Impact of a Nursing-Driven Sleep Hygiene Protocol

on Sleep Quality
Iris Faraklas, RN, BSN, Brennen Holt, BS, Sally Tran, BS, Hsin Lin, PharmD,
Jeffrey Saffle, MD, FACS, Amalia Cochran, MD, FACS

The purpose of this study was to evaluate the impact on sleep quality of a nursing-driven
sleep hygiene protocol (SHP) instituted in a single burn-trauma intensive care unit. Criteria
for eligibility were adult patients admitted to the Burn Service who were not delirious, able
to respond verbally, and had not received general anesthesia in the prior 24 hours. Patients
were surveyed using the validated Richards–Campbell Sleep Questionnaire prior to imple-
mentation (“PRE”; May to December 2010) and following implementation (“POST”;
January to August 2011) of a SHP that sought to minimize environmental stimuli and
limit disruptions during the night. This analysis includes only initial survey responses
from each patient. A total of 130 patients were surveyed, 81 PRE and 49 POST; 60%
were burn admissions. There was no significant difference in responses to the question-
naire between burn and nonburn patients. All patients in the POST group were signifi-
cantly older and more frequently endorsed taking sleep medication at home. Although not
significant, POST patients reported falling asleep somewhat more quickly, but no other
differences were identified between the two groups. Among patients who reported hav-
ing sleep difficulties prior to admission, POST patients not only reported a significantly
higher pain score than PRE patients, but also reported significant improvement in falling
asleep and being able to go back to sleep. Frequency of complaints of sleep disruption was
unchanged between PRE and POST patients. POST patients did complain significantly
less than PRE patients about sleep disruptions by clinicians. Implementation of the SHP
permitted acutely injured or ill patients in our intensive care unit to fall asleep more quickly
and to experience fewer sleep disruptions. A sleep protocol may be helpful in improving
sleep and overall well-being of burn center patients. (J Burn Care Res 2013;34:249–254)

Sleep is an important component of health and
recovery. Critical care settings notoriously result in
disrupted and fragmented sleep.1,2 In the intensive
care unit (ICU) setting, there are multiple factors
that contribute to sleep disruption, including pain,
ambient noise and light, nursing disruption, age, and
medical illness.3 Critically ill patients often receive
treatments for their disease processes which also
negatively influence sleep patterns. Recent research has
highlighted the influence of sleep on the development
of ICU delirium, with ICU delirium creating a known
From the Burn Center at the University of Utah, University of
Utah Health Sciences Center, Salt Lake City.
Presented at the 44th annual meeting of the American Burn
Association, April 24–27, 2012, Seattle, Washington.
Address correspondence to Iris Faraklas, BSN, 3B110 SOM, 30
North 1900 East, Salt Lake City, Utah 84132.
Copyright © 2013 by the American Burn Association.
1559-047X/2013
DOI: 10.1097/BCR.0b013e318283d175
risk for increased morbidity and mortality in these
patients.1,4,5 Sleep deprivation studies demonstrate
that even short-term sleep deprivation results in
derangements in multiple organ systems, including
decreased glucose tolerance, increased activation
of the hypothalamic–pituitary–adrenal axis with
increased heart rate and blood pressure, disrupted
thermoregulation, elevated levels of inflammatory
cytokines, increased anxiety, and impaired cognitive
performance.1,4,5 Research by Hardin6 reported
that more than half of ICU patients report poor
sleep as well as nightmares and altered perceptions.
Gottschlich et al7 showed through polysomnography
that burn patients have a reduced amount of time
in deeper stages of sleep after burn injury. Lawrence
et al8 revealed that 50% of burn patients reported
chronic sleep disturbances during hospitalization.
This study was initiated as a quality improvement
project to evaluate our patient population’s subjec-
tive perception of quality of sleep while in the Burn

