Sleep has physiologic importance and adequate sleep is necessary for the maintenance of good health and well-being (Carskadon Dement, 2005). Lack of sleep of adequate quality and length in an intensive care unit (ICU) is a significant negative factor affecting the recovery of patients. Many patients in ICUs are suffering from sleep deprivation. Critical illness is a time of extreme vulnerability for patients. Sleep plays an important role in the recovery of ICU patients. Sleep deprivation can lead to a higher risk for loss of memory and cognitive functions of patients in ICUs (Merriam Webster).

The major environmental factors like light and noise are hindering sleep in the ICUs which lead to sleep deprivation (Daneshmandi et al, 2012). The sleep disturbance of patients in ICUs can be reduced by controlling environmental factors such as light, nighttime noise, nursing interventions that cause sleep disturbance, and allowing uninterrupted sleep. Pharmacological measures may cause side effects, hence non-pharmacological measures are safer. The combined use of an eye mask and ear plug may help control the factors like night-time light and noise and are cost-effective and do not produce any after effect.

Need of the study

The causes for sleep deprivation are multifactorial. The sleep problems will affect the quality of life among the ICU patients, and it will adversely affect their recovery. The sleep problems among the ICU patients also create a strain among the care givers. A wide number of interventions are practiced by the nurses working in ICU to improve the sleep status of the patients. But unfortunately, these techniques are unable to address the problem among the ICU patients. Novel interventions are necessary for improving sleep quality of ICU patients. While developing an intervention, the ICU nurses should consider the important factors affecting the sleep quality. The literature available regarding sleep quality among ICU patients has limited generalisability due to geographical and population constraints. The present study aimed to identify the factors affecting the quality of sleep in ICU patients, and select suitable interventions to improve the sleep quality of patients in ICUs based on the most common factors.

Objectives

The objectives of the study were to:

• Identify the factors affecting the quality of sleep in Intensive Care Units.
• Test the effect of eye mask and ear plug on quality of sleep among patients admitted in Intensive Care Units.

Hypothesis

H1: There is significant difference in the quality of sleep of patients with or without eye mask and ear plug during sleeping at 0.05 level of significance.

H2: There is an association between quality of sleep and selected variable of patients in Intensive Care Units at 0.05 level of significance.

Review of Literature

A prospective study (Dave et al, 2013) was conducted to assess the effects of ear plug and eye masks on perceived quality of sleep during night among patients in ICUs of AIIMS hospital, Delhi. A randomised crossover design was used and 50 patients were allocated randomly into two groups. One group received ear plugs and eye masks during first night and only routine environment provided on the second night, while another group did not receive ear plugs and eye masks on first night and received on second night. Sleep was assessed in the coming morning by modified Richard Campbell Sleep Questionnaire (RCSQ). Data analysis was done using STATA 11.1, with the level of significance at 0.05. There was significant improvement in mean sleep score when ear plugs and eye masks (70.26 ± 5.89 and 68.74 ± 6.54) versus routine environment (45.86 ± 4.86 and 43.06 ±7.31) was used ( 0.01). Noise and light were major sleep disturbing factors among ICU patients; ear plugs and eye masks were found to be significantly (p = 0.04) correlated with noise and light. It is concluded that earplugs and eye masks are relatively cheap interventions with notable improvements in quality of sleep and valuable addition to the patients attempting to sleep in an intensive care unit.

A study on 100 patients of selected ICUs of DMC and Hospital, Ludhiana showed that the use of eye mask ear plugs had a significant effect in improving the sleep fragmentation, sleep latency, sleep quality, sleep length and sleep supplementation of critically ill patients admitted in ICUs than the control group (Bajwa et al, 2015). Another study (Vazdannik et al, 2014) in 50 patients admitted in the ICUs of Al-Zahra Medical Center in Isfahan University of Medical Science Iran also showed the positive effects

of eye mask and earplugs on the sleep quality of the patients admitted in ICU, especially their positive effect on sleep supplementation and reduction of narcotics consumption and it was significantly improved ( 0.005) the perceived sleep quality in ICU patients.

