Continuous quality and safety improvements are essential in all aspects of nursing. It is the Doctor of Nursing Practice’s task to ensure that they take place based on established and reliable evidence. To that end, workers in the role should continuously review the current practices at their institutions and any areas where it may underperform, then consider contemporary evidence-based interventions. This case report will discuss patient sleep difficulties in intensive care units and how they may be addressed.
Due to the discomfort from their conditions as well as disruptions such as light and noise, patients may not get the sleep that they require, which would inhibit their recovery and possibly damage their health further. As such, it is necessary to consider the principal causes of the problem and the interventions that have been shown to be effective.
Literature Review
To conduct a successful quality improvement initiative, it is essential to define a set of indicators that it aims to change and demonstrate meaningfully superior results after the intervention has been implemented. The Institute of Medicine (2001) recommends facilities to focus on a limited number of indicators that create a comprehensive set when combined nationwide.
They are known as quality indicators and have to be selected carefully depending on the issue in question, aiming to cover all of the potential improvements while eliminating as many of the confounding factors as possible. Alsulami et al. (2019) recommend the daily usage of the Richards-Campbell Sleep Questionnaire and the Sleep in Intensive-Care Unit Questionnaire, which aim to assess self-reported sleep quality. They target sleep quality, the disruptions that affect it, and the daytime sleepiness of the patients.
The intensive care unit’s environment is not conducive to sleep because of its patient base, which requires extensive attention and effort from the nurses. As a result, patients tend to report that the non-circadian light, constant monitoring, and noise interfere with their sleep and significantly change them compared to those of healthy adults (Menear et al., 2017).
In particular, patient sleep at night tends to be fragmented because of the periodic disruptions, which prevents the emergence of slow-wave sleep and rapid eye movement, both of which have substantial roles in maintaining one’s health (Korompeli et al., 2017). Considering the already severe state of most ICU patients, such health risks are excessively dangerous and should be minimized. To that end, researchers have been studying potential interventions that can cost-effectively address some or all of the issues.
Many interventions focus on the immediate factors that impede patients’ ability to sleep, such as light, noise, and medication. Kamdar et al. (2014) propose a multi-stage approach where televisions would be turned off at night, lights would be dimmed, non-pharmacological sleep aids would be offered to patients, and zolpidem and haloperidol (depending on the absence or presence of delirium) would be supplied to the patients who could not sleep despite these interventions.
These interventions are aimed to address patient sleep issues efficiently without introducing additional health risks. However, Kamdar et al. (2014) admit that it did not improve perceived sleep quality in a statistically significant manner. On the other hand, Karadag et al. (2017) propose the use of aromatherapy using lavender essential oils, which they claim reduces anxiety and improves sleep quality. These nonstandard approaches warrant attention, though the direct causes of sleep issues should not be disregarded.
Case Description
The intensive care unit aims to provide treatment to patients with a variety of severe, often life-threatening illnesses. As a result, many patients are likely to stay there for substantial periods until their health is no longer an immediate threat. These conditions can be associated with a variety of factors that interfere with sleep, such as pain or delirium. Patients can experience sleep difficulties because of their issues or be disturbed by others who make noise or watch television.
The medical workers in the ICUs will try to alleviate the symptoms and minimize the disturbances that patients present to others, but their effectiveness is limited. The factors that inform this limitation are technology and the procedures necessary for the maintenance of patient well-being, both of which can conflict with creating an environment that promotes healthy sleep.
The techniques that can be used for the management of patients who are experiencing pain or delirium as a result of their conditions are limited. While many interventions can help alleviate a patient’s pain, it is challenging to eliminate it. A similar concept applies to delirium, with most approaches aiming to manage rather than remove it.
Medications can be effective at addressing both of these issues, but they are also associated with a variety of substantial side effects that complicate their usage and make these drugs the final measure that is used when alternatives are ineffective. Overall, it is challenging to address the disruptions that come from other patients because their symptoms often cannot be alleviated. As such, patients who are struggling to sleep will have to cope with these issues with the assistance of the workers.
