Factors That Affect Inpatients' Quality of Sleep Factors That Affect Inpatients' Quality of Sleep Original Article

* Taken from the Scientifi c Initiation Project " Factors interfering in the sleep quality of hospitalized patients " , RESUMO Este estudo obje vou iden fi car fatores que interferem na qualidade do sono de pacien-tes internados em hospital universitário do interior de São Paulo. Trata-se de estudo exploratório, de corte transversal, com amos-tragem não probabilís ca. Par ciparam 117 pacientes (59% homens, idade média de 48 anos, desvio padrão 16,9) internados há pelo menos 72 horas, em condições clínicas estáveis. Os instrumentos u lizados foram: ques onário de iden fi cação e Fatores In-tervenientes na Qualidade do Sono (FIQS). O tratamento dos dados foi feito com esta s-ca descri va e cada item do FIQS foi subme-do a teste e reteste. Os fatores apontados com maior frequência foram: acordar cedo (55,6%), sono interrompido (52,1%), ilumi-nação excessiva (34,2%), recebimento de cui-dados pela equipe de enfermagem (33,3%) e distúrbios orgânicos como dor e fadiga (26,5%). Sugere-se que os enfermeiros plane-jem intervenções buscando modifi car fatores que propiciam ruídos e iluminação intensos à noite, visando reduzir interrupções e, conse-quentemente, a privação de sono. ABSTRACT The aim of this study was to iden fy factors that interfere with the sleep quality of pa ents admi ed to a university hospital in a city in the state of São Paulo, Brazil. This was an exploratory, cross-sec onal study using non-probability sampling. Par cipants were 117 pa ents (59% men, mean age 48.0 years, standard devia on 16.9) hospitalized for at least 72 hours in stable clinical condi on. The data were collected with an iden fi ca on ques onnaire and the Factors Aff ec ng Sleep Quality (FASQ) ques onnaire. Data processing was performed with descrip-ve sta s cs; each item of the FASQ underwent a test and a retest. The factors most o en reported were waking up early (55.6%), disrupted sleep (52.1%), excessive ligh ng (34.2%), receipt of care by nursing staff (33.3%) and organic disorders such as pain and fa gue (26.5%). It is suggested that nurses should plan in-terven ons to modify factors that require intense noise and ligh ng at night in order to reduce disrup on and, consequently, sleep depriva on among pa ents. DESCRIPTORS Sleep Inpa ents Nursing care RESUMEN Se obje vó iden fi car factores que interfi-eren en la calidad del sueño de pacientes internados en un hospital universitario del interior de São …


ABSTRACT
The aim of this study was to iden fy factors that interfere with the sleep quality of pa ents admi ed to a university hospital in a city in the state of São Paulo, Brazil. This was an exploratory, crosssec onal study using non-probability sampling. Par cipants were 117 pa ents (59% men, mean age 48.0 years, standard devia on 16.9) hospitalized for at least 72 hours in stable clinical condi on. The data were collected with an iden fi ca on ques onnaire and the Factors Aff ec ng Sleep Quality (FASQ) ques onnaire. Data processing was performed with descripve sta s cs; each item of the FASQ underwent a test and a retest. The factors most o en reported were waking up early (55.6%), disrupted sleep (52.1%), excessive ligh ng (34.2%), receipt of care by nursing staff (33.3%) and organic disorders such as pain and fa gue (26.5%). It is suggested that nurses should plan interven ons to modify factors that require intense noise and ligh ng at night in order to reduce disrup on and, consequently, sleep depriva on among pa ents.