249

250   Faraklas et al March/April 2013
Unit. The hypothesis of this study was that a program
of nonpharmaceutical interventions would improve
the quality of sleep in our patient population.
METHODS
Sleep Hygiene Protocol
The sleep hygiene protocol (SHP) was a quality
improvement project designed to minimize envi-
ronmental stimuli and limit disruptions during
the night. This SHP required the entire team to
change their practice in our ICU. Once a patient’s
status stabilized, orders were written to not disturb
the patient for vital signs, lab draws, or housestaff
pre-rounding between midnight and 6 am. Nurses
queried patients about their out-of-hospital night-
time routine and worked to provide consistency
with that routine. Staff decreased environmental
stimuli by closing patient room doors and turning
lights and TV off when appropriate. After receiv-
ing evening report, the night nurse would review all
intravenous pumps, thus anticipating alarms. Nurses
scheduled evening wound care to be completed by
23:00. Family and patients were asked to limit visita-
tion after 23:00. Patients were encouraged to limit
caffeine intake after 15:00 as well as to turn lights
and TV off. The SHP was implemented unit-wide
in November 2010, with all team members working
collaboratively to keep noise and patient interrup-
tions during the night to a minimum.
Data Collection
This was an institutional review board–approved pro-
spective survey-based study at a regional American
Burn Association-verified burn center. We approached
patients to participate in the survey if they met the
following criteria: adult patients admitted to the Burn
Service who were not delirious, who were able to
respond verbally, and who had not received general
anesthesia in the prior 24 hours. Only investigators
who were not part of the patient’s care team admin-
istered the survey. We measured subjective patient
perception of sleep using the validated Richards–
Campbell Sleep Questionnaire (RCSQ).9–11 RCSQ
is a five-item analog scale questionnaire (Appendix)
that measures the subjective patient perception of
sleep and has validated reliability when compared to
polysomnography assessment.9–11
Patients surveyed prior to implementation of our
SHP were in the pre-protocol group (“PRE”; May
to September 2010). After SHP was implemented
unit-wide, patients surveyed were in the post-pro-
tocol group (“POST”; January to August 2011).
Journal of Burn Care & Research
Although patients may have been surveyed multiple
times, this analysis includes only the initial survey
response from each patient.
Comparison analysis was performed for each of
the following subgroup dyads: burn vs soft-tissue
injury, acute vs non-acute injury, patients with a his-
tory of mental illness vs those with no mental illness
history, and patients endorsing sleep problems prior
to admission vs those with no sleep history issues.
PRE and POST comparison analysis for each sub-
group was also completed.
We also asked patients the opened-ended ques-
tion, “Did anything bother you during the night?”
All issues specific to clinician disruptions (alarms,
noise, lab draws, and dressing changes) were com-
bined into one clinician disruption category.
Statistical Methods
Data were analyzed using Stata 11.2™ (StataCorp,
College Station, TX). Every reason listed in response
to the open-ended question, “Did anything bother
you during the night?” was analyzed as a separate
variable using χ2 test (one patient could have
complained about pain and also alarms). Wilcoxon
rank-sum test was used for continuous variables.
Fisher’s exact test was used for any comparisons in
which the sample size was less than 10. Data are
expressed as median values, with interquartile ranges
where appropriate, unless otherwise stated. A P < .050
was considered significant.
RESULTS
A total of 130 patients met the inclusion criteria and
were surveyed, 81 PRE and 49 POST. Acute and
reconstructive burn admissions constituted 60% (78)
of the survey participants; all the other patients were
being treated for soft-tissue surgical infections and
other skin and soft-tissue disorders. Most patients in
PRE and POST groups were men (Table 1). POST
patients were significantly more likely to be an acute
admission, older, and more frequently endorsed tak-
ing sleep medication at home.
When patients were asked, “Did anything in par-
ticular bother you during the night?” the number
of patients who did not complain about sleep dis-
ruption (Table 2) was unchanged between PRE
and POST (53% vs 59%, P = .311). POST patients
complained significantly less about clinician disrup-
tions than PRE patients (22% vs 6%, P = .012). The
number of patients complaining about pain affect-
ing their sleep did not change significantly between
groups (52% vs 48%, P = .237).
Journal of Burn Care & Research
Volume 34, Number 2 Faraklas et al   251

