of sleeping medication
• daytime dysfunction.17

Global scores range from 0 to 21, with higher scores indicating greater sleep disturbances. The test has a sensitivity of 89.6%, a test-retest reliability of 0.85, and an adequate internal consistency measured by Cronbach's alpha (alpha = 0.83), with 0.0 representing a poor score and 1.0 being perfect.17

RCSQ is a five-item measure of sleep quality designed to assess critically ill patients. It uses a 100 mm visual analog scale, with higher scores representing better sleep. The RCSQ has also been shown to have a high internal consistency (alpha = 0.90).18

Biomotion sensor tracking provided data on patient sleep patterns using bedside table monitors to record movement and respiration. Actigraphy describes the prolonged measurement of sleep and activity with a noninvasive accelerometer worn on the wrist.19 Polysomnography describes an in-lab diagnostic test to assess respiratory disorders while a patient is sleeping, as well as several additional sleep disorders.20 Each is considered an industry standard for high-quality sleep research, but these technologies can be expensive.18,21

Table

The study utilized a noncontact biomotion sensor device to track and analyze sleep quality, monitoring the four stages of sleep (see Understanding sleep) by measuring breathing and physical movements and recording the light, noise, and temperature conditions in the room.22,23 Biomotion sensors tracked the total time for each of the five study measurements in hours and minutes, including:

• sleep interruptions
• total sleep time
• wake time
• rapid eye movement (REM) time
• light sleep time
• deep sleep time.22

The sleep score was calculated using a device-specific formula owned by the manufacturer and rated on a scale of 0 to 100 (with higher scores indicating better sleep quality). This score takes the elements of sleep into consideration, as well as the known averages for each participant's applicable demographic.24

Study population

Of the total participants, 11 (73%) were White and 4 (27%) were Black. Of those, 13 (86%) were non-Hispanic and 1 (7%) was Hispanic. The ethnicity of one patient (7%) was unknown. The age range of participants was 21 to 71, with an average age of 37. Eleven participants (73%) were female.

Upon admission, eight participants (53%) had been diagnosed with CF and seven (47%) had been diagnosed with PH. On average, patients were enrolled for 3.7 nights, and data were collected over an average of 3.5 nights. One night of biomotion sensor data was missing for one participant due to technical difficulties.

Study results

According to PSQI scoring, which served as the baseline sleep quality index in this study, any score above 5 is considered poor sleep. Participants' scores ranged between 6 and 19, with an average of 12.3.

Figure

Table

In total, 52 RCSQ surveys were completed; 53.3% of the participating patients reported better sleep over the course of the study, but this was not statistically significant. On average, patients reported RCSQ scores of 38.1 on their first night. These had improved slightly to 38.6 on their last night in the study (see RCSQ comparison).

An open-ended question invited patients to comment on their sleep quality trends, including:

• discomfort or pain
• staff interruptions
• noise from alarms
• anxiety
• temperature
• uncomfortable beds.

The biomotion sensor data indicated no statistically significant differences over time in minutes for REM, light, or deep sleep, nor were there any differences in sleep score. Additionally, participant sleep durations remained consistent over all 4 nights and were not significantly different either (see Biomotion sensor trend data).

Implications of the study

Although personalized sleep hygiene and biomotion sensor feedback were not associated with any statistically significant changes in sleep quality, researchers gathered key takeaways from the study. Poor sleep among patients is well recognized, having been reported in many settings.5,10,14,23,25 As such, it is not surprising that patients with chronic respiratory disorders experienced poor sleep while hospitalized. The study results support the need for interventions to improve sleep quality in these patients.

Respiratory illness may have a direct correlation with poor sleep hygiene. In a 2016 study, patients with respiratory symptoms reported a higher incidence of insomnia and daytime fatigue.26 Pain or illness, including coughing, was reported as the main barrier to sleep quality in the study RSCQs. Similarly, a systematic review found a strong association between sleep disruption and respiratory-related illnesses.26 A 2017 study supports the hypothesis that patients with respiratory illnesses may cough more frequently during waking hours than while sleeping.27 Coughing helps CF patients clear their secretions, but it may also act as a potential barrier to sleep. Common cough suppressants were contraindicated for use in these patients to promote better sleep quality.

Despite reporting poorer sleep quality (see Respiratory impact on sleep quality), patients with CF and PH noted other considerations to be taken into account to explain their sleep difficulties. For example, to provide care, healthcare professionals are sometimes required to interrupt patients in hospital settings, regardless of whether or not they are sleeping. Although staff interruptions were not specifically considered in this study, they were reported as a hindrance to sleep in the open-ended question featured in the RSCQ.

Patients with CF whose lung disease is more advanced have poorer sleep quality than those with less severe lung disease. Severe lung disease results in increased coughing and sleep fragmentation, as well as decreased oxygen saturation levels. This nocturnal hypoxemia may be correlated with PH.28

Limitations and conclusions

Device-related errors were a reported limitation. In filling out the open-ended RSCQ remarks, some patients noted that they felt as though they had slept better than indicated by the biomotion sensor. The device was selected as a product available for home use. The reliability and validity of commercial products designed for general use is a recognized limitation. The inability to provide the exact number of sleep interruptions was a notable obstacle, and the device did not account for each patient's complicated health history. The comparative use of another sleep measurement device with the biomotion sensor could be helpful in determining accuracy in future studies.

Understanding the impact of outside variables on sleep could further assist in tailoring sleep hygiene to certain patients with CF and PH. Some of the other potentially relevant factors that were not considered in this study include:

• previous or upcoming sleep studies
• noninvasive ventilation, such as BiPAP or CPAP therapy
• medications impacting sleep
• staff interruptions
• daytime sleep and napping habits.

Getting good quality sleep in a new environment can be difficult. This study filled a gap in the literature by examining sleep quality and potential interventions specific to patients with CF and PH. Poor sleep hygiene among these hospitalized patient populations was exacerbated by health-related issues, environmental factors, and interruptions. Although the study did not find statistical significance in the interventions, it was a step in the right direction. Patients in this study were open to seeking a good sleep hygiene regimen to improve their sleep quality while in the hospital. Future studies are needed to explore improvements in sleep quality for these patients.

Respiratory impact on sleep quality5,26

Patients with chronic respiratory disease experience poor sleep quality, leading to:

• delayed healing
• longer periods of hospitalization
• higher incidences of depression and anxiety
• weight fluctuations due to metabolic disturbances, which can lead to or worsen diabetes
• extended use of potent antibiotics or steroids, with adverse drug reactions such as insomnia, restlessness, and hyperglycemia.

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