INTRODUCTION
Sleep is an unconscious state in which a person can be woken up by sensory or other s muli (1) . In human beings, sleep is a cyclical process that is composed of fi ve alternang and mutually diff erent stages or phases. In physiological terms, these diff er according to the pa ern of brain waves retained through the encephalogram (EEG), to the presence or lack of rapid eye movements and changes in other variables such as muscle tension and cardio-respiratory pa ern. The propor ons of each stage vary according to age (2) .
To be in a good state of alertness, adults require an average of seven to eight hours of sleep in a 24-hour period, and waking up during the night represents up to 5% of the total me spent in bed. Sleep cycles in that age range present a pa ern in which the person spends approximately 30% in paradoxical sleep, 20% in deep sleep and 50% in superfi cial sleep (3) .
Homo sapiens is a day species that is adapted to perform ac vi es during the light period of the light/dark cycle and rest during the dark period. The development of the human visual system and its dependence on light informa on is what makes it a day species. The main sleep period for the human species is, therefore, during the dark phase (4) .
In addi on to the physiologic parameters, sleep quality is an important factor to be assessed for two reasons. Firstly, complaints about sleep quality are common. Diffi culty in falling or staying asleep is the main factor aff ec ng sleep quality and aff ects approximately 15% to 35% of cases. Secondly, poor quality sleep is an indica on of various illnesses. Sleep quality disorders can nega vely aff ect people's feelings, ideas and mo va on.
The physical and cogni ve symptoms of people with poor sleep quality are the following: redness, loss of concentra on, fa gue, increase in pain sensibility, anxiety, distress, irra onal ideas, hallucina ons, loss of appe te, cons pa on and increased risk of accidents. It is known that sleep problems cause tension, delay wound healing, increase the percep on of pain and also contribute to the diffi culty in performing daily tasks (5) .
Hospitals are usually environments where having high--quality sleep is a challenge. The reasons why sleeping in a hospital might not be a res ul or restora ve experience can be classifi ed into the following three groups of factors: environmental (for example, loud noises and excessive ligh ng), physiological or organic (such as pain and nausea) and psychological (for example, distress and anxiety) (5)(6) .
In a study undertaken at a specialized women's health service at a teaching hospital located in Campinas (SP), the author observed that the main factors pa ents men oned as being responsible for the interrup on of their night sleep were environmental factors, such as the care health professionals provided to them (92%) and their fellow pa ents (84%). In addi on to these factors, among female pa ents, 44% referred to the noise caused by equipment placed near the bed, the noise caused by pa ents who were generally in poor health or who were agitated and the need to use the bathroom or the urinal. Excessive ligh ng was cited as an infl uen al factor by 52%, and environment noises were cited by 36% (7) .
However, it is known that in a hospitaliza on situa on, pa ents' intrinsic factors can also nega vely aff ect their night sleep. Amongst them, organic factors related to their clinical situa on and treatment, such as pain and emesis, and psychological factors related to their own stressful situa on, such as fear, concern, distress and anxiety can be involved. In the above men oned study (7) , 52% of the women referred to psychological factors as being harmful to their sleep quality during their hospital stay, and 44% of them referred to organic disorders, such as gastrointesnal disorders, fa gue and pain.
This set of intrinsic and extrinsic factors can seriously compromise the sleep quality of hospitalized pa ents. Based on the iden fi ca on and analysis of these factors, and seeking to assess which are the most frequent and relevant in their daily pracce, nurses can plan interven ons to assist pa ents in achieving be er sleep quality during their hospital stay.
The objec ve of this study is to iden fy the factors that most frequently aff ect the sleep quality of pa ents staying in wards at a teaching hospital located in a country town in the state of Sao Paulo.

METHODS
Type of study: Exploratory and observa onal cross--sec onal study with non-probability sampling.
Research fi eld: Developed at clinical and surgical hospitaliza on units for adults (except for the neurology, neurosurgery and psychiatry clinics) at a university hospital of a country town in the state of Sao Paulo. Subjects: One hundred seventeen pa ents hospitalized at selected units who complied with inclusion and exclusion criteria. The sampling size was based on the dura on of data collec on, which was from September 2009 to February 2010. Exclusion criteria: Recently post-opera ve (up to 24 hours); an cipated hospital discharge on the day of the data collec on; serious visual disability with non-tolerance to light; serious hearing disability (deafness); previous par cipa on in the same study (cases of re-admission to the hospital during the data collec on period).
The IQ contains ques ons about demographic informaon (gender, age, marital status), lifestyle, hospitaliza on, clinical and health condi ons, and it was specifi cally developed by the authors for this study. The FASQ was adapted (7) according to a ques onnaire used in a study about sleep quality and noises undertaken at a hospital in Belo Horizonte in the state of Minas Gerais (8) . Such change was considered necessary because the original ques onnaire was aimed at assessing pa ents' sleep during the last night of their hospital stay, while the present study sought to cover a period of up to one week before the use of this quesonnaire. It was submi ed to judges before being used by the author (7) , who authorized its use in this study. It is aimed at iden fying changes in sleep habits and frequency in the occurrence of sleep disorders during hospitaliza on that are caused by factors related to the hospital environment and the clinical condi on of the pa ent.
The factors assessed as possibly causing disorders include the following: noises, ligh ng, temperature, bed comfort, psychological and organic problems, and interrup ons of night sleep due to the assistance provided to pa ents or other pa ents in the same room. The frequency of their occurrence was assessed based on how many days per week such factors had occurred, and the pa ents were given the following response op ons: zero, once to twice a week, three to four mes a week, and fi ve mes a week or more. The pa ents answered the IQ and the FASQ, and the researcher registered their responses.

