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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 4  |  Page : 201-206

Factors affecting quality of sleep in hospitalized patients: A cross-sectional survey in a tertiary care hospital


1 Department of Psychiatric Nursing, Father Muller College of Nursing, Mangalore, Karnataka, India
2 Department of Community Nursing, Father Muller College of Nursing, Mangalore, Karnataka, India
3 Father Muller Research Centre, Mangalore, Karnataka, India

Date of Submission09-Mar-2019
Date of Decision17-Jul-2019
Date of Acceptance15-Aug-2019
Date of Web Publication18-Nov-2019

Correspondence Address:
Dr. Manjeshwar Shrinath Baliga
Mangalore Institute of Oncology Pumpwell, Mangalore - 575 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_17_19

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  Abstract 


Background: Sleep is very important for humans and more so to hospitalized patients. Alterations in the normal sleep pattern have negative impact on the medical conditions, mental health, cognitive performance and recovery of the hospitalized individuals. The primary aim of this study was to assess the quality of sleep among hospitalized patients and to find the correlation between the factors affecting sleep and sleep quality. The secondary objective was to understand the quality of sleep in people admitted for surgical and medical treatment. Methods: In this cross-sectional study, the hospitalized patients were examined. Sleeping habits of 100 inpatients of surgical and clinical wards were assessed through the Pittsburgh Sleep Quality Index (PSQI). A self-designed questionnaire was also used to ascertain the factors affecting the sleep. Content validity and test–retest reliability were evaluated. The data obtained were analyzed by the statistical methods of frequency, percentage, and Chi-square. Results: The cross-sectional study showed that the mean score for PSQI was 7.58 ± 3.14 and that 69% of the patients had poor sleep as inferred from the global PSQI >5 scores. Age and gender had no effect on the PSQI total score, but the number of roommates, type of the ward, hospitalization period, presence and severity of pain, taking sleep medication, and attitude toward the overall atmosphere and interior of wards has caused deviation in scores. Conclusion: Sleep problems are quite frequent in medical inpatients. Pain management and modification of the ward interior and atmosphere can impact inpatients sleep quality.

Keywords: Hospitalized patients, Pittsburgh Sleep Questionnaire, sleep quality


How to cite this article:
D souza OL, Alvares IT, Baliga MS. Factors affecting quality of sleep in hospitalized patients: A cross-sectional survey in a tertiary care hospital. Indian J Med Spec 2019;10:201-6

How to cite this URL:
D souza OL, Alvares IT, Baliga MS. Factors affecting quality of sleep in hospitalized patients: A cross-sectional survey in a tertiary care hospital. Indian J Med Spec [serial online] 2019 [cited 2019 Dec 14];10:201-6. Available from: http://www.ijms.in/text.asp?2019/10/4/201/271221




  Introduction Top


Sleep is important for humans and its alterations in quantity and quality and deficiency, in particular, can affect the physical well-being and health of the individual.[1],[2] Sleeplessness leads to copious negative cognitive, metabolic,[3] autonomic, and hormonal changes that lead to profound physical effects including fatigability, pain[4],[5] intolerance, misperception, disorientation,[6],[7],[8] decreased immune functioning, and reduced secretion of growth hormone[9],[10] which is known to regulate body growth and stimulates tissue restoration by anabolic activity.[11] In addition, emotional consequences such as irritability, depression, and decreased physical activity[12] are also common.

Studies have shown that hospitalized patients are more prone to have sleep disturbances.[4],[5],[6],[13],[14],[15] This may be primarily due to various factors such as exogenous which include demographic and environmental or endogenous which are illness-related such as stress, depression, and pain.[16],[17],[18] Necessary steps such as identifying accurately the sleep activity and associated problems due to sleep deprivation can help to improve sleep patterns. Once identified, it is necessary to develop individualized interventions[19] in order to resolve such problems.[14],[20] Care interventions should be planned by the health professionals that cause minimal sleep interruptions. This cross-sectional, descriptive study was aimed at determining sleep disturbances in patients without any previous history of insomnia and to identify major contributing factors due to hospitalization. The second objective was also to understand the quality of sleep in people who had undergone surgical treatment with ones who had not.


  Methods Top


Subjects

The current study was conducted at Father Muller Medical College Hospital, Kankanady, Mangalore, from June 27, 2016 to July 30, 2016. Father Muller Medical College Hospital is 1250-bedded multispecialty hospital. The patients were selected from medical and surgical wards. Formal permission for the study was obtained from the Father Muller Institutional Ethics committee before the data collection. The patients satisfying the inclusion criteria were approached and briefed about the study objective by the investigators. They were also informed that their participation was voluntary and that the confidentiality of the data collected would be assured. Informed consent was obtained from willing participants. The baseline pro forma, PSQI, and Likert scale on factors disturbing sleep were given to the participants and questionnaire was collected back. The average time taken by the participant to complete the tool was 20–25 min.

