Nursing Care and Sleep Issues in Patient

Nursing Care and Sleep Issues What is Sleep and the Biological Circadian Rhythm

Sleep is a behavior characterized by a series of distinct changes in brain and bodily states that alternate with wakefulness regularly, aligning with the environmental light and dark cycle (circadian = every 24 hours).

Inadequate sleep leads to numerous health-related consequences, such as diminished attention, memory, and problem-solving abilities, as well as reduced physical performance, altered immune system function, and impaired tissue healing. In some instances, poor sleep may signal the early onset of psychiatric issues, particularly major depression.

Additionally, poor sleep has been linked to an increased number of injury accidents, work absences, medical issues, visits to healthcare providers, and hospitalizations.

Physiological Changes During Sleep as Observed by Sonography

In research settings, sleep can be measured physiologically using sonography techniques like electroencephalograms (EEG), electromyograms, and electrooculograms to identify various sleep stages. Alternatively, activity monitors can differentiate between sleep and wakefulness. Sleep assessment can also be conducted behaviorally through direct observation or via self-reported methods, such as retrospective recall or real-time diaries and logs.

Sonography reveals that sleep initiates with transitional signs, advances into a light sleep stage, then into deep (slow-wave) sleep, and finally into a period of rapid-eye-movement (REM) sleep, completing one sleep cycle that lasts approximately 60-90 minutes. Consequently, a full night’s sleep comprises 3-6 cycles, depending on the total duration of sleep.

However, sleep measurement methods have limitations. Physiological measures are time-consuming, require costly technology, and may disrupt natural sleep. Behavioral observations are laborious, time-intensive, and can be inaccurate. Self-report methods are vulnerable to biased responses and a tendency to report negative impressions broadly. People’s perceptions of their sleep often do not align with physiological data.

Sleep Patterns

Biological scientists aim to comprehend the regulation of sleep and wake states. Behavioral scientists seek to understand the functions of sleep, normative patterns across different age groups or species, the necessity for sleep, and predictive features of poor sleep.

Abnormal sleep behaviors, such as apneas or significant muscle movements, and irregular sleep durations or timings, like narcolepsy, are areas of interest for clinical scientists.

Nursing scientists typically focus on understanding how sleep, particularly sleeplessness, relates to health and illness, methods to promote sleep, and how sleep is influenced by environments and life contexts. These contexts often include care settings, such as critical or long-term care, or situations involving enduring pain, injury, diseases, or major life transitions.

Sleep and Nursing Scientists

Sleep research conducted by nursing scientists is primarily based on the premise that personal stress affects sleep and wake quality. Illness, disease, and hospitalization are recognized as significant sources of stress that disrupt normal sleep and wake behaviors. Most of the existing work is descriptive, with only a few individual or environmental interventions having been tested.

For instance, KC Richards (1998) evaluated the effects of massage and found it tended to improve sleep in critically ill older men. Other studies conducted several years prior utilized ocean sounds, showing evidence of better perceived sleep in patients post-coronary artery bypass graft surgery, and progressive muscle relaxation in seniors, which demonstrated improvements in both perceived and sonographic sleep variables.

A review highlighted that sleeplessness is very common in infants and children, with clinicians frequently seeking treatment advice. Cognitive behavioral treatments were reviewed by Owens, France, & Wiggs (1999), which included behavior extinction and modification of parental behaviors believed to reinforce waking behaviors. Techniques such as minimal checks, parental presence, stimulus control, and scheduled awakenings were examined.

While these interventions are relevant to nursing practice, only one study appeared to involve nursing scientists: a parent sleep education program showed that a significantly smaller percentage of babies in the intervention groups experienced settling and night-waking difficulties compared to the control group (Kerr, Jowett, & Smith, 1996).

Earlier research tested the use of recorded bedtime stories on the time it took hospitalized children to fall asleep, suggesting that the use of a parental voice might extend the time needed to fall asleep. Redeker (2000), in an integrative review of sleep in acute care settings, found that sleep disturbances are common but highly variable due to multiple personal, health status, and environmental factors. She advocated for systematic research to identify correlates of sleep disturbances to determine those most at risk and to develop theoretical and conceptual foundations for sleep-promoting interventions.

KA Lee (2001) and colleagues investigated sleep and fatigue during transitional periods in women, such as the menstrual cycle, pregnancy, postpartum, and in nurses working shifts. During the luteal phase of the menstrual cycle, the time to REM sleep was shorter compared to the follicular phase. Women with premenstrual negative affect symptoms experienced less deep sleep during both menstrual cycle phases. Women transitioning through pregnancy reported sleep problems both prenatally and postpartum, with primigravidae more affected than multigravida.

In a descriptive study of registered nurses working day and non-day shifts, shift work was associated with increased sleep disturbances and sleepiness. Factors such as age and family responsibilities, more than alcohol and caffeine intake, contributed to the differences in types of sleep disturbances. This group also examined fatigue issues in women with HIV/AIDS.

Sleep Problems

Two groups of investigators have developed research programs focused on individuals with sleep problems. Roger’s group has a research program investigating subjects with narcolepsy. They have discovered that individuals with narcolepsy experience disturbed sleep and take more naps. While memory is not significantly affected, concentration is impaired. Timed naps can help certain patients fall asleep more quickly (Rogers & Dreher, 2002).

Shaver (2002) and her colleagues have ongoing work describing sleep in midlife (perimenopausal) women, particularly those with insomnia. They found that menopausal status is not strongly linked to sonographic sleep patterns unless hot flashes are present.

One group of midlife women reporting insomnia experienced high life strain and significant psychological distress but showed little abnormality in sonographic sleep patterns and few classical menopausal symptoms like hot flashes. Another group with insomnia reported hot flash activity but had less overall distress and life strain than the first group. These findings suggest that interventions to manage hot flashes and menopausal symptoms are more appropriate for the latter group, while life and stress management skills may be more effective for the former group.

Illness and Sleep Issues

Research programs are expanding to explore the relationship between sleep and major illnesses. Examples include studies in renal dialysis patients (Parker, KA, 2003); women with chronic fatigue and fibromyalgia (Landis et al., 2003); sleep apnea (Chasens & Umlauf, 2003); Parkinson’s disease; post-abdominal surgery recovery; post-coronary artery bypass graft (CABG) surgery; cancer; and sleep issues in hospitalized adults and children.

Nursing Research on Sleep During Illness or Disease

Aligned with a central focus of nursing practice, studies conducted by nursing scientists primarily aim to understand sleep in relation to illness and disease. Most of these studies utilize descriptive methodologies that rely on self-reported sleep data.

For the advancement of nursing sleep science, it is crucial to conduct more extensive research to predict those at high risk for negative consequences, especially among vulnerable populations such as older adults and the chronically ill. This includes individuals suffering from sleep disorders where behavioral treatments are prominent (e.g., insomnia, narcolepsy) and those in high-risk environments (e.g., hospitals, high-stress settings).

Since sleep is a behavior responsive to behavioral interventions, it is essential to test behavioral interventions, including dose-response relationships, titration, timing, individualized response types, and the factors affecting behavioral choice and adherence.

Furthermore, applying biobehavioral methods that combine physiological and perceptual measures will significantly enhance our future knowledge. This advancement is important for symptom management, illness and disease prevention, and health promotion.