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Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 34-42

Influence of nursing care intervention on quality of sleep in hospitalized patients at Riyadh, Saudi Arabia

1 Associate Professor, Department of Nursing, College of Applied Medical Sciences, Majmaah University, Majmaah, Saudi Arabia
2 Principal, Uttaranchal College of Nursing, Uttaranchal University, Dehradun, Haryana, India
3 Professor, Department of Physiotherapy, Faculty of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad, Haryana, India

Date of Submission15-Jan-2022
Date of Decision08-Mar-2022
Date of Acceptance09-Mar-2022
Date of Web Publication2-May-2022

Correspondence Address:
Moattar Raza Rizvi
Department of Physiotherapy, Faculty of Allied Health Sciences, Manav Rachna International Institute of Research and Studies, Faridabad - 121 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_7_22

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Background: In clinical practice, patients' sleep is disrupted by medical professionals' care or evaluations both at night and during the day. Multiple factors contribute to this sleep disruption resulting in poor clinical outcomes. Aims: This study aims to determine the quality of sleep perceived by patients admitted to various hospital settings, as well as the factors affecting sleep quality. Settings and Design: Descriptive explorative design involving purposive convenient sampling of 90 hospitalized admitted at King Khalid General Hospital, Al Majmaah, and General Hospital, Zulfi. Methodology: St. Mary's Hospital Sleep Questionnaire used to assess patients' sleep and sleep-disturbing scale. Statistical Analysis Used: The Chi-square test was used to compare the different parameters related to sleep. Results: Subjective conclusions suggested that 38 (26.4%) patients slept lightly, 67 (46.5%) were moderately satisfied with their last night's sleep, and only 9 (6.3%) were mildly dissatisfied. Continuous light, uncomfortable Pillow, strange fragrances (P = 0.004), hearing frequent sound (P = 0.018), telephone (P = 0.046), and machine alarms (P = 0.006) were the elements impacting sleep pattern connected to the patient themselves. Tubings, monitor leads, pain, and fear of death all significantly influenced sleep pattern. Many of the healthcare workers' behaviors such as awakening by doctors and nurses (χ2 = 13.08, P = 0.02), making loud noise (χ2 = 15.85, P = 0.007), assessing vitals (χ2 = 12.90, P = 0.02), hygiene care (χ2 = 5.24, P = 0.14), feeding (χ2 = 9.82, P = 0.09), tubing and drain (χ2 = 17.92, P < 0.002), and suctioning (χ2 = 21.30, P = 0.0001) had significant influence on sleep pattern. Conclusion: Based on the results, nurses can minimize the factors that cause sleep interference in hospitalized patients and avoid the possible negative effects caused by sleep deprivation.

Keywords: Awakenings, quality of sleep, sleep deprivation, sleep duration, sleep latency

How to cite this article:
Alotaibi JS, Dharmarajan B, Rizvi MR. Influence of nursing care intervention on quality of sleep in hospitalized patients at Riyadh, Saudi Arabia. Saudi J Health Sci 2022;11:34-42

How to cite this URL:
Alotaibi JS, Dharmarajan B, Rizvi MR. Influence of nursing care intervention on quality of sleep in hospitalized patients at Riyadh, Saudi Arabia. Saudi J Health Sci [serial online] 2022 [cited 2023 Apr 1];11:34-42. Available from: https://www.saudijhealthsci.org/text.asp?2022/11/1/34/344491

  Introduction Top

One of the vital roles of sleep is involved in healing and repair of heart and blood vessels. In children and teens, sleep helps to support growth and development. Ongoing sleep deficiency could raise risk for some chronic health problems such as heart and kidney disease, hypertension, diabetes, stroke, and the risk of obesity.[1] Sleep is a dynamic and essential part of human life and health. Standardized sleep assessment does not currently occur in the care of acute hospitalized patients. An effective, efficient sleep assessment tool is needed to aid clinicians. Such assessment would enable specific nursing intervention to be tailored to individual patients.[2] The promotion of patients' sleep during hospital care is an important intervention for the nursing profession. To promote sleep and to initiate sleep-promoting interventions, nurses need basic knowledge about sleep and its physiology. Therefore, it is of importance to explore and expand knowledge about how nurses experience patients' sleep and how they perceive working with it while providing care.[3]