Ethical Aspects:
The study received approval from the Research Ethics Commi ee of the ins tu on (Registra on number 037/2009, homologated on March 17 th 2009). All par cipants signed the informed consent form.

Data Collec on:
Data collec on began with the choice of the approach sequence in rela on to the hospitaliza on units and was followed by data collec on from all pa ents who matched the inclusion and exclusion criteria. The FASQ was used twice with 51 pa ents, with a 24-hour-interval between interviews, in order to assess the consistency of the answers (test and re-test). Then, data collec on con nued un l the comple on of the intended sample of 120 individuals. A er this, due to incomplete informa on, three individuals were excluded, yielding a total sample of 117 par cipants.

Data analysis:
The analysis of the data was undertaken through descrip ve sta s cs (posi on measures, central trends and variability, frequencies and propor ons). The FASQ was submi ed to test and re-test (a er 24 hours) in order to assess the consistency of the answers, using the intra-class correla on coeffi cient (ICC). The following classifi ca on was used: very good (ICC 0.81 to 1.00), good (ICC 0.61 to 0.80), moderate (ICC 0.41 to 0.60), poor (ICC 0.21 to 0.40), and bad (ICC less than 0.20) (9) . The factors assessed by the FASQ were organized according to the proporon of responses of "fi ve mes a week or more". The items with higher propor ons of this response were evaluated as the ones that most aff ected the par cipants' sleep quality.

RESULTS
The 117 par cipants in this study were staying in one of the 13 hospitaliza on units studied. On average, they were 48 years old (standard devia on 16.9, median 48.9) and possessed 7.3 years of formal educa on (standard devia on 3.9, median 7.0). On average, they had been in the hospital for 10 days (standard devia on 8.4, median 7.0). Other characteris cs of the par cipants are described in Table 1.
The analysis of the consistency in the responses to the FASQ among 51 par cipants, undertaken through the use of the intra-class correla on coeffi cient (ICC), did not have signifi cant results (p>0.05) for all items, thus showing its consistency.
The results obtained through the FASQ, as well as the ICC coeffi cients for each item, are shown in Table 2.
It was verifi ed that a high propor on of pa ents reported waking up earlier in the hospital than at home, having interrupted sleep, sleeping less than they had wished and sleeping earlier than at home. The factors most frequently men oned as being responsible for disturbed sleep were the following: excessive ligh ng, care provided by the nursing staff and organic disorders like pain and fa gue. However, there were few complaints about the care provided to other pa ents in the room, the room temperature and the uncomfortable hospital bed. Sixteen par cipants (13.3%) men oned the occurrence of other factors, such as the noise made by the bin lid when closed by the cleaning staff , loud talking, abrupt entry into the room by the nursing staff who turned on the light, and being away from family and from domes c chores. The existence of a sleep prepara on rou ne at home was reported by 62 (51.7%) par cipants and, amongst them, 39 (32.5%) missed this rou ne in the hospital.

