Kristen Ahearn

Carter Laboue
Marissa Mitrovic
Alina Murphy
Julie Palmer
Andrea Tanner
Research Analysis Paper
I. Introduction:
In intensive care units, along with acute illnesses and life-threatening conditions, sleep
deprivation is an issue for most patients on these units. Sleep deprivation has a great affect on the
body and the healing process that needs to take place for the patients in this type of setting. With
hourly assessments, vital signs, bright lights and noises that can take place in the intensive care
units at night, can contribute to the quality of sleep of a patient. The problem in the intensive care
units is that sleep deprivation could contribute to the length of stay for patients in these units
from the delayed body healing process. Does sleep deprivation influence the length of hospital
stay within the intensive care unit? This is an important incidence in these units because although
caring for the patients diagnosis is important, it is just as important to holistically treat the
patient and allow their body to heal and recover from the diagnosis to achieve an earlier
discharge. This study could impact nurses and how and when interventions are performed to
allow for a more restful sleep for the patients.

II. Comparison of Articles

There are several similarities that run between the articles that were analyzed. One of the
main similarities that were constant in almost all of the articles is that quality sleep is almost
always disturbed in critically ill ICU patients. Several non pharmacological interventions were
implemented to be able to determine if they provided better quality sleep for those who were in

the intensive care unit. Another main similarity that was seen in the studies was how the
environment of the ICU played into disturbances of sleep. The noises, lighting, number of
patient- nursing interactions played into if the patient was able to rest and to the quality of that
sleep. In almost all of the studies, it was found that if those disturbances were reduced, then
patients subjective report of their quality of sleep is improved.

III. Contrasting Articles

The majority of our studies were very similar in nature however there were also
significant differences. Some of our studies included pretty large participant groups while others
only looked at around 10-12 patients. The majority of our studies tried to identify factors that
influence patients sleep while in the ICU setting. These studies found that while on the intensive
care unit patients did in fact have a shorter night sleep and experienced a decrease quality of
sleep. We also looked at some studies that included possible factors that could improve sleep
quality. These studies found that sleep quality on the ICU unit could be improved with ear plugs,
soothing music, eye masks, and even the use of melatonin. We found that multiple studies used a
questionnaire or interview type process when determining sleep quality, which could be very
subjective. There were two studies however that used polysomnography so we also had an
objective point of view. All in all even though some of the studies purposes and methods were
different they all came up with the similar idea in that sleep during the ICU is negatively
impacted.

IV. Limitations

Many patterns of limitations existed throughout each of the studies used to gather
research on the topic. Although many studies exceeded the necessary sample size, a select few of
them simply included 12 to 34 participants or no sample of any kind. By using small sample
sizes in the studies, it is difficult to conclude if the results would be relevant to larger population
sizes. Several studies selected participants solely based upon the fact that the participant was
admitted to the ICU, without factoring in the time they spent in the hospital or their diagnosis.
Also, various studies tended to use ICUs all around the world, but the researchers did not take
into account the different demographics of the patients in each area. Each person has a slightly
different perspective on how they perceived their sleep patterns during their stay in the ICU,
therefore many of the responses were subjective findings. Lastly, self-reporting methods were
used in many of the studies. Results were compiled based upon questionnaires and structured
interviews, limiting the standardization of the responses.

V. Implications for Nursing

Sleep deprivation has been linked to negatively affect the immune, metabolic and
cognitive functions of the body; which in turn leads to complications with patient recovery.
Patients must have quality sleep for their health and wellbeing. This can be achieved by
reducing the amount of excess noise in the critical care unit. Implementing certain interventions
such as: dimming the main unit lights at night, providing earplugs to patients, decreasing volume
of the phone-rings, providing melatonin, and limiting the amount of unnecessary interruptions
into the patients room; have shown to improve the quality of the patients sleep.

VI. Conclusion

Through analysis of many different studies, which looked at the effects of sleep
deprivation on patients in intensive care units, we found many similar findings as well as many
differences. Overall, we found that patients in the ICU were not satisfied with the sleep quality
that they had received during their stay. Poor sleep quality has been shown to have negative
effects on both patient psychosocial and physical health, which can persist beyond their hospital
stay. In general, the largest factors contributing to this lack of sleep or decreased quality
included environmental noise, human interventions, pains levels, and medication use all which
interrupt patient circadian rhythm. Methods to help reduce these disturbances by staff members
can have major benefits on patient sleep quality and, therefore, overall health and wellness.