Many patients experience sleep disturbances and a reduced quality of sleep while hospitalized. Studies have shown that a person with a disease and/or a bodily injury has an increased need for sleep. Patients' experiences of sleep should govern how sleep disturbances should be managed. It is thus necessary to focus upon and describe patients' needs and experiences.[3] Multiple factors are believed to contribute to disruption of patients' sleep and negatively affect clinical outcomes in the intensive care unit (ICU). Achieving restorative sleep for critically ill patients remains a challenge.[4] According to one study, hospital staff did not allow for the importance of sleep when planning patient care even though effective sleep assessment by nurses can help to measure improvements in patients' sleep patterns.[5] A recent study evaluating sleep quality in the hospitalized patient recommended nurses should develop a way for collecting data to determine and assess patients' sleep quality.[6]

Staff nurses who work in a hospital's inpatient department require a broad knowledge base and advanced skills when caring for patients, particularly if their patients have severe illnesses and complex problems. The improvement of this knowledge should not be limited to only clinical skills but should extend to physiological matters, including caring for patients during their daily activities such as assisting with bathing, helping them to walk, teaching them about diet and medication, and monitoring if they are getting enough sleep.[7]

During clinical practice, patients experience sleep interruptions, both at night and during the day, due to the care or evaluations conducted by health professionals. Patients are awakened from sleep to undergo interventions, which could disturb their sleep patterns. Furthermore, some patients have reported they did not rest at night due to various environmental factors. Therefore, the question is what care interventions are performed by the nursing health professionals and what is the influence of these interventions on the hospitalized patients' quality of sleep. If staff nurses take appropriate steps to prevent common sleep disorders, it is expected that the patients will benefit more from care and treatment, which will improve the recovery process.[8],[9]

Although the relationship between the poor sleep of critically ill patients and their ultimate outcomes remains unknown, it is potentially important. Poor quality of sleep may lead to the larger problem of brain dysfunction, such as the manifestation of delirium. A collaborative and multidisciplinary approach for understanding and treating the problem requires immediate attention, perhaps leading to significant improvement in ICU care and patient outcomes.[10],[11] Therefore the present study aims to identify the influence of nursing care interventions on the quality of sleep in hospitalized patients.

  Methodology Top

Study design

The present is based on the descriptive explorative approach, which is used to evaluate the quality of sleep pattern and various factors influencing the sleep pattern of hospitalized patients in the selected hospitals of the Kingdom of Saudi Arabia. The study settings included King Khalid General Hospital, Al Majmaah, and General Hospital, Zulfi. To collect the data, the researcher designed a modified version of a self-reported questionnaire based on St. Mary's Hospital Sleep Questionnaire (SMHSQ). The study protocol was in accordance with the ethical guidelines of the modified 1975 Declaration of Helsinki. Since patients were invited to participate in one part of the study only, and since the study did not include invasive questions, ethical approval was not necessary.


One hundred and forty-four participants were selected based on the purposive convenient sampling technique in the selected areas such as medical, surgical, ICUs. These individuals were, alert, able to convey, and were not on any kind of hypnotics or sedatives.

Description of the tool

A self-reported Questionnaire consisting of 14 items meant for evaluating the subjective domain of quality of sleep such as pattern of sleep-wake, frequency of awakenings at night, and instabilities in sleeping was used. A bilingual questionnaire based on Likert's scale was developed for measuring factors affecting sleep quality that included four categories as 1 = No disturbance, 2 = mild disturbance, 3 = Moderate disturbance, and 4 = Severe disturbance. This questionnaire included a total of 26 items embodying predisposing factors to sleep interruption in the hospitalized patients. These were categorized further down into four main domains: Unit design and structure, patients themselves, other patients, and healthcare personnel. For the validity of the factors affecting the quality questionnaire content validity was used so that the questionnaire was initially presented to 15 faculty members of College of Applied Medical Sciences at Majmaah University and their comments were applied. Cronbach's Alpha was used to evaluate the reliability and the reliability of the factors affecting sleep quality questionnaire was confirmed with the value of 0.8. Following data collection through SMHSQ, the sleep latency and sleep duration were calculated. Sleep latency was calculated by subtracting Q2 (Fall asleep last night) from Q1 (settle down for the night). Sleep duration was calculated by subtracting Q2 (Fall asleep last night) from Q3 (finally wake this morning).