A quasi-experimental study was conducted on 103 ICU patients in two governmental hospitals in Jordan to assess the combined effect of eye mask and ear plugs on the perceived quality of sleep among patients. The pre-test and post-test, quasiexperimental design was used. The participants were assigned either an experimental or a control group. The experimental group received routine care on the first night and they used the eye mask and ear plugs during their sleep on the second night. The control group received routine care only on both nights. The number of hours slept was reported by nurses, and the perceived quality of sleep was self-reported by participants using the Richards-Campbell Sleep Scale. The study found that experimental group participants slept more hours and reported significantly better-perceived quality of sleep after the use of eye mask and ear plugs, as compared with control group participants. The study concluded that the combination of eye masks and ear plugs is effective in prolonging the sleep of ICU patients and improving its quality (Vidhaya et al, 2018).

A study on 60 patients in CCUs of Shahid Beheshti Hospital in Kashan, Iran showed the comparison of mean sleep scores in both the control group and experimental group. It revealed statistically significant results (p=0.0001) which extrapolates that the quality of sleep in the experimental group increased due to the use of earplugs and eye mask (Yazdannik et al, 2014).

A study (Mashayekhi et al, 2013) conducted on 30 CCU patients of Shahrekord University of Medical Science, Shahrekord, Iran showed that using ear plugs statistically significantly ( 0.005) increased the quality of sleep in three subscales (disturbance, effectiveness and supplementation).

Inclusion criteria: All patients who were admitted in intensive care units, staying two or more nights in ICU, conscious and willing to participate in the study.

Exclusion criteria: Patients who were, sedated, receiving mechanical ventilati

on, aphasic, known to have obstructive sleep apnoea, eye or ear diseases or injury, having cognitive impairment and altered sensorium.

Material and Methods

This study used a crossover research design. The study was conducted in the cardiac ICU, neuro MARCH - APRIL 2024 | VOL. CXV, NO. 2 53 ICU and surgical ICU of Baby Memorial Hospital, Kozhikode (Kerala). The sample size was 40. Fourtyeight subjects were selected by using consecutive sampling and the selected subjects were randomly allocated into two groups, group A and group B by lottery method. Eight subjects discontinued the study. The tools used were a personal and clinical data sheet, Richard Campbell Sleep Questionnaire (RCSQ) and Visual Analogue Scale to measure the factors causing sleep disturbance in ICU. Richard Campbell Sleep Questionnaire (RCSQ) is a standardised tool and permitted to be used (Richards et al, 2000). Ethical clearance was obtained from the Institutional Ethical Committee and confidentiality was ensured throughout the study.

Subjects were randomly allocated to group A and group B. Group A subjects received the intervention during the night from 9 pm to 6 am on the first day and second night they did not receive the intervention. Subjects in group B did not receive the intervention on the first night and they received intervention on the second night from 9 pm to 6 am. The quality of sleep was assessed in the morning following both nights.

Results The analysis of data was done using SPSS 18 version. The selected setting had 65 patients in intensive care unit during the study period and out of them, 48 patients were meeting the inclusion criteria. They were randomly assigned to two groups, group A (n=22) and group B (n=26). During the study, 6 subjects were lost to follow-up and 2 did not use the intervention for the stipulated time. The analysis and interpretation were done with data from 40 subjects (Figure-1).

It was found that among 40 subjects majority (67.5%) were males and great majority (92.5%) of the subjects were between the age group of 38-77 years (Table 1). The mean age of the subjects was 59 years with SD 11.8. Majority of the subjects (67.5%) were having primary education; 82.5 percent had a history of previous hospitalisation; out of them 65 percent had the history of ICU admission.

Analysis of sleep pattern of the subjects before hospitalisation showed that 72.5 percent of subjects in the group were sleeping for 6 hours or more and 87.5 percent of the subjects were not having any bedtime rituals. Difficulty in returning to sleep once awake were reported by 57.5 percent of subjects and 97.5 percent were not using any drugs to get sleep.

All of the subjects reported poor seep while sleeping without eye mask and ear plug. After using eye mask and ear plug, 27.5 percent reported very good sleep and 65 percent reported good sleep and only 7.5 percent reported poor sleep (Table 2).

