Download EM -Sleep interventions V1

What interventions are effective in improving the sleep
experience of hospital in-patients?
Evidence map and narrative summary
1. Summary
This evidence map and narrative summary looks at potential interventions
to improve the sleep experience of adult hospital inpatients. The following
interventions were identified

Environmental factors
o Noise – raising staff awareness of noise, reducing noise from
equipment, use of sound absorbing tiles and curtains, visual
cues to warn staff of rising noise levels
o Light – dimming electric light at night, use of mini flashlights,
use of window blinds, exposure to daylight to maintain
circadian rhythm
o Maintaining comfortable temperature

Patient comfort/care activities/pharmcotherapy
o Identify and address any medical factors that may cause sleep
disturbance for example alcohol withdrawal, delirium,
medication, inadequate pain management
o Encourage sleepiness by use of eye masks, ear plugs warm
blankets, night time drinks, massage, music therapy and
relaxation exercises
o Avoid behaviours that interfere with sleep such as caffeine
near bed time

Whole system approaches
o Require strong leadership
o Use of sleep protocols
o Individualised ward action plans
o Staff training and education
2. Background and purpose
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This narrative summary, based on an evidence map, is concerned with
the question of potential interventions to improve the sleep experience of
hospital inpatients. Specifically adult patients in community hospitals in
Powys.
Evidence mapping is an emerging tool to systematically and
comprehensively identify,organise and summarise the distribution of
scientific evidence on a broad topic1. Evidence mapping does not include
critical appraisal of the identified sources or any evidence synthesis. The
purpose of this map is to sketch the terrain in terms of the range of
potential interventions to improve sleep for community hospital
inpatients, to summarise the extent to which these have been explored in
the literature and to provide structured access to this literature.
3. Method
A systematic search of the literature was undertaken using a range of
core databases. The details of this search are contained within a technical
document which is available on request. Seventy four sources were
identified. Abstracts were reviewed, sources were categorised and those
relevant to the question identified. This is detailed in the appendix.
Although the evidence has been categorised by types of source, there has
been no review or critical appraisal of the full-text of any of the sources
and no assumption should be made that any particular type of source is
more reliable than any other.
4. Narrative summary
The sources in the Evidence Map have not been critically appraised and
the summary presented here is based on the conclusions of the authors of
those sources. Twenty one sources potentially relevant to the question
and the patient population in community hospitals in Powys were
identified and have been included. These sources were three non
systematic reviews, one mapping of the literature, one randomised
intervention study, four non randomised intervention studies, six
observational studies, four quality improvement reports, one opinion
piece and one study where the design was not specified.
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Key issues identified from the sources were; environmental, these were
largely external to the patient such as light and noise; issues around care
of individual patients, these were more about knowing your patient and
recognising their needs and the need for a whole system approach to
achieve change. The included sources suggest that interventions should
be aimed at ameliorating factors responsible for impairing sleep. Key
findings are summarised below.
4.1 Environmental factors

Noise
A range of sources including a mapping of the literature8, three non
systematic reviews 9,10,16 , an observational study15, three quality
improvement projects6,11,18 , one opinion piece19 and one other
study4(type not specified) identified noise as a factor in poor sleep
experience. Noise was attributed to staff numbers, visitor numbers,
patients and equipment (this included both hospital equipment and other
patients’ mobile devices and televisions8) 4, 8, 11, 15, 19.
A mapping of the literature 8 reported that talking was cited by inpatients
as the most common cause of noise. This included staff conversations
especially during shift change and suggested designated report rooms
instead of nurses’ stations and visual noise reminders such as a flashing
electronic light when noise reached a certain level8. Authors of the
mapping of this paper also reported one study that had found that a
reduction in patients’ exposure to staff conversations improved patient
satisfaction and led to a reduction in sedative prescriping8.
A non systematic review9, an observational study14, the mapping paper8
and a quality improvement paper18 concluded that sleep improved
following staff training to raise awareness of noise levels on the ward and
by turning down equipment noise.
The introduction of a Quiet Time for patients to improve night time sleep
was advocated by authors of a non randomised intervention study10, an
observational study15 and by the mapping paper.
The mapping paper 8 reported that cheap interventions such as the use of
ear plugs had, on a small scale, improved inpatient sleep. In situations
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where other interventions to reduce noise had failed or where it was
difficult to reduce noise because of the use of noisy equipment ear plugs
were recommended8.
Sound blocking
found beneficial
mapping of the
suggested noise