Statistical analysis

The collected data were entered into IBM SPSS Statistics for Windows, version 20.0 (IBM Corp, Armonk, NY, USA). Descriptive statistics were derived for each of the variables. The Chi-square test was used for the categorical variables, and the Wilcoxon test and the Mann–Whitney U-test were employed for the statistical analysis of the nonparametric data. In all analyses, a significance level of 0.05 was considered. The categorical variables were demonstrated in numbers (%).

  Results Top

The result showed that the majority of the participants were male 107 (74.3%), most of the subjects 65 (45.1%) belong to the age group of 26–40 years, whereas pertaining to marital status maximum number of subjects 100 (69.4%) were married. Majority of the subjects 72 (50%) were from male medical ward and only 6 (4.2%) were from female surgical ward [Table 1]. From [Table 2], it was clear that 68 (47.2%) subjects expressed sleep latency period of 16–30 min and almost equal number of subjects 17 (11.8%) and 16 (10.4%) had sleep latency of <15 min and more than 60 min respectively. Pertaining to sleep duration maximum number of subjects 50 (55.6%) had 6–7 h of sleep, while 18 (12.5%) subjects had <5 h of sleep duration.
Table 1: Demographic profile of the subjects

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Table 2: St. Mary hospital sleep questionnaire

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Quality of sleep based on the subjective inferences revealed that 38 (26.4%) subjects had fairly light sleep and more or less equal number of subjects 7 (4.9%) and 6 (4.2%) expressed deep and very deep sleep pattern; regarding clear-headed after getting up from the sleep showed that 45 (31.3%) subjects felt Still slightly drowsy and only 4 (2.8%) expressed very alert. In relation to satisfaction with last night sleep 67 (46.5%) subjects expressed fair level satisfaction and only 9 (6.3%) subjects expressed slightly unsatisfied level of satisfaction [Table 2].

Pertaining to number of times the patient woke up during last night sleep, it was seen that maximum number of subjects 38 (26.4%) got up twice and only few subjects 3 (2.1%) got up by six times. Further majority of the subjects 85 (59%) experienced trouble to get off sleep again by waking early. In addition, 82 (56.9%) subjects faced very little difficulty while 28 (19.4) patients had some difficulty and only 32 (22.2%) subjects had trouble getting off to sleep last night [Table 2].

As per [Table 3], it was evident that most of the factors under unit design had a significant influence on quality of sleep among the subjects mainly continuous light (P = 0.004), uncomfortable pillow (P = 0.018), strange odors (P = 0.046) and hearing frequent sound, telephone and machine alarms (P = 0.006). Though 31 (48.4%) subjects expressed no disturbance in male medical ward, 15 (55.6%) subjects stated severe disturbance due to continuous light. Around 38 (52.1%) subjects stated uncomfortable Pillow was not a factor leading to sleep pattern disturbance in male medical ward, but equal number of subjects 4 (13.3%) in female medical and surgical ward expressed Uncomfortable Pillow lead to a severe disturbance in sleep pattern. 50 (52.6%) subjects and 39 (52.7%) in male medical ward and 6 (6.3%) and 6 (8.1%) subjects female surgical ward expressed strange odors and hearing a frequent sound, telephone and machine alarms created a mild disturbance in sleep pattern [Table 3].
Table 3: Factors affecting sleep pattern - unit design

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[Table 4] represented various factors affecting sleep pattern under disturbance related to patients themselves. It was evident that the presence of tubing, leads of monitors (P = 0.002), pain (P = 0.0001), fear of death (P = 0.04) had a significant positive influence on sleep pattern disturbance among the subjects though there was no significant influence found between the sleep pattern and other factors such as lack of privacy, isolation, medical expenses, fear of disease, and cough.
Table 4: Factor affecting sleep pattern - disturbance related to patient themselves

