INTRODUCTION:

“Sleep is that golden chain that ties health and our bodies together”

-Thomas Dekker

“Sleep is an important and essential process in all our lives. Rest and sleep are essential for good health. According to Maslow’s hierarchy of needs, sleep is one of the most basic needs or drives to motivate human beings to achieve the fullest potential in life. According to WHO, Sleep is triggered by a complex group of hormones that are active in the body, and that respond to cues from the body itself and the environment. Sleep disturbance is a frequently overlooked complication of intensive care units (ICU).

There are two different states–non–rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, which are distinguished by specific types of brain activity. NREM sleep is also called slow-wave sleep, and reveals that it is characterized by a regular occurrence of local and global slow cortical oscillations, visible at the level of the EEG as slow waves. In contrast, during REM sleep, the brain is about as active as it is in waking, although some notable differences with respect to the regional patterns of activation have been found in humans.¹

Many intensive care patients experience sleep disruption potentially related to noise, light and treatment interventions. The purpose of this study was to characterize, in terms of quality of the sleep of intensive care patients, taking into account the impact of environmental factors. Finally, although protocols for sleep promotion in the ICU have recently been implemented and studied, the degree to which sleep can be improved in ICU patients, as well as the best strategies for sleep promotion, has yet to be defined. While all such questions remain unanswered, it seems appropriate to provide patients with the necessary conditions for restorative sleep if the goal can be achieved safely. So this is the most relevant study to assess the quality of determinants of sleep among ICU patients.²

STATEMENT OF THE PROBLEM:

A descriptive study to assess the quality and factors influencing sleep among patients admitted in Intensive Care Unit of a tertiary care hospital, Ernakulam

OBJECTIVES:

1. To assess the quality of sleep among patients admitted in intensive care units.

2. To identify the factors influencing quality of sleep among patients in intensive care unit

Hypothesis (level of significance P<0.05):

H₁:There will be a relationship between quality and factors of sleep among patients in intensive care units.

H₂: There will be a significant association between the quality of sleep and selected demographic variables:

MATERIALS AND METHODS:

· Setting of the study: The study was conducted in a tertiary care centre in Ernakulam district.

· Research approach: The approach used in this study was descriptive analytical survey design.

· Sample size: 54 people

· Sampling Technique: Convenient sampling technique

· Inclusion criteria: Age 18-60 yrs old patients.

· Patients admitted in medical ICU.

Stay at least 24 hours.

Capable to answer the research instrument

Exclusion criteria:

· Patients who have past and current history of CVA.

· Not capable of answering the research instrument.

· Taking any drugs affecting sleep quality.

· History of known sleeping disorders and psychiatric patients.

· Data collection instruments:

Section A: Tool 1: Demographic and clinical data:

A structured questionnaire of 17 items developed for assessment of the demographic variables, clinical data and hospital setting of the patients. The items included are age, sex, marital status, education, duration of sleep, occupation, day time sleep

Section B: Richard Campbell sleep questionnaire which consists of 5 questions for assessment of quality of sleep. It consists of a 5-item questionnaire evaluating sleep depth, latency, number of awakenings, efficiency, and quality. The participants were instructed to place an ‘x’ on the answer line

Reliability of the tool:

Reliability of the tool was established by the split-half method, and the correlation coefficient was r=0.76. Hence, the tool was considered reliable and feasible for the main study.

RESULTS:

Data were analysed by descriptive and inferential statistics using Microsoft excel and R software.

Section A: Selected demographic variables of ICU patients

Table 1: Frequency and percentage distribution of socio demographic variables (n=54)

Sl. No.	Demographic Variables	Frequency (f)	%
1	Age in years
	a. 18-30	3	5.5
	b. 30-50	6	11.11
	c. 50-70	32	59.25
	d. Above 70	13	24.07
2	Gender
	a. Male	35	64.8
	b. Female	19	35.18
3	Marital status
	a. Married	50	92.59
	b. Single	4	7.40%
4	Education
	a. Primary education	20	37.13
	b. High school	25	46.25
	c. Plus two/pre degree	8	14.81
	d. Post graduate	1	1.85
5	Occupation
	a. Unemployed	33	61.1
	b. Daily wager	14	25.9
	c. Self employ	5	9.25
	d. Service and others	2	3.7
6	Duration of sleep
	a. 3-5hrs	15	27.77
	b. 5-7hrs	34	62.46
	c. 7-9hrs	5	9.25
7	Day time snap
	a. Yes	28	51.85
	b. NO	26	46.14

Among the 54 subjects, 59.25% belong to the age group of 50 - 70 years, 24.07% belong to the age group of >70 years , 11.1% belong to the age group of 30 - 50 years, 5.5% belong to the age group of 18 - 30 years. Among the gender, males have 64.8% and female has 35.18%. With regard to the marital status of the subjects, 92.59% were married. Majority of the patients, 46.29% had educational qualifications of high school level most of the patients 62.4 % had duration of sleep 5 - 7 hours daily. 25.9% of patients are daily labourers. 51.85% patients had day time snap.