VII. References
Bihari, S., Doug McEvoy, R., Matheson, E., Kim, S., Woodman, R. J., & Bersten, A. D. (2012).
Factors Affecting Sleep Quality of Patients in Intensive Care Unit. Journal of Clinical
Sleep Medicine, 8(3), 301307. doi: 10.5664/jcsm.1920
Chianca, T., Souza, C., & Hamze, F. (2015). The influence of care interventions on the continuity
of sleep of intensive care unit patients. US National Library of Medicine National
Institutes of Health, 23(5), 789-796. doi:10.1590/0104-1169.0514.2616.
Ehlers, V., Watson, H., & Moleki, M. (2013). Factors contributing to sleep deprivation in a
multidisciplinary intensive care unit in South Africa. Journal of the Democratic Nursing
Organization of South Africa, 36(1). doi:10.4102/curationis.v36i1.72
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(4), 1155-1162. doi: 10.1164/ajrccm.159.4.9806141

Frisk, U., Nordstrom, G. (2003). Patients sleep in an intensive care unitpatients and nurses
perception. Intensive and Critical Care Nursing, 19(6), 342-349. doi:10.1016/S09643397(03)00076-4
Hardin, K. A. (2009). Sleep in the ICU: potential mechanisms and clinical implications. CHEST
Journal, 136(1), 284-294. doi:10.1378/chest.08-1546
Huang, H.-W., Zheng, B.-L., Jiang, L., Lin, Z.-T., Zhang, G.-B., Shen, L., & Xi, X.-M. (2015).
Effect of oral melatonin and wearing earplugs and eye masks on nocturnal sleep in
healthy subjects in a simulated intensive care unit environment: which might be a more
promising strategy for ICU sleep deprivation? Critical Care, 19(1), 124. doi:
10.1186/s13054-015-0842-8
Hu, R., Jiang, X., Chen, J., Zeng, Z., Chen, X., Li, Y., ... Evans, D. (2014). Non-pharmacological
interventions for sleep promotion in the intensive care unit. The Cochrane Library, (10).
doi: 10.1002/14651858.CD008808.pub2
Pilkington, S. (2013). Causes and consequences of sleep deprivation in hospitalised patients.
Nursing Standard, 27(49), 35-42. doi: 10.7748/ns2013.08.27.49.35.e7649
Podgorski, T., & Wise, C. (2015). Sleep deprivation in the intensive care unit: promoting sleep in
the patients who need it most. Critical Care Nurse, 35(2), 73-74. Retrieved from
http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=85564a8a-22a2-4da2-9fd05c2544a986c7%40sessionmgr4003&vid=7&hid=4103
Scott, L., Arslanian-Engoren, C., & Engoren, M. (2014). Association of sleep and fatigue with
decision regret among critical care nurses. American Journal of Critical Care, 23(1), 1323. doi: 10.4037/ajcc2014191

Timbo, A.C., Parker, V., Higgins, I. (2013). The experience of sleep deprivation in intensive care
patients. Intensive and Critical Care Nursing, 19(6), 310-316. doi:
10.1016/j.iccn.2013.05.003

Summary of Studies Evidence Table

PICO: Does sleep deprivation influence length of hospital stay in patients within the ICU?
Group #10
Group Names: Julie Palmer, Andrea Tanner, Kristen Ahearn, Alina Murphy, Carter LaBoue, Marissa Mitrovic
Author/Year
LOE

Sample

Study Purpose

Variables

Instruments
with Validity
and Reliability

Results/Statistical
Evidence

Summary/Conclusion

Podgorski et
al., 2015
LOE 4

N=106
ICU
patients

Enhance patientreported sleep

quality in cardiac
ICU
patients by
implementing an
evidence-based
sleep
protocol

Sleep
promotion
bundle and
sleep quality

Confusion
Assessment
Method for ICU;
RichardsCampbell Sleep
Questionnaire

Sleep quality
improved from a
mean of 53 to 59;
warm blanket
(33%) and music
(25%) were most
popular sleep aids

Staff found sleep

promotion bundle
valuable, and
implementation
improved patientreported sleep quality

Timbo, A.C.,
Parker, V.,
Higgins, I.
(2013)

N= 12
ICU
patients

Describe the
experience of
critical illness in
ICU with daily
sedation interruption
and how this
impacted the
participants
outcomes

No
interventions
were
reported

A selective
highlighting
approach was
used to analyse
the transcribed
interviews

Sleep deprivations
emerged as a major
concern for many
(n = 8) of the
participants

Patients continue to
experience sleep
deprivation at various
stages of their
trajectory of critical
illness in and beyond
ICU. The findings
suggest a need for
models of care that
seek to support restful
sleep and prevent or
alleviate sleep

LOE 6

deprivation and
nightmares.
Freedman,
N.S., Kotzer,
N., Schwab,
R.J. (1999)

N=203
discharge
d ICU
patients

Determine whether
sleep quality and
daytime sleepiness
changed over the
course of a patients
ICU stay, whether
there were
differences in sleep
quality between
ventilated and nonventilated patients,
whether there were
differences in sleep
quality between
different types of
ICUs, and the
relative roles of
other environmental
factors on perceived
sleep disruption.