Table 1. Demographics: PRE vs POST intervention*

Pre N=81 Post N=49 P**

% Male (n) 69% (56) 76% (37) .435

Age, yr 41 (27–58) 49 (33–62) .027
Burn injury 68% (53) 32% (25) .075
Acute admission 35% (28) 70% (34) <.001
Endorsed having sleep problems prior to admission 38% (31) 41% (20) .773
Take medication to sleep at home 15% (12) 29% (14) .048
No prior history of psychological issues 72% (58) 67% (33) .608
Pain score: no pain (0) to worst pain (10) 5 (2–6) 5 (3–6) .645
Sleep medication 24 hr before survey 19% (15) 20% (10) .791
Anxiolytic or antipsychotic medications 24 hr before survey 31% (25) 33% (16) .832
Endorsed feeling anxious or depressed at time of survey 43% (35) 41% (20) .789

* Median (interquartile range) unless otherwise stated.

** Compared Pre vs Post group; Wilcoxon rank-sum test for continuous variables; χ2 for categorical variables.

RCSQ Analysis No significant difference was seen between those

Table 2 shows RCSQ responses between PRE
and POST groups. The only significant difference
between group responses was that POST patients
reported falling asleep faster (P = .022).
Subgroup Analyses
There were no significant differences in responses
between burn and nonburn patients in PRE vs POST
groups. The only significant difference in the burn
group was being able to fall asleep more quickly in
the POST vs PRE group (9 vs 7, P = .029). No sig-
nificant difference was found in the nonburn patient
group when comparing PRE vs POST groups.
There were no significant differences between
acute admission and non-acute patients when com-
paring PRE vs POST groups. However, the non-
acute POST group endorsed a deeper level of sleep
than the PRE group (8 vs 5, P = .011). No sig-
nificant differences were found in the acute patient
group when comparing PRE vs POST.
patients with a mental illness diagnosis vs those who
did not have a diagnosis prior to admission. However,
POST patients with mental illness were significantly
more likely to fall asleep faster than PRE patients
(8 vs 7, P = .042). There was no significant sleep
difference in patients who had no history of mental
illness when comparing PRE vs POST groups.
The subgroup analysis showing the most change
between PRE and POST were those patients who
reported sleep difficulties prior to admission. These
POST patients reported a significantly higher pain
score (6 vs 3, P = .034) in the 24 hours prior to
survey administration, but when specifically asked if
something bothered them during the night, they did
not complain more frequently about having difficulty
sleeping due to pain (58% vs 42%, P = .550). They
also did not differ in age, gender, or complaints of
feeling anxious or depressed (Table 3). These POST
patients saw a significant improvement in falling
asleep quickly (9 vs 4, P = .002) and being able to
go back to sleep if awakened (8.5 vs 5, P = .033)

Table 2. All patients surveyed: PRE vs POST intervention*

Pre N=81 Post N=49 P**

Number of days post admission survey administered 4 (3–9) 6 (4–11) .058

Number of patients who were not bothered during the night 53% (43) 59% (29) .311
Number of patients complaining that pain affected their sleep 52% (13) 48% (12) .237
Number of patients complaining that clinician disruption affected their sleep 22% (18) 6% (3) .012
Light sleep (1) to deep sleep (10) 6 (3–8) 6 (4–9) .309
Never fall asleep (1) to asleep instantly (10) 6 (3–8) 8 (5–9) .022
Awake all night (1) to never woke up (10) 5 (3–8) 5 (3–7) .712
Couldn’t go back to sleep (1) to back to sleep right away(10) 6 (4–9) 8 (4–9) .140
Bad night’s sleep (1) to good night of sleep (10) 7 (4–8) 7 (3–9) .404

* Median (interquartile range) unless otherwise stated.