Procedure

Convenient sampling technique was used to recruit the samples for the study. First, the specific wards were chosen by using the lottery method. Then, the investigators visited the concerned wards and screened the patients based on the inclusion and exclusion criteria. Inclusion criteria included patients aged below 60 years (because of normal physiologic sleep-related changes), patients who were getting treatment in the hospital from 3 days. Patients who were excluded from the study were those who were suffering with sleep disorder, patients who were receiving sedatives, and critically ill patients.

Measures

The study consisted of 12 baseline variables such as age, gender, and religion; type of family and family income; educational status and insurance facility; number of previous admissions; breadwinner of the family; ward; diagnosis; and comorbidity [Table 1]. The PSQI (Pittsburgh Sleep Quality Assessment), a self-rated questionnaire which consists of 24 questions, 19 of which are self-rated was used to assess the quality of sleep.[21] The Cronbach's alpha internal consistency coefficient of the scale is 0.80. The scale is divided into seven subcomponents: subjective sleep quality – 1 item (5.2%), sleep latency – 2 items (10.5%), sleep duration – 1 item (5.2%), habitual sleep efficiency – 3 items (15.5%), sleep – 9 items (47.3%), use of sleep-promoting medications – 1 item (5.2%), and daytime dysfunction 2 – items (10.5%); each of the responses were marked as “never,” “not often,” “often,” and “very often” and the scores were 0, 1, 2, and 3. The PSQI total score of 5 and above indicates poor sleep quality. The reliability and validity of PSQI is well documented in elderly,[22] panic disorders,[23] and cancer patients.[24]
Table 1: The self-designed questionnaire to ascertain the factors affecting sleep during hospitalization

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A self-prepared Likert scale was used to ascertain the factors affecting sleep during hospitalization [Table 1]. The scale consisted 23 items which were placed against five responses as “not at all,” “rarely,” “sometimes,” “often,” “always” and the scoring was 0, 1, 2, 3, and 4. The domains measured by the scale were physical – 3 items (max score = 12, 13%), physiological – 3 items (max score = 12, 13%), environmental – 11 items (max score = 44, 48%), and psychological – 6 items (max score = 24, 26%). The items in the scale were developed after literature review and expert opinion. Content validation was done by the experts and Cronbach's alpha internal consistency coefficient of the scale was 0.73.

Data analysis

The demographic and patient's details were analyzed using descriptive statistics. The baseline characteristics are age, gender, and religion; type of family and family income; educational status; insurance facility; number of previous admissions; ward; diagnosis; comorbidity; and breadwinner are represented as frequency and percentage. The results arrived at in the sleep scale are expressed as mean and standard deviation. Inferential statistics like correlation between factors disturbing sleep and quality of sleep and Chi-square test was carried out to determine associations between quality of sleep and baseline characteristics. Analysis was done using the SPSS version 21 (IBM version 22, Chicago Inc, USA).


  Results Top


Demographic details

This was a cross-sectional survey conducted in a tertiary care hospital with 100 consecutive continuous hospitalized patients satisfying the inclusion criteria. The demographic and patient's details are enlisted in [Table 2]. In this study, it was observed that majority (55%) of the patients were male and that 51% of all participants were in the age group of 51–60 years. Most of the patients were Hindus (51%) and were from nuclear family (65%), minimally educated (80% had <10 years of schooling), and from lower socioeconomic strata (61% had income <10,000). Majority of the participants were not having insurance facility (75%) and also that 13% of them were having complete insurance and 12% partial insurance. Most of the participants (61%) have had previous admissions in hospitals for 1–5 times, while 33% were admitted for the first time. Majority of the participants (68%) were admitted for their medical problem, while the remaining (32%) were hospitalized for surgical interventions. Most of the patients did not have any comorbidities, while 25% of them had chronic illness (such as hypertension and diabetic mellitus) at the time of diagnosis and admission. Most of the patients (58%) were admitted in the general wards, 29% were in semiprivate and 13% were in private wards.
Table 2: Baseline characteristics of patients (100)

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Quality of sleep and the factors affecting them

The data on quality of sleep in these patients are presented in [Table 3]. The results indicate that 31% of the participants had good quality of sleep and 69% of participants had poor quality of sleep [Table 3]. A detail analysis of the domains indicated that the mean percentage of quality of sleep in the area of sleep disturbance (4.70) was lower than the mean percentage of quality of sleep reported in the other areas such as subjective sleep quality (39.33), sleep latency (30.83), sleep duration (44.67), habitual sleep efficiency (12.11), and daytime dysfunction (14.67) [Table 3].
Table 3: The mean, standard deviation and mean percentage of quality of sleep as measured by Pittsburgh Sleep Questionnaire

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With regard to the aspects that have a forbearing on the sleep, the results indicated that the mean percentage of quality of sleep in patients admitted for medical conditions was less than the mean percentage in the surgical patients (13.53 vs. 15.10) and was statistically not significant [Table 4]. The other important observation was that environmental factors (51.68), physical factors (45.67), physiological factors (31.75), and psychological factors (25.17) contributed for sleep disturbance [Table 4]. Data obtained also indicated a significant association between quality of sleep and variables such as type of family (0.03), income (0.006), education (0.009), ward (0.02), and comorbidity (0.044) [Table 4].
Table 4: Association between quality of sleep and selected demographic variables