No
interventions
were
reported

No
sample.

Reviews the
literature describing
sleep in ICU
patients, factors that

No
None used.
interventions
were
reported.

LOE 6

Hardin, K. A.
(2009)
LOE 1

Multivariate and
univariate
repeatedmeasures
ANOVAs, oneway ANOVAs,
chi-squared
analysis,
Pearsons,
Spearmans,
unpaired t-test,
Wilks' lambda
F-statistic (p <
0.05)

Sleep quality in the

ICU was perceived
as significantly
poorer than sleep at
home by all
subjects. There
were statistically
significant
differences
between the
individual
environmental
factors in terms of
their perceived
degrees of ICU
sleep disruption.
Checking of vital
signs and
phlebotomy were
perceived as
significantly more
disruptive (p =
0.006) to sleep than
was the mean of
the other factors.

Poor sleep quality and

and sleep disruptions
are problems common
to many ICU patients.
Good-quality sleep
may be difficult to
achieve in patients
under intensive care.
Human interventions
and diagnostic studies
are among the most
disruptive factors to the
sound sleep among
patients in the ICU.

Factors: noise,
patient care
activities, circadian
rhythm disruptions,

Noise, particularly staff

talking and patient-care
activities, are clearly
contributing factors and

affect sleep in
critically ill patients,
and the potential
mechanisms and
clinical implications
of disturbed sleep in
the ICU setting with
directions to
consider for future
investigations.
Frisk, U.,
Nordstrom,
G. (2003)
LOE 6

Ehlers, V.,
Watson, H.,
& Moleki,
M. (2013)

N= 31
ICU
patients

mechanical
ventilation,
medications, and
the inherent effects
of critical illness

represent a majority of
the source of sleep
disruption in patients in
the ICU.

Describe how
patients treated in an
ICU perceive their
sleep and to
compare patients
and nurses
perceptions of the
patients sleep

No
interventions
were
reported

Unpaired t-test,
paired t-test,
Pearsons
product moment
correlation,
Cronbachs
alpha, RichardsCampbell Sleep
Questionnaire

The total sleep

score ranged
between 0 and 97
(mean 45.5). Nine
patients (29%)
scored a total sleep
score of 25 or
below (i.e. very
poor sleep) and
eight (26%) a total
sleep score of over
75 (i.e. very good
sleep) Crohnbachs
alpha for the five
questions about
sleep was 0.92.

Pain was the

commonest cause of
disturbed sleep. Noise,
monitoring controls
and care and treatment
procedures are
perceived as being
disturbing to a very
small number of
patients. Patients given
hypnotics and sedatives
during the night slept
much worse than those
who hadnt received
them.

N=34 ICU Identify factors

patients
influencing patients
abilities to sleep
well in the ICU
setting; as well as

No
interventions
were
reported.

Quantitative,
descriptive
design using
structured
interviews.

Most respondents
(94.1%) reported
sleeping better
once they knew the
nurses. The

This article
demonstrates the
involvement in the
nursing staff and
nursing care affects

LOE 3

Hu et al.,
(2015)
LOE 5

obtain patients
suggestions for
enhancing their
abilities to sleep in
the ICU.

N=1569
ICU
patients

To assess the
effectiveness of
nonpharmacological
interventions for
sleep promotion in
critically ill adults in
the ICU setting. As
well to establish
whether nonpharmacological
interventions are
safe and clinically
effective in

Several
interventions
were tested
such as
ventilator
mode, use of
earplugs and
eye masks,
massage and
aroma
therapy.

Combined
results from
multiple
interventions to
create metaanalyses using
mean
differences and
standardized
mean
differences for
continuous
outcomes and

remaining 5.9%
reported that as
long as the nurses
seemed to be doing
their job, it did not
matter. If patients
were feeling
uncomfortable with
a nurse around
their bed, they
would talk to the
nurse whilst 38.2%
would keep quiet,
remain powerless
to effect change,
and 11.8% would
talk to a familiar
ICU nurse.

sleeping and the rest of

the patients. The article
also discussed how
much patients are
psychologically is
impacted during these
time spent in the ICU
and how much it can
impact the patients
sleep schedule and
cycle.