Table 2: Frequency and percentage of clinical data

SI. NO.	Clinical Data	Frequency	Percentage
1	Pain
	a. Acute	29	53.75
	b. chronic	7	12.9
2	Medication in between sleep
	a. Yes	9	16.6
	b. No	45	83.3
3	Dialysis
	a. Yes	0	0
	b. No	54	100
4	Sleep disorder
	a. Yes	8	14.81
	b. No	46	85.1

Among 54 samples 53.75% have acute pain, 12.9% have chronic pain. 83.3% have no medications in between sleep and 16.6% have medication in between sleep. No patients have dialysis. 83% have no sleep disorder and 14.81% have sleep disorder.

Table 3: Frequency and percentage of health care system

SI. NO.	Health care system	Frequency	%
1	Lighting in the ICU
	a. Yes	33	61.15
	b. No	21	38.85
2	Alarms in ICU
	a. Yes	35	64.8
	b. No	19	35.1
3	Procedures at night
	a. Yes	22	40.75
	b. No	32	59.25
4	Positioning
	a. Yes	16	29.6
	b. no	38	70.3
5	Disturbance of other patients
	a. Yes	13	24.07
	b. No	41	75.9
6	Disturbance of other patients
	a. Yes	13	24.07
	b. No	41	75.9
7	Communication between health care members
	c. Yes	10	18.5
	d. No	44	81.4

Among 54 samples 61.1% have disturbance with light and 38% have no disturbance with light. 64.8% have disturbance with alarms and 35.1% have no disturbance with alarms. 59.2% have no procedure at night and 40.7% have disturbance with procedure at night. 70.3% have no disturbance with positioning and 29.6% have disturbance with positioning. 75.9% have no disturbance of other patients and 24.07% have disturbance with other patients. 81.4% have no disturbance with noise produced by conversation and 18.5% have disturbance with noise produced by conversation.

Section B:

Table 4: Quality of sleep among ICU patients (n=54)

Sl No.	Grade	Frequency (f)	%	Valid Percent	Cumulative Percent
1	Poor	19	35.2	35.2	35.2
2	Good	35	64.8	64.8	64.8
	Total	54	100	100	100

Among 54 samples 35.2% have poor quality of sleep and 64.8% have good quality of sleep.

Section C:

Table 5: Association between the quality of sleep and selected demographic variables (n=540)

Sl. No.	Variables	Sleep quality		Chi square/Fishers exact test	p value
Sl. No.	Variables	Poor sleep	Good sleep	Chi square/Fishers exact test	p value
1	Age in years
	a. 18-50	3	7	0.14	0.5
	b. >50	16	28
2	Gender
	a. Male	13	22	0.16	0.46
	b. Female	6	13
3	Marital status
	a. Married	19	13	2.99	0.103
	b. Unmarried	0	5
4	Education
	a. High school	14	31	1.96	^0.15
	b. Higher secondary	5	4
5	Duration of sleep
	a. 3-5hrs	6	w10	0.33	1) 1
	b. 5-7hrs	11	22
	c. 7- 9 hrs	2	3
6	Occupation
	a. unemployed	8	18	2.92	0.25
	b. daily labour	6	14
	c. self employed	5	3
7	Day time snap
	a. yes	13	16	2.55	0.09
	b. no	6	19
8	Pain
	a. acute	11	18	2.87	022
	b. chronicle	4	3
9	Medication in between sleep
	a. yes	1	8	1.9	0.35
	b. no	18	27
10	Sleep disorder
	a. yes	4	4	0.904	^0.28
	b. no	15	31
11	Lighting
	a. yes	12	21	0.52	0.52
	b. no	7	14
12	Alarm
	a. yes	13	22	0.16	0.46
	b. no	6	13
13	Procedure
	a. yes	8	14	0.023	0.55
	b. no	11	21
14	Positioning
	a. yes	7	9	0.73	0.29
	b. no	12	26
15	Disturbance of other patients
	a. yes	7	6	2.61	0.10
	b. no	12	29
16	Noise produced by conversation
	a. yes	7	3	6.52	0.016
	b. no	12	32

*Significant (P<=0.07)

DISCUSSION:

This chapter discusses the main findings of the research study and the quality of sleep.