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There was a significant influence between the factors of crying of surrounded patients and watching treatments of other patients on sleep pattern. 14 (45.2%) subjects in male medical ward and the same proportion of subjects 4 (12.9%) expressed crying of surrounded patients had a moderate disturbance, while 35 (51.5%) subjects and 15 (55.6%) subjects in male medical ward expressed no disturbance and moderate disturbance respectively due to watching treatments of other patients [Table 5].
Table 5: Factor affecting sleep pattern - observation of other patients

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As shown in [Table 6], it was clear that most of the activities related to health care professionals such as awakening by doctors and nurses (χ2 = 13.08, P = 0.02), a loud noise by the personnel (χ2 = 15.85, P = 0.007), assessing vitals (χ2 = 12.90, P = 0.02), hygiene care (χ2 = 5.24, P = 0.14), feeding (χ2 = 9.82, P = 0.09), care of tubing and drain (χ2 = 17.92, P = 0.002) and suctioning (χ2 = 21.30, P = 0.0001) had significant influence on sleep pattern disturbance among the study participants. Equal number of subjects 2 (28.6%) and 5 (71.4%) in male medical and surgical ward expressed moderate disturbance in sleep pattern due to awakening by doctors and nurses and a loud noise by the personnel; whereas the same number of subjects 8 (30.8%) in male medical and surgical and 10 (38.5%) subjects in female medical ward complained that administration of medications leads to a severe disturbance in their sleep pattern. Whereas, the majority of the subjects in the entire ward expressed that there was no disturbance due to assessing vital signs and hygiene care, though other subjects stated mild disturbance in their sleeping pattern. In relation to feeding, care of tubing and drain, and suctioning maximum number of subjects expressed there was no disturbance, and least numbers of subjects stated moderate disturbance in their sleep pattern.
Table 6: Factor affecting sleep pattern - activities by healthcare personnel

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  Discussion Top

The exact function of sleep remains unclear, yet it is evident that sleep is important for many vital functions, such as energy conservation, thermoregulation (control of bodily temperature), and tissue recovery.[12] The present was conducted by means of a modified structured questionnaire of SMHSQ to evaluate sleep status of patients while admitted in the hospital. This study included 74.3% male and 25.7% females admitted to medical and surgical wards. The study revealed that about 45% of patients belong to the age groups 26–40 years. The present study was similar to Uğraş and Oztekin, who explored the awareness of patient's concerning environmental factors resulting in sleep disturbances in a neurosurgical intensive care setting. This study showed that the bulk of the studied sample was in the middle adulthood.[13] On the other hand, Ehlers et al., (2013), performed an investigation of factors causing sleep deprivation in a multi-disciplinary ICU in South Africa, opposed the present study's finding where they documented older adults to be more than half of the studied sample.[14]

Further, the present study showed that most of the patients admitted to the different clinical units were married (69.4%). Similar results were obtained from a study by Orwelius et al., researching the prevalence of sleep disturbances and quality of life after critical care, and found that the majority of the studied sample was married.[15] In addition to this, a randomized controlled trial by Su et al., studying the impact of listening music by noncommercial music on quality of nighttime sleep in medical ICU reported that most of the studied samples were married.[16] The normal average sleep has been reported to be 6–9 h per night.[17] The current study revealed that 55.6% of hospitalized patients in different wards had sleep duration of 6–7 h while 12.5% had sleep duration of <5 h [Table 2].

In this study, about 60% of patient reported to have light sleep while only 40% had deep sleep. In addition to this, approximately 65% of patients complained of feeling drowsy after getting up from sleep. However, only 32% of hospitalized patients were unsatisfied with the last night sleep. Further, there were only 15% of patients who did not wake up not even for once during the last night sleep, while 85% complaint of getting up from once to six times during the night. Of which about 26.4% of patients got up twice and 22.2% of patients got thrice during the last night sleep. A significant number of patients (85%) reported to have troubled by waking early and being unable to get off to sleep again. A similar sort of findings was documented in a prospective descriptive study performed to determine the pattern, quantity, and quality of sleep and the prevalence, causes and effect of sleep deprivation/disturbance among 183 adult patients admitted into the two hospitals and 80 nurses caring for them. The Sleep Behavior Observation Tool) and a patients' self-report interview schedule (Sleep Quality Tool) was used to collect the patient's sleep data by means of an observation checklist while structured questionnaire and scrutiny of nurses night reports were used to collect data of nurse.[18]