There was some

evidence that the
use of earplugs
and/or eye masks
may have
beneficial effects
on the quality of
sleep in the
intensive care
population but the
quality of this
article was low,
and more studies

Critically ill patients

who are in the ICU are
very much in need of
better quality sleep, as
they are often not able
to rest for long periods
of time. This article
helps to determine how
healthcare providers
can help provide better
non-pharmacologically
based sleep for ICU
patients, and that in

improving sleep
quality and reducing
length of ICU stay
in critically ill
adults.
Huang et al.,
(2015)
LOE 2

N= 80

Determine the effect

of stimulated ICU
noise and light on
nocturnal sleep
quality, and compare
the effectiveness of
earplugs and eye
masks on sleep
quality in these
conditions.

Interventions
such as the
use of
earplugs, eye
masks, or
melatonin
were used. A
placebo of
melatonin
was also
used.

risk ratios for

dichotomus
outcomes. Post
test scores were
used in this
review.

should be done.

turn can help reduce

the length of stay for
patients who are
receiving critical care.

Measurement
was used by a
weighting sound
level
meter.Sleep was
assessed by PSG
using the
Polysmith 2003
sleep acquisition
and analysis
system. Subjects
were hooked up
for recording of
an electroencephalogram,
(EEG), eye
movement, and
a submental
electromyogram
(EMG) in the
sleep laboratory.

Subjects had
shorter night sleeps
with noise and
light and had
greater anxiety
while on the ICU
stimulated unit.
Melatonin and
earplugs increased
their quality of
sleep and they
were less likely to
wake up
throughout the
night

Its response was that

reductive measures can
improve sleep quality
during an ICU stay.

Bihari et al.,
(2012)
LOE 4

N=148

Evaluate sleep
quality among
patients admitted to
the ICU and
investigate
environmental and
non environmental
factors that affect
sleep quality

No
interventions
were
reported

A modified ICU
quality of sleep
questionnaire
developed by
Freedman et al.
Dementia status
was assessed
using the global
clinical dementia rating
score (CDR).

Sleep quality
Sleep quality decreases
within the ICU was when at stay in the
reduced. SelfICU compared to home
reported sleep
quality score at
home (1 = worst;
10 = best) was 7.0
2.2; this
decreased to 4.0
1.7 during their
stay in ICU (p <
0.001)

Pilkington, S.
(2011)

No
sample

LOE 1

Linda, S.,
ArslanianEngoren, C.,
and
Engoren, M.,
(2014)
LOE 2

N= 605

A literature review
that tries to
determine the
factors that affect
the quality of sleep
experienced by
patient and the
effects of sleep
deprivation on the
health and wellbeing
of these
individuals.
To examine the
association between
selected sleep
variables,
impairment due to
fatigue, and clinicaldecision selfefficacy and regret
among critical care
nurses.

No
interventions None used.
were
reported

Decision
regret for
nursing care

Self-reports and
questionnaires;
Winwood PC:
Occupational
Fatigue,
Exhaustion, and
Recovery Scale

Eliminating
excesses noise
from units (staff
conversations,
telephone ring and
unnecessary
nursing
interruptions into
the patients room)
and dimming main
lights at nights
were effective for
most of the
patients.

Sleep deprivation has

been linked to
negatively affect the
immune system and
cognitive function
which in turn leads to
complications with
recovery. Patients must
have quality sleep for
their health and
wellbeing; by reducing
the amount of excess
noise in a unit.

157 (29%) of
critical care nurses
had decision regret.
The nurses that
reported regret
were more often
those who worked
nights or 12 hour
shifts. Nurses that
reported acute
fatigue, sleepiness
and poor sleep
quality notably had
higher decision
regret than nurses
without decision

Critical care nurses that

reported decision regret
due to fatigue and sleep
loss were more likely
to work 12-hour and
night shifts than those
that did not.

regret.
Hamze,
Souza,
Chianca
(2015)
LOE 7

N=12

To identify care
interventions,
performed by the
health team, and
their influence on
the continuity of
sleep of patients
hospitalized in the
Intensive Care Unit

No
interventions
were
reported.

A filming
technique was
used for the data
collection. The
awakenings
from sleep were
measured using
the actigraphy
method. The
analysis of the
data was
descriptive.

It was found that

there were
numerous care
interventions that
caused awakening
of sleep for the
ICU patients. The
administration of
oral medicine and
food were the
interventions that
caused the most
sleep disturbances
in these patients.

While sleep
disturbances can reduce
the quality of sleep in
intensive care patients,
there are some
interventions that
cannot be prevented,
and disturbances may
be neccessary in order
to provide quality
nursing care.