** Compared Pre vs Post group; Wilcoxon rank-sum test for continuous variables; χ2 or Fisher’s exact for categorical variables.
 Journal of Burn Care & Research
252   Faraklas et al March/April 2013

Table 3. Demographics for patients endorsing sleep problems prior to admission: PRE vs POST intervention*

Pre N=31 Post N=20 P**

% Male (n) 87% (27) 65% (13) .065

Age, yr 42 (27–58) 48 (37–57) .369
Burn injury 74% (23) 55% (11) .156
Acute admission 32% (10) 50% (10) .249
No prior history of psychological issues 45% (14) 65% (13) .166
Pain score: no pain (0) to worst pain (10) 3 (2–6) 6 (4–6) .034
Sleep Medication 24 hr before survey 10% (3) 30% (6) .129
Anxiolytic or antipsychotic medications 24 hr before survey 32% (10) 40% (8) .765
Endorsed feeling anxious or depressed at time of survey 52% (16) 45% (9) .776

* Median (interquartile range) unless otherwise stated.

** Compared Pre vs Post group; Wilcoxon rank-sum test for continuous variables; χ2 or Fisher’s exact for categorical variables.

than did PRE patients who reported sleep difficulties
(Table 4).
DISCUSSION
Sleep fragmentation in the ICU setting results in a
predominance of Stage I sleep and decreased rapid
eye movement sleep, decreased total sleep time, poor
progression through sleep cycles, frequent arousals
and awakenings, and altered circadian rhythms.2,6,7
Using polysomnography, Gottschlich et al7 found
that over the course of hospitalization there was
an increasing amount of time spent in the deep,
restorative stages of sleep, but abnormally low levels
of deep sleep persisted until close to the time of
discharge in burn patients. Pharmacologic sedation
is also known to significantly disrupt intrinsic sleep
patterns or result in atypical sleep patterns with
absent normal stages. Daytime sleep represents more
than 40% of ICU patient total sleep time, often
caused by nighttime disruptions and atypical patterns
of light exposure.6 Lawrence et al8 showed a strong
negative correlation in burn survivors between sleep
disturbance and satisfaction with life post discharge.
The negative consequences of sleep disruption in
the ICU have spurred interest in factors that con-
tribute to poor sleep, particularly those that are
modifiable. As the causes of sleep disruption are mul-
tifactorial and vary widely between patients, a single
effective early intervention to avoid sleep fragmenta-
tion is unlikely; therefore, for our SHP, we chose to
pursue multiple modalities for sleep improvement.
These modalities included encouraging patients to
take an active role in their sleep management by turn-
ing lights and TV off, and limiting caffeine intake.
Nurses and staff were involved in the implementa-
tion by being vigilant about keeping interruptions
and noise on the unit to a minimum, and physicians
wrote orders to ensure that patients were not inter-
rupted for routine care. Signs were also placed on
patient doors as a reminder to all staff members that
patients were on the SHP.
Significant limitations to this study were that
results were self-reported by patients and are there-
fore subjective in nature. The post group data col-
lection stopped at 49 patients, although 81 were
planned, because of loss of the study coordina-
tor. Neither polysomnography nor nursing evalu-
ations were used to corroborate survey responses.

Table 4. Patients endorsing sleep problems prior to admission: PRE vs POST intervention*

Pre N=31 Post N=20 P**

Number of days post admission survey administered 4 (3–8) 5 (3–10) .704

Number of patients who were not bothered during the night 42% (13) 65% (13) .153
Number of patients complaining that pain affected their sleep 23% (7) 25% (5) .842
Number of patients complaining that clinician disruption affected their sleep 30% (9) 0% (0) .008
Light sleep (1) to deep sleep (10) 6 (3–7) 7.5 (4.5–9) .086
Never fall asleep (1) to asleep instantly (10) 4 (2–7) 9 (5.5–9.5) .002
Awake all night (1) to never woke up (10) 5 (2–7) 5 (2.5–8.5) .540
Couldn’t go back to sleep (1) to back to sleep right away(10) 5 (3–8) 8.5 (6–10) .033
Bad night’s sleep (1) to good night of sleep (10) 5 (2–8) 8.5 (4–9) .063

* Median (interquartile range) unless otherwise stated.