The findings of the study are discussed with reference to the related literature and have been organised under following headings.

Section 1: Findings related to the quality of sleep among patients admitted in intensive care units.

Section 2: Findings related to association between the quality of sleep among ICU patients and selected demographic variables, clinical variables and hospital settings.

Section 1: Findings related to the quality of sleep among patients admitted in the Intensive Care Unit.

The present study reveals that 68.4% subjects have good quality of sleep and 35.2% subjects have poor quality of sleep. In a similar cross sectional study conducted in AIIMS New Delhi, by Karthik Gupta, Ramvath Devandra Naik, Sanjeev Sinha, regarding the relevance of poor sleeping among patients in medical ICU. The sample size was 32 and the tool was RCSQ Sleep Questionnaire.³

Section 2: Findings related to association between the quality of sleep among ICU patients and selected demographic variables, clinical variables and hospital settings.

Among the 54 subjects, 59.25% belong to the age group of 50 - 70 years, 24.7% belong to the age group of >70 years, 11.1% belong to the age group 30- 50 years, 5.5% belong to the age group 18 - 30 years. Among the gender male 64.8% and females 35.18% with regards to the marital status of the subjects, 92.59% were married. Majority of the patients (46.29%) had educational qualification of high school level. Most patients 62.46% had duration of sleep hours daily. 25.9% of patients are daily labourers. 51.85% of patients had a date time snap. In a clinical setting 52.7% have acute pain and 12.9% have chronic pain. 83.3% has no medication in between sleep and 16.6% has medication in between sleep. There are no patients with dialysis. 85.1% have no sleep disorder and 14.81 % have sleep disorder. In the hospital setting 61.1% has disturbance with light and 38.8% has no disturbance with light. 64.8% have disturbance with alarms and 35.1% have no disturbance with alarms. 59.2% have no disturbance with nursing procedure and 40.7% have disturbance with nursing procedure. 70.3% have no disturbance with positioning during sleep and 29.6% have disturbance with positioning during sleep. 75.9% have no disturbance of no disturbance with other patients and 27.07% have disturbance of other patients. 81.4% have no disturbance with noise produced by conversation and 18.5% have disturbance with noise produced by conversation. The present study reveals that there is a significant association between qualities of sleep among ICU and produced by the conversation.

This finding is in agreement with the study done by Qinglan Ding, Nancy S Redeker, Margaret A Pisani, Henry K Yaggi on assessment of quality of sleep among ICU patients and hospital setting found patients are satisfied with the current ICU setup for sleep. Participants from the patients and surrogate group identified noise and in-room interruption as factors that influence overnight sleep in the MICU, but they considered these facts to be expected in the hospital. Most patients (88%) were satisfied with the current nursing care and 50% of patients considered in-room interruption necessary at night.⁴

CONCLUSION:

From the findings of the study it is clear that there is a significant association between quality of sleep and determinants of sleep among patients admitted in Intensive Care Unit. Data were analysed using descriptive methods and inferential statistics.

The findings showed that, out of 54 subjects, 64.8% have good sleep and 35.2% have poor quality of sleep. The study revealed that there is a significant difference between quality of sleep and noise produced by conversation.

ACKNOWLEDGEMENT:

Here we extend our sincere thanks to all people who participated in the study.

CONFLICT OF INTEREST:

The authors declare no conflict of interest in the study.

REFERENCES:

1. Lovell K, Liszewski C. Normal sleep patterns. Michigan State University.

2. Pisani MA, Friese RS, Gehlbach BK, Schwab RJ, Weinhouse GL, Jones SF. Sleep in the Intensive Care Unit. American journal of respiratory and critical care medicine. 2015 Apr 1; 191(7): 731-8.

3. Nike RD, Gupta K, Soneja M, Elavarasi A, Sreenivas V, Sinha S. Sleep quality and quantity in intensive care unit patients: A cross- sectional study. Indian journal of critical care medicine: peer- reviewed, official publications of in dian Society of Critical Care Medicine. 2018; 22(6): 408.

4. Ding Q, Redeker NS, Pisami M A, Yaggi H K, Knauert MP.Factors influencing patients’ sleep in the intensive care unit: perceptions of patients and clinical staff. American Journal of Critical Care. 2017 Jul 1; 26(4): 278-86.

Received on 25.08.2021 Modified on 21.09.2021

Asian J. Nursing Education and Research. 2022; 12(1):119-123.

DOI: 10.52711/2349-2996.2022.00025