Additionally, the environment of the unit is shaped by the needs of the patients, which do not necessarily prioritize the ability to sleep. Due to the potential for many patients to develop complications overnight, medical staff regularly inspect patients, which often disturbs their sleep. Moreover, the light that is necessary to conduct these checks and the noise that is generated in the process affects patients.
Many ICUs keep lights on at night to enable comprehensive evaluations, disturbing the residents substantially and reducing their overall quality of sleep. To alleviate the negative atmosphere of the unit, many also install televisions that patients can watch. These televisions can disturb patients who are trying to sleep during the daytime and present a further potential for issues if used by people who cannot sleep at night.
Discussion
Any intervention that aims to improve patient sleep quality in the ICU has to ensure that it does not harm patient health. For example, shutting lights off at night would help patients sleep better. However, it would also interfere with the workers’ ability to conduct inspections and increase the likelihood of a complication developing undetected. Meanwhile, mild interventions such as the dimming of the lights do not necessarily produce a substantial positive effect on sleep quality, though they may be beneficial in other ways (Kamdar et al., 2014).
It is possible to assert that the practices used at many facilities have been adapted to suit patient needs, and any changes would create significant tradeoffs that warrant consideration. As such, while it is vital to find light and noise management configurations that facilitate sleep without jeopardizing health outcomes, the introduction of new elements is more likely to generate substantial change.
Medications such as sedatives may be overly powerful for the task, significantly affecting the patient’s condition and potentially having dangerous side effects. However, chemical stimulation through senses such as smell may still be effective at addressing the problem while also overriding the potentially distracting odors of the ICU (Karadag et al., 2017).
Methods such as the one proposed there, which take advantage of factors that are not considered in the traditional framework, can counteract the issues that complicate sleep without jeopardizing care. With that said, it is necessary to consider the potential side effects of such approaches, such as allergies. To that end, research into the effectiveness of specific novel interventions is needed to determine their advantages and potential dangers. After refinement and evidence collection, they can be integrated into care to improve its overall quality.
Case Summary
At the ICU featured in this report, complaints by patients of inadequate sleep have been increasing in number recently. It keeps lights on at night and has televisions, though there is a curfew on their use in place. Patients have been complaining about feeling uncomfortable and unable to sleep due to the light and the noise.
The ICU has implemented a policy of dispensing masks and earplugs to the patients who complained, but the approach did not lead to a substantial reduction in the reports. The medical workers on staff objected to the implementation of more impactful measures that were proposed, such as the shutting off of lights and medicine dispensation. As a result, the management started looking into other methods that could improve the conditions at the unit and maintain patient satisfaction and health.
The management conducted a survey using the Richards-Campbell Sleep Questionnaire and found that several factors were particularly prevalent among the patient population. Patients would describe difficulty getting to sleep, whether at the beginning of the night or once woken up for whatever reason.
With that said, these waking events would occur infrequently once the patient fell asleep, with most being the result of medical workers rousing the patient in question for inspection rather than an unrelated influence. Regardless, many patients reported that they spent a substantial portion of the night awake, which the management identified as an issue and potential health hazard that needed to be addressed in some way. To that end, they started searching for ways to improve the patients’ sleep quality without jeopardizing the work of the unit.
Proposed Solutions
The author proposes a multifactorial intervention to address the problems that the patients are experiencing. On the one hand, it is essential to minimize the stress factors that prevent patients from going to sleep, such as light and noise. To that end, the ICU should implement a light-dimming policy at night in addition to its current practices of non-pharmacological sleeping aid dispensation.
Any sources of noise will be minimized through efforts such as a policy on nurse station doors, door closing, and the prevention of any alarms going off. Additionally, the facility will implement temperature control to sustain temperatures that are comfortable for the patients, especially at night. For people who experience difficulties regardless, the medical workers will dispense sleeping medications regardless, choosing ones that are appropriate and have minimal risk.