such as the introduction of sound absorbing tiles was
to inpatients and staff in several studies included in the
evidence8 and a quality improvement study which also
absorbing curtains6.
Light
A mixture of sources including a non systematic review20 three
observational studies5, 6, 11 , two quality improvement papers11, 18one
opinion piece19 and one source where the study type was not specified4
identified light as a causative factor in sleep impairment . Both the need
for daylight to ensure maintenance of circadian rhythm5, 6, 9, 18 ,19 ,20 and
the dimming of electric lights in the ward at night to promote sleep4,11 ,15
,18 were recommended by source authors. One quality improvement
project advocated the use of window blinds to promote sleep18. Another
quality improvement project recommended the use of torches at night to
reduce the need for overhead lighting16. The introduction of eye masks
was recommended by the mapping paper 8 and a quality improvement
report16.
4.2 Patient comfort/Care activities and pharmacotherapy.
One review reported underlying medical illnesses, such as delirium,
certain medications, alcohol withdrawal and pain as risk factors in sleep
disturbance and insomnia, especially in older patients and those unable to
communicate well9.
A range of interventions to encourage sleep were suggested by source
authors. One randomised intervention study 17 and one review9 reported
that relaxation exercises such as deep breathing exercises and or
massage reduced anxiety, psychological distress and improved sleep
quality17. A non systematic review recommended ensuring good pain
management to improve inpatient sleep experience20.
A non systematic review 9 suggested that room temperature may be
associated with poor sleep especially in elderly patients who have less
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subcutaneous fat and reported warm blankets were the most common
requested item in a multi component intervention to improve sleep9
The authors of a randomised intervention study concluded that music
assisted relaxation and produced a statistically significant improvement in
sleep quality of inpatients with psychiatric problems7. A non systematic
review reported that music therapy was effective in reducing anxiety and
pain and promoted relaxation9.
After conducting a non randomised trial its authors concluded that the
introduction of a nurse led ‘sleep enhancement’ programme had a positive
effect on mental health inpatients12. Sleep enhancement in the American
Nursing Interventions Classification is defined as ‘facilitation of regular
sleep/wake cycles’. The Nursing Interventions Classification (NIC) is a
comprehensive,
research-based,
standardized
classification
of
24
interventions that nurses perform .
According to authors of a non-randomised intervention study3 their aim
was to develop a feasible, point of care computerised reminder to improve
sedative-hypnotic prescribing in hospitalised older people. The
intervention was a computer-based reminder directing clinicians to
prescribe either a non pharmacological sleep protocol which suggested a
safer choice such as warm milk, herbal tea and relaxation methods , or to
minimise the potential for harm such as delirium, falls and functional
decline associated with diphenhydramine and diazepam use by
prescribing alternative medication such as trazodone or lorazepam. Study
authors report a post intervention reduction in prescribing of all four
drugs and that 95% of patients offered the intervention accepted either
the safer alternative drug or the offer of a non pharmacological
alternative. Study authors do not report the impact of the intervention on
inpatients’ sleep experience.
The authors of an observational study surveyed middle-aged and older
inpatients to examine the relationship between participants’ perceived
control over sleep, noise levels and objective measurement of sleep2.
They concluded that higher perceived control over sleep is associated with
longer sleep duration, better sleep quality and fewer reports of noise
disruption.
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4.3 Whole System Approach
Authors of a mapping of the evidence8, a non systematic review22 and a
quality improvement report16 all concluded that a
whole systems
approach was needed to bring about the necessary change to improve
inpatients sleep experience. This would involve buy in at all levels of the
organisation and all staff groups. It included a corporate approach to staff
training to raise awareness of the causes of poor patient experience of
sleep and to ensure interventions to aid good quality sleep were
implemented and fully evaluated.
A number of interventions were suggested to implement change. These
included the introduction of sleep protocols in two observational
studies13,14 and one non systematic review 9.Quality improvement reports
advocated individualised ward action plans18 and strong leadership buyin16 as a positive means to achieving whole system change.
A non systematic review20, a mapping of the literature8 and an
observational study advocated staff training to raise awareness and
reduce sleep disturbing factors.
The key role of the nurse in instigating change featured in many of the
sources including one non systematic review20 two observation studies14,
21and one quality improvement report 6.
4. Conclusion
Overall, authors’ conclusions, drawn from a small number of potentially
relevant studies for the situation in Powys suggest that a whole system
approach might be relevant to improve in-patient sleep experience. Key
issues identified were environmental factors such as noise and light which
were external to the patient and those that were directly associated with
the patient such as management of medical conditions including pain
control, night time sedation and individual care and general comfort of
patients.
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Appendix
Table 1 Categorisation of sources retrieved from search
Type of source
Number
relevant
to
question
Systematic review
Non systematic
review & literature
searches
Mapping of the
literature*
Randomised
intervention study
Non randomised
intervention study
Observational study
Quality improvement
approach1
Discussion document
Opinion
piece/commentary
Not specified, not
able to tell
Total
0
3
Number not included in narrative summary
ICU
Child
Not
Duplicate
focussed
focussed
relevant
included in
to
other included
question
source*
1
3
5
1
2
1
1
0
0
0
0
1
6
1
2
0
4
5
0
1
0
6
4
2
2
0
0
3
0
4
0
0
1
4
4
0
0
0
1
0
0
1
3
0
2
0
21
32
2
11
8
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1
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