DISCUSSION
The sleep quality of the pa ent who is frequently hospitalized is not a cause of concern for the health professional except when it is obviously lacking or poor and when it results in complaints from the pa ent. Generally, pa ents seem to sleep well according to professional assessment; however, from the pa ent's perspec ve, sleep may not be restora ve or relaxing. This divergence may aff ect the planning of nursing intervenons in a way that the pa ents are able to have balanced sleep and that adequate supervision during falling and staying asleep is maintained (6,10) .
The majority of par cipants in this study were male, between the ages of 40 and 60, of Caucasian origin, married, and with fewer than eight years of formal educa on. Most par cipants reported drinking coff ee daily and most claimed not to smoke or consume alcohol. Approximately one-third of the par cipants reported doing regular physical exercise. All pa ents used medica on in the hospital, and most of them stated that they also used medica on at home.
It is important to note that nurses should consider socio-demographic and lifestyle factors whilst advising pa ents in rela on to sleep quality because, according to the literature, these factors may infl uence the counseling required. As for gender, for example, a study undertaken with 150 pa ents in a hospital concluded that men had be er sleep quality than women because women are always more concerned about not performing their home du es and caring for their families during their stay in the hospital (5) .
In the present study, approximately 25% of the par cipants were over the age of 60. The elderly deserve special a en on, as they almost always suff er from mul ple illnesses that may aff ect sleep quality, such as diabetes, arthri s, cardiovascular diseases and demen a (11,12) . Furthermore, sleep quality could decrease with increased age, leading to an increase in the alertness period during the night (3,5) .
Many pa ents reported consuming coff ee, and a smaller propor on reported the use of alcohol and cigare es. These substances cannot be used during the hospital stay, which provides a unique opportunity for the nurse to counsel the pa ent on how the use of these substances can aff ect sleep quality. The literature regarding sleep hygiene mainly suggests that caff eine consump on should be reduced because the higher the intake, the worse the quality of sleep (13) . In addi on, caff eine can damage REM sleep (6) . Nico ne also causes a delay in falling asleep but, at the same me, sudden absnence may cause sleep disorders for one or two nights. Therefore, smokers may have poor quality sleep in their fi rst nights spent in the hospital. Alcohol, although inially assis ng with falling asleep, has a contrary eff ect when metabolized. This causes more frequent sleep interrup ons that can be accompanied by heart palpitaons, intense perspira on and nightmares (6) .
Physical ac vity posi vely aff ects sleep quality. Parcularly for the elderly, physical exercise has been shown to be benefi cial for sleep problems related to disorder of the circadian rhythm, such that regular physical ac vity seems to increase the depth and dura on of sleep (3) .
Whilst analyzing the reports related to sleep characteris cs during hospitaliza on, pa ents reported waking up earlier in the hospital than at home, having interrupted sleep, sleeping less than they wished and going to sleep earlier than at home. Regarding the factors aff ecng the night sleep, a large number of pa ents cited the following environmental factors: excessive ligh ng and the care provided by the nursing staff . Physiological factors were also frequently cited, and they were represented by organic disorders like pain and fa gue. A small propor on of pa ents complained about the care provided to other pa ents in the room, room temperature and the uncomfortable hospital bed.
It was also shown that a high propor on of pa ents stated that their sleep was disturbed by environmental factors, such as excessive ligh ng and the assistance provided during the night, by physiological factors (organic disorders) and psychological factors such as fear, concern and anxiety.
The facts suggest that sleep disturbance is more likely to happen due to a combina on of intrinsic and extrinsic factors that aff ect hospitalized pa ents in diff erent ways according to individual circumstances, which can include the pa ent's personal illness and previous experiences together with the variable gravity of the illness impac ng the pa ent's life (14) . Furthermore, the impact of environmental factors, as shown in the present study, should also be considered.
A study recently undertaken in Brazil with pa ents admi ed to medical clinic units showed that 55.8% of the par cipants stated that their sleep was interrupted two to four mes per night. This fi nding is consistent with the results obtained in the present study, in which the pa ents reported that their sleep was frequently interrupted during their hospital stay. Similarly to the present study, the study men oned above showed that environmental factors also had a relevant eff ect in rela on to these interrupons and were cited by 34.6% of the par cipants (15) .
Nursing interven ons were cited by 13.5% of the parcipants; however, the authors assessed only the intervenons related to medica on administra on (15) , which contributed to the diff erence in rela on to the present study, where this factor was cited by 33.3% of the par cipants. In general, sleep interrup ons occur as a result of hygiene and other care provided by the nursing staff , as well as the administra on of medica on to pa ents.
Interrupted sleep is directly related to the diffi culty in having enough sleep, a fact that varies depending on the individual. This was a frequent complaint in the present study, where the par cipants stated that they slept less than they wished to. It is important to note that many pa ents fi nd it hard to fall asleep again once woken up at night.
The pa ents o en have diffi culty in falling asleep and having an eff ec ve sleep, and this is shown by their complaints about waking up during the night and not having a restora ve sleep. Sleep disturbance, as men oned, can be caused by mul ple factors, such as pa ent illness, medical treatment and the hospital environment. However, these factors may not be recognized as causing sleep disturbance or as capable of causing sleep depriva on during hospitaliza on, and consequently, as causes of a chronic lack of restora ve sleep (16) .
Noises resul ng from loud talking, the ac vi es of the cleaning staff , nursing staff walking into the room abruptly and turning on the light, and missing their families and home du es were other factors that pa ents men oned as disturbing, although less o en than the other factors assessed.
The ac vi es of the nursing staff , such as a change in bed posi oning, dressing change, administra on of medica on, hygiene and others, need adequate ligh ng in order to be safely performed. Such ac vi es, however, should be planned in a way such that they do not disturb pa ents' sleep with frequent interrup ons. For example, these ac vi es should be concentrated in certain periods in order to allow uninterrupted rest periods (17) .
The regula on of sleep is the balance between the organism's homeosta c requirement and the circadian pacemaker or biological clock. The circadian pacemaker is located in the suprachiasma c nucleus, and it determines the beginning and the end of sleep. It is par ally regulated by environmental s muli, such as light, noise and room temperature.The hormone melatonin, a promoter of physiological sleep, is secreted mainly in the beginning of the night, and it is inhibited by the light, such that its circula on in the organism is reduced during the day. The excre on of cor sone by the adrenal gland, which is associated with alertness, follows the circadian pa ern, as the cor sone peak excreted in the beginning of the morning is regulated by the hypothalamic axis in prepara on for the increase in the metabolic needs during the period of alertness (17) . Therefore, light during the night not only interrupts sleep, but it can also cause disorders in the circadian organiza on of the alertness/sleep cycle, consequently disrup ng melatonin excre on and thus aff ec ng the whole organism. It is essen al that nurses understand that poor quality sleep, which was reported by a large number of paents during hospitaliza on, can have nega ve eff ects on pa ents' recovery. In a study undertaken in a coronary unit, lack of sleep was the second most frequent factor pa ents cited amongst the 42 possible stressors that occurred during hospitaliza on (18) .
Sleep is an important process of energy preserva on, and its depriva on can cause sleepiness during the day, fa gue, altered mood and periods of disorienta on (5) . It can also reduce pain tolerance due to the increase of fague in the sympathe c central nervous system, which may lead to increased use of pain control drugs, which can themselves contribute to sleep depriva on (14) . Sleep, therefore, cons tutes a basic human need that deserves full a en on and interven on by nurses (5) .