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  Discussion Top


Sleep is an essential part of the normal human circadian rhythm. It is essential for maintenance of physical, sexual, and mental functions of the body. Studies well document the negative effectors of sleep deprivations.[25] Sleep deprivation is also well recognized as a stressor, affecting human health in many adverse ways, including memory impairment and prolonged treatment spans or patient suffering from various illnesses. This may result in increased cost from prolonged hospitalization for the patients admitted to a hospital. It has been noted in various hospital-based studies that nocturnal interactions of health-care providers with inpatients have actually been counter-beneficial.[26]

The present study was conducted to assess the quality of sleep, and more importantly, the factors disturbing sleep in hospitalized patients and the results indicated that 69% of patients had poor quality of sleep and that the patients who have had undergone surgical procedures and comorbidities were affected more. These observations are in agreement to earlier reports where studies have shown that patients who underwent surgical procedures had a compromised sleep.[4] In medical care patients who have undergone surgical process need all day close monitoring and vigil by health-care staff during the night. On the contrary, patients needing treatment for their medical conditions are more likely to receive sedative or hypnotic medication and less procedural care, such as monitoring of vital signs, venipuncture, or dressing care, during the night.[4] This high intensity of all daycare merited for people who have undergone surgical interventions affects the sleep.

On the aspect of nonmedical factors in this study, it was observed that the quality of sleep was below optimum in people from low financial strata, in those who were not educated, were devoid of insurance and were in admitted in general ward. Previous studies have shown that presence of strange and bad odors, poor ventilation of the room, assessment and treatment during sleep, frequent visits by nurse/health-care workers, duration of hospital stay, the number of roommates, type of the ward, hospitalization period, noise of opening of door, attitude toward the overall atmosphere, and interior of wards.[14],[27] In addition to this, patient-specific aspects such as age, body mass index, number of comorbidities, educational level, smoking, alcohol addiction, obesity, presence and severity of pain, taking sleep medication, psychological factors (anxiety, demoralization, depression, stress), fear of death, family aspects, previous number of hospitalizations, number of medications consumed, significantly affecting the sleep quality.[28]

While the patient-related sleep-disturbing factors are varied and specific to every individual, the environmental factors are aspects that need to be considered critically by the administration. Among the environmental factors, noise is a major contributing factor. In this regard, visits by family members and friends, disturbance from copatients (in the general wards and shared rooms), and having the lights on are important.[29] The ringing of telephone and beeping of monitors also cause considerable sleep disturbance.[28] Awakening by the doctors and nurses for procedures such as vital signs and doctors rounds are also reported to contribute to sleep disturbance.[30]

Reports indicate that when compared to medical patients, sleep disturbance was more common in surgical patients by the physical factors. This was mainly due to the fear of dislodging the monitors and tubing's attached after the procedure or expectations to lie down in certain position after the procedures. A study assessing factors affecting sleep patterns in intensive care unit (ICU) patients showed that change position (93%), devices and connections in the body (94.2%) and reduction of the movement in the bed (91.9%) lead to sleep disturbance.[30]

Pain was the most common factor under physiological factors followed by difficulty in breathing and chocking which is in line with a study conducted in ICU that showed pain and difficult breathing contributed in sleep disturbance.[31] A study conducted in Brazil highlighted that uncertainties about the illness followed by missing their families and home duties interrupted their sleep.[32] The findings were consistent with the current study where patients agreed that uncertainty regarding the consequence of illness and missing their children at home followed by the concerns about the medical expenses lead to lack of sleep.[32]

The results of this study have important implications in patient care, and especially for nurses and health-care workers. The study highlights that in addition to the nursing care, aspects such as area of practice, education of the staff on the importance of sleep for patients, formulating guidelines for usage of light in the night as well as day time, proper waste disposal, prevent bad odor, and maintaining cleanliness of the ward also play a vital role. This study also serves as baseline data for nursing based research and can help the nurses to initiate more in-depth studies in the areas of quality of sleep and on to bring about awareness in the staff.


  Conclusion Top


The results of the study suggest that sleep problems are quite frequent in people being treated for their ailments and that it was more in people who have had surgery. Pain management and modification of the ward interior and atmosphere can impact inpatients sleep quality.

The limitations of this study are that this was a single-center study and was conducted in patients who are not suffering from sleep disorder and are below the age of 60 years. The other aspect that needs to be addressed is to ascertain which ailment affects the quality of sleep. From an ailment perspective, comparative studies carried out in a multispecialty hospital of Turkey have shown that when compared to the health individuals, people affected by psychiatric ailments experienced worse sleep quality than the patients recuperating after surgical procedures and for medical ailments.[14] This is extremely important for tertiary care hospital to develop protocols for optimizing sleep in the admitted patients. Furthermore, studies are required to assess the quality of sleep in patients being admitted to various hospitals and also on ways to mitigate the problem for faster recuperation and better quality of life.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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