In regards to the unit design and structure, the present study revealed that continuous light, uncomfortable pillow, strange odors, and hearing of frequent sound, telephone and machine alarms significantly affected the sleep pattern of hospitalized patients. The noise was also reported to be the most influential disturbing factor of patient's sleep in a study done to examine the effects of intensive care environment on sleep state.[19] The presence of strange odors may be as result of poor ventilation with large capacity of patients in confined areas and because delayed maintenance of air conditioners leading to strange and bad odors.

In the present study, the presence of tubings, leads of monitors, having pain, and fear of death were the most significant factors instigating sleeping disturbances related to patients themselves. A similar finding was reported in ICU presented pain as contributing factor to sleep disturbance. In addition to this, it was obvious that crying of surrounding patients and watching the treatment of other patients significantly led to sleep disturbance amongst the hospitalized. Uğraş and Oztekin also documented similar results and reported more than one-third of the sample studied in ICU had sleep disturbance due to sounds of surrounding patients.[13]

In this study, we found that sleep awakening by doctors and nurses, loud noise by the staffs, assessing vitals, care of tubing and drain, and suctioning are the most significant contributing factor affecting sleep pattern among all the activities by healthcare personnel. On the contrary, Elliott et al., (2011) showed that sleep awakenings of about 1/3rd of ICU patients' was as a result of noise generated by chats and activities of patient care, which constrain these as an exceptional substantial reason for sleep disturbances.[20]

Another study evidenced similar findings where the most frequently reported factors were early awakening (55.6%), lack of sound sleep (52.1%), unnecessary lights (34.2%), nursing intervention of patients providing care (33.3%), and biological sickness such as pain and fatigue (26.5%). This study also suggested that nurses must build strategies to transform issues that involve powerful noise and lighting during the nighttime so as to minimize disruption and subsequently, sleep deprivation among patients.[18] Similar to these, one study presented that the leading grounds of poor sleep in the hospitalized patients comprised of environmental factors such as intense light, noise, temperature variations and bite by mosquitoes, repeated wakening by nurses aimed at various nursing procedures and discomforts owing to the illness. The findings of this raised concern to reassess the pattern of disturbing patients' sleep for various nursing procedures and treatments.[21]

Further, an Iranian study in Kashan Hospital evaluated the quality of sleep and its associated risk factors using Farsi Pittsburgh Sleep. This study presented pain, environmental factors, worries, and anxiety, as the most predominant sleep-disturbing elements. On the other hand, from dyspnea, environmental lights, and changes in the sleep habits had the most negative effects on the Pittsburgh Sleep Quality Index (PSQI) mean.[22] In another study, to determine the quality of sleep and disturbing factors of inpatient using PSQI and self-designed questionnaires and to compare the perception of sleep-disturbing factors between nurses and inpatients conducted in Chinese General Hospital, it was found that the most influential factors causing sleep disturbances were concerns about illness, distress related to diseases, using of lavatory during night and noise from nurses' shoes.[23]

  Conclusion Top

The pattern of abnormal sleep leads to acute illness, especially in clinical settings among the hospitalized patients. The permanence of sleep may be impeded due to loud noises, and frequent care-related interruptions in the hospital environment. Medications frequently prescribed for patient's relaxation also have striking consequences on sleep. Noise pollution in most of the critical care settings can be avoided for instance switching up of unnecessary ringing alarms with vibrating pages, followed with limited conversation and noise through television during night time. Further in order to maintain normal circadian rhythm efforts can be made towards lighting of critical care settings during sleeping hours of the patients.

Financial support and sponsorship

The project was funded by Basic and Health Science Research Center, Deanship of Scientific Research, Majmaah University, Majmaah 11952, KSA.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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