CONCLUSION
This study, undertaken with 117 pa ents admi ed at clinical and surgical hospitaliza on units at a teaching hospital of a country town in the state of Sao Paulo, during the period between July 2009 and May 2010, led to the following conclusions: A high propor on of pa ents cited waking up earlier in the hospital than at home (55.6%), having interrupted sleep (52.1%), sleeping less than they wished (38.5%) and going to sleep earlier than at home (35.9%).
For a large number of pa ents, the factors responsible for disturbing their sleep were excessive ligh ng (34.2%), care provided by the nursing staff (33.3%) and organic disorders like pain and fa gue (26.5%).
The results of this study show the importance of nursing interven on planning in order to improve the sleep quality of hospitalized pa ents, to change the environmental factors that cause loud noises and excessive ligh ng during the night, with a goal of reducing sleep interrup ons and, consequently, sleep depriva on in pa ents.
As interven ons have yet to be tested, the organizaon of the daily care ac vi es in a pre-determined period with the purpose of allowing uninterrupted sleep and the transi on of on duty staff out of pa ents' rooms for paents in semi-cri cal and non-cri cal condi ons are measures that can be proposed. It should be highlighted that the importance of sleep in hospitalized pa ents needs to be more broadly incorporated into nurses' qualifi ca ons, and the adequate evalua on of sleep should also be incorporated into the educa on of the health staff as a whole.
Sleep is a subjec ve experience of the pa ent and should be respected as such. Further studies regarding nursing interven ons aimed at improving the sleep quality of hospitalized pa ents are recommended, as well as studies that create condi ons to s mulate nurses to discuss this theme. With this in mind, nurses will have more support to plan interven ons aimed at improving the sleep quality of their pa ents and reducing the factors that nega vely aff ect this improvement.