In addition, the facility will introduce aromatherapy to help patients relax, alleviating their anxiety, and enabling them to sleep better. To that end, it will contact an aromatherapist and learn about the various oils used for the purpose and then procure them. According to Karadag et al. (2017), such an intervention should be cost-effective, with the price not being excessively high. The aromas will then be used in the unit, being changed depending on the medical history of the patients.
The workers will take care not to let patients with a medical history of allergy to a particular substance be affected by it. Additionally, if a patient manifests an adverse reaction to a specific aromatic oil, it will be removed immediately and replaced with another one that is not associated with the same response.
Data Collection Instrument
The Richards-Campbell Sleep Questionnaire will be used to collect data before and after the intervention to assess the improvement in the quality of the patients’ rest. It consists of five items that evaluate one’s depth of sleep, onset latency, awakening frequency, time spent awake, and general sleep quality using visual scales (Menear et al., 2017). As the questionnaire considers subjective values rather than objective data, it should be used regularly to help patients frame and assess the continuous improvement of their sleep.
The author proposes that the workers survey each responsive patient daily and compile the data over three months after the implementation of the intervention as well as immediately before. In that manner, the instrument will provide a comprehensive picture of outcome improvement through specific measures while giving the workers time to identify and correct any issues that emerge.
As the ICU patients’ sleep problems are mostly associated with prolonged sleep onset, it will be the primary measure in which substantial improvements should be expected. As a result, the time that the patients spend sleeping should improve, as well, with patients spending less time trying to fall asleep. The awakening frequency and depth of sleep may also achieve superior values, but as these values are already at satisfactory levels, a substantial improvement should not be expected.
As a result, while the overall quality of the patients’ sleep should improve, the growth is unlikely to be as substantial as that of the first two factors described because of the multifactorial nature of the statistic. Overall, the initiative will focus on these three factors when determining its success or failure and considering potential improvements throughout the evaluation period.
Conclusion
Patient sleep quality is a substantial issue in intensive care units, which they often struggle to address because of the unavoidable nature of many of its causes. The intervention that is proposed in this paper attempts to solve this problem by introducing a new dimension of the environment, smell. It incorporates best practices from traditional interventions, such as light dimming and closed-door policies, while also adding aromatherapy to help patients relax and relieve their anxiety.
Smell management in medical facilities is usually minimal and focused on removing unpleasant odors, which creates opportunities for additional interventions. The Richards-Campbell Sleep Questionnaire will supply the outcome measures that will be employed to evaluate the initiative’s success. The author expects substantial improvements in the patients’ sleep onset latencies and time spent sleeping alongside moderate gains in overall sleep quality.
References
Alsulami, G., Rice, A. M., & Kidd, L. (2019). Prospective repeated assessment of self-reported sleep quality and sleep disruptive factors in the intensive care unit: Acceptability of daily assessment of sleep quality. BMJ Open, 9(6).
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press.
Kamdar, B. B., King, L. M., Collop, N. A., Sakamuri, S., Colantuoni, E., Neufeld, K. J., Bienvenu, O. J., Rowden, A. M., Touradji, P., Brower, R. G., & Needham, D. M. (2014). The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Critical Care Medicine, 41(3), 800-809.
Karadag, E., Samancioglu, S., Ozden, D., & Bakir, E. (2017). Effects of aromatherapy on sleep quality and anxiety of patients. Nursing in Critical Care, 22(2), 105-112.
Korompeli, A., Muurlink, O., Kavrochorianou, N., Katsoulas, T., Fildissis, G., & Baltopoulos, G. (2017). Circadian disruption of ICU patients: A review of pathways, expression, and interventions. Journal of Critical Care, 38, 269-277.
Menear, A., Elliott, R., M Aitken, L., Lal, S., & McKinley, S. (2017). Repeated sleep‐quality assessment and use of sleep‐promoting interventions in ICU. Nursing in Critical Care, 22(6), 348-354. Web.