** Compared Pre vs Post group; Wilcoxon rank-sum test for continuous variables; χ2 or Fisher’s exact for categorical variables.
Journal of Burn Care & Research
Volume 34, Number 2 Faraklas et al   253
Polysomnography is considered the most reliable
test for measuring sleep patterns but does not
associate specific causes with abnormalities, and
is a difficult test to administer in the clinical set-
ting. Nursing evaluation is only accurate 75 to 81%
of the time, with overestimation of time patients
were asleep as the major limitation.6,10 PRE and
POST patients were two entirely separate cohorts
of patients, meaning that sample variation may play
a role in our findings. When the SHP was imple-
mented, it represented a change in unit practice.
We did not begin to survey post patients until SHP
was implemented in our unit for over a month.
Although the most obvious interventions physicians
order to not disturb a patient for vital signs, lab
draws, or early pre-rounding between midnight and
06:00 could have been randomized, the other inter-
ventions (decreased environmental noise, and fam-
ily and patient participation) mandated complete
unit involvement and could not be randomized.
These other interventions required a cultural and
environmental change involving all members of the
team. Thus, it would have been nearly impossible to
use a patient as their own control or to randomize
patients. Although the RCSQ survey failed to show
a significant change in overall quality of sleep in all
patients, a modest improvement was seen in the
POST group as the SHP appeared to help patients
fall asleep more quickly (Table 2). The decrease in
clinician disruptions and ambient noise noted in
the POST group may have influenced patient sleep
in ways not captured with the RCSQ. The open-
ended question, “Did anything bother you during
the night?” allowed patients to list multiple disrup-
tions, including such disruptions as pain and alarms.
The number of patients who did not list anything
when asked, “Did anything bother you during
the night?” was virtually unchanged from PRE to
POST. There was no significant change in the num-
ber of complaints related to pain, but POST patients
complained significantly less about clinician disrup-
tions or ambient noise than PRE patients (Table 2).
One possible reason that might explain the change
in complaints is that improving the environmental
factors influencing sleep, individual patient factors
that are less easily modified – such as pain – became
the focus of patient concern.
The objective of this study was to evaluate the
impact of implementing a unit-wide SHP for all
patients treated by the burn team in our ICU.
However, evaluation of the subgroup of those
patients who endorsed difficulty sleeping prior
to admission revealed a significant improvement
in falling asleep quickly and being able to return
to sleep if awakened after implementation of the
SHP (Table 4). These POST patients also had sig-
nificantly higher pain scores but did not complain
more frequently about pain, neither differed in age,
gender, or feeling anxious or depressed than their
PRE counterparts. The implementation of a SHP in
a critical care environment may be most helpful for
those patients who need it most because of preex-
isting sleep disturbances.
In conclusion, the SHP instituted in our unit was
associated with less time until patients fell asleep.
While our identified intervention was successful in
decreasing environmental disruptions influencing
sleep, pain continues to impact sleep quality. Future
research should focus on how to address individu-
alized factors and how to ameliorate their nega-
tive impact on sleep. More research is also needed
to establish definitively that altered perceptions are
associated with poor sleep and not a consequence of
anxiety or posttraumatic stress disorder.
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 Journal of Burn Care & Research
254   Faraklas et al March/April 2013

Appendix. Richards–Campbell Sleep Questionnaire

The following questions are to describe how you slept last night:

1. My sleep last night was:

Light sleep 1 2 3 4 5 6 7 8 9 10 Deep sleep

2. Last night, when I first fell asleep, I:

Just never 1 2 3 4 5 6 7 8 9 10 Fell asleep
could fall asleep right away

3. Last night, I was:

Awake all night 1 2 3 4 5 6 7 8 9 10 Never woke up
long

4. Last night, when I woke up or if someone woke me up, I:

Could not 1 2 3 4 5 6 7 8 9 10 Got back
go back to to sleep
sleep right away

5. I would describe my sleep last night as:

A bad 1 2 3 4 5 6 7 8 9 10 A good
night's sleep night's sleep

6. Was there anything in particular that bothered me during the night?