Table 3 shows that the mean and standard deviation of quality of sleep of patients in ICU while sleeping without eye mask and earplugs was 17.90 ±3.90 which increased to 36.87±4.09 while sleeping with eye mask and ear plugs. This difference was highly significant (p=0.000 at 0.05 level of significance).

Table 4: Difference in the mean score of various aspects in the quality of sleep of patients in ICU with and without eye masks and ear plugs (n=40)

Table 4 show that the use of eye mask and earplugs were also found very effective in improving different aspects of sleep like sleep depth (p=0.000), sleep latency (p=0.000), number of awakenings during sleep (p=0.000), returning to sleep after awakening (p=0.000) and sleep quality (p=0.000).

The factors affecting sleep were ranked based on their mean and standard deviation (Table 5). The most important factor affecting the quality of sleep in ICU was light (4.95±2.06) followed by anxiety (3.5±2.03), pain (3.45±1.96), alarms (3.20±1.91), noise from other patients (2.05±1.85), intervention/procedures (1.87±1.58), noise of staff (1.58±0.95), tubes and catheters (1.28±.93) and others (phone ringing, sound of equipment) (1.05±.22).

Discussion

and earplugs. Similarly, a study conducted in 203 patients in the University of Pennsylvania Medical Center, Philadelphia, Pennsylvania also showed that the perceived ICU sleep quality was significantly poorer than baseline sleeps at home (p=0.0001). Another study (Freedman et al, 1999) conducted in 116 patients in Mount Sinai Hospital, Canada showed that the majority (69%) of the subjects reported poor or very poor quality of sleep in the ICU (Little et al, 2012).

Use of eye mask and ear plugs significantly improved the sleep of the subjects in this study (t=19.98, p=0.000). This study also showed that the various aspects of quality of sleep like depth of sleep, sleep latency, number of awakenings during sleep, returning to sleep after awakening and the overall quality of sleep also were improved with the use of eye mask and ear plugs. Similar findings were observed in all 6 studies reviewed.

Many studies have shown that the most important factor affecting the quality of sleep in ICU was light followed by anxiety, pain, alarms, noise from other patients, interventions, the noise of staff, tubes and catheters and other sounds like a phone ringing and sounds of equipment. Findings of six studies reviewed showed that noise and light were the most important factors affecting the sleep in ICUs (Freedman et al, 2001; Salandin et al, 2011; Elliotta et al, 2014; Parthasarathy Tobin, 2009; Meyer et al, 1994; Weinhouse Schwab, 2006). But four other studies showed that anxiety, pain and some patient care activities were the important factors affecting the sleep in ICUs (Freedman et al, 1999; Little et al, 2012; Kuivalainen et al, 1998; Vati et al, 2008).

Nursing implication

The nurse administrator should can plan various in-service training programmes to create awareness among health care professionals on ensuring high quality of nursing care, rest, sleep, comfort and wellbeing of the patients. __ampersandsignmiddot; Non-pharmacological interventions like eye mask and ear plugs can to be used as an adjuvant therapy to improve the quality of sleep of patients in ICU.

Recommendation

The study can be replicated on a large sample other than ICU settings for more generalisation. __ampersandsignmiddot; A comparative study can be done to compare the sleep quality of patients admitted in ward and ICUs. __ampersandsignmiddot; Studies can be done with eye mask and ear plugs separately.

Limitations

Patients admitted in the Cardiac ICU constituted most of the samples. __ampersandsignmiddot; Generalisation of the study was limited since the sample size was small. __ampersandsignmiddot; Due to time shortage the study was conducted in a single setting

Conclusions

Patients admitted in the intensive care units suffer from poor quality of sleep. Use of eye mask and ear plugs are highly effective non-pharmacological intervention for improving the quality of sleep of patients admitted in the ICU. The most important factors affecting the quality of sleep in ICU are light followed by anxiety and pain, alarms and noise from other patients. Nurses have to take measures to control the environmental factors like lights and noise in the ICU and the anxiety and pain of patients to promote sleep. They can also use eye mask and ear plug to improve the quality of sleep of patients in ICUs.

Keywords: Natural child birth, Relaxation technique, Midwife