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166  |  wileyonlinelibrary.com/journal/wvn Worldv Evid-Based Nu. 2022;19:166–168.© 2022 Sigma Theta Tau International

BACKGROUND

Sleep is an essential basic need. However, patients in critical care often experience poor and fragmented sleep (Kamdar et al., 2012),

which can negatively affect them. For example, poor sleep quality in patients can increase the incidence of delirium (Xie et al., 2009). As such, there is a need to examine strategies to promote sleep in critical care patients.

Received: 31 March 2021  | Accepted: 16 May 2021

DOI: 10.1111/wvn.12558

I M P L E M E N T I N G E B P C O L U M N

Improving critical care patients' sleep quality in a surgical high- dependency unit: An evidence- based practice project

Keh Kiong Ong BSc (Nursing) (Honours), RN1  | Lee May Khoo MHSc (Management), PGDHE, BSc (Nursing), Adv Dip (Critical Care), RN1 | Yuanpei Zhou MSN, RN, APN(intern)1 | Poh Chi Tho BN, Adv Dip (Ortho), RN2,3

1Nursing, National University Hospital, Singapore City, Singapore 2Evidence- Based Nursing Unit, Nursing, National University Hospital, Singapore City, Singapore 3Singapore National University Hospital, Centre for Evidence- Based Nursing: A Joanna Briggs Institute Centre of Excellence, Singapore City, Singapore

Correspondence Keh Kiong Ong, Nursing, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore City, Singapore. Email: [email protected]

Abstract Background: Sleep is an essential basic need. However, patients in critical care often experience poor and fragmented sleep. As such, there is a need to examine strategies to promote sleep in critical care patients. Aim: This project aimed to promote sleep in surgical high- dependency patients through the implementation of evidence- based best practice. Methods: An evidence- based practice (EBP) project was implemented in May 2015 in a 24- bed surgical high- dependency (progressive care) unit in a public tertiary hospi- tal in Singapore in three phases using the JBI framework. Outcomes measured were sleep quality, using the Richards- Campbell Sleep Questionnaire, and nurses' adher- ence to sleep promotion activities, using an audit tool adapted from the JBI- Practical Application of Clinical Education System. Data were collected at baseline, 1, 3, 6, and 12 months. Getting Research into Practice analysis was done at each time point. Results: A total of 120 patients were surveyed, and 150 observation audits were con- ducted over 1 year. Sleep quality was similar between pre- audit (mean 53, SD 19.89) and month 1 (mean 54, SD 24.40), improved at month 3 (mean 64, SD 19.34), and sustained at month 6 (mean 64, SD 24.13) and 12 (mean 64, SD 19.4). The effect size between pre- audit and month 3 was a medium effect size of 0.49, which continued to improve at month 12, with a medium effect size of 0.56. Nurses' adherence to the EBP generally improved, and the thresholds of 80% were exceeded by month 12. Linking Evidence to Action: Sleep is an essential basic need and can be improved through simple evidence- based interventions. Best practice for promoting sleep in- cludes grouping nursing activities and reducing light and noise at night.

K E Y W O R D S adult health/adult care, critical care/intensive care, evidence- based practice, nursing practice, quality improvement, sleep

[Correction added on 12 December 2022, after first online publication: The spelling of the co-author Poh Chi Tho's name has been corrected.]

    | 167IMPROVING CRITICAL CARE PATIENTS' SLEEP QUALITY IN SURGICAL HIGH DEPENDENCY

PICOT QUESTION

PICOT (population, intervention or issue, comparison, outcome, and time frame) question: How do sleep quality nursing interventions compared to current practice affect the sleep quality of critical care patients?

This project aimed to promote sleep in surgical high- dependency patients through the implementation of evidence- based best practice.

SE ARCH STR ATEGY

A literature search was done using Joanna Briggs Institute (JBI) con- nect+, CINAHL, and Scopus. Keywords included “sleep promotion,” “ICU,” “critical care,” “nurse,” and “sleep.” Relevant articles were criti- cally appraised.

CRITIC AL APPR AISAL

The evidence was critically appraised using relevant JBI critical ap- praisal tools. Light, noise, and nursing activities were identified in the literature as factors that disrupt the sleep of critical care patients (Kamdar et al., 2012). A JBI evidence summary was used as the basis for supporting the practice change of grouping nursing activities and minimizing light and noise to promote sleep, and educating nurses to promote nursing behavior change (Marin & Fong, 2021). Ear plugs and eye masks were also offered.

CLINIC AL DECISION AND IMPLEMENTATION OF PR AC TICE CHANGE

An evidence- based practice (EBP) project was implemented May 2015 in a 24- bed surgical high- dependency (progressive care) unit in a public tertiary hospital in Singapore. The project was implemented in three phases using the JBI framework (Joanna Briggs Institute, n.d.- a).

The outcomes measured were sleep quality and nurses' ad- herence to sleep promotion activities. Data were collected at baseline and then subsequently at months 1, 3, 6, and 12 post- implementation. Sleep quality was measured using the Richards- Campbell Sleep Questionnaire (RCSQ), a five- question, self- reported visual analog scale, with scores ranging from 0 to 100, that was previously validated (Richards et al., 2000). Patients were also asked if light, noise, nursing activity, or other factors had disrupted their sleep. Nurse adherence was assessed using an audit tool that was adapted from the JBI- Practical Application of Clinical Education System (Joanna Briggs Institute, n.d.- b), an online evi- dence implementation tool for conducting audit and data analysis. The system also has an added feature for performing situational analysis using Getting Research into Practice (GRIP). Twenty- four

patients were surveyed, and 30 nurse observation audits were con- ducted at each time point.

For sleep quality, patients with a length of stay of at least 48 h in the high- dependency unit were invited to rate their sleep quality just prior to departure. Patients with neurologic disorders or altered mental status were not included in the data collection, as their self- reported data may not be accurate.

Nurse adherence audits evaluated three adherence indicators: (1) did nursing staff attend the educational in- service; (2) did staff modify their behavior (lights dimmed, blinds half- lowered, ear plugs and eye masks offered, and activities grouped together); and (3) was patients' sleep quality documented. The data were collected through team member observations, and to ensure consistency, all members received a briefing about the tools and how to conduct the surveys and observation audits. The threshold for nursing adherence for all audited areas was set at 80%. Blinds being half- lowered was elimi- nated at month 6, as the ward was renovated and some blinds were removed.

Preparation

The project team identified sleep deprivation among patients as a clinical issue in the setting. Baseline data related to patients' sleep quality and nursing adherence were collected to identify areas of concern in practice.

Implementation

Baseline data collection and audits were conducted prior to imple- menting the EBP change aimed at modifying nurse behavior during night shift. The initiative included in- service education sessions for nursing staff that were conducted over 3 weeks and covered the impact of sleep disturbance on patients and an overview of how nursing behavior could be modified during night shift. The sessions focused on grouping of nursing activities, appropriate dimming of lights, controlling noise level (e.g., alarms and speech volume), and offering patients ear plugs and eye masks.

Analysis and evaluation

An audit was done 1- month post implementation, and after eval- uating the results, a GRIP analysis was performed that identified forgetfulness and resistance to change as barriers. Forgetfulness was addressed by placing cue cards at computer desktops and distributing information sheets to the nurses, while resistance was addressed by involving stakeholders and identifying cham- pions. Champions have been found to be useful for facilitating change in nursing practice (Ploeg et al., 2010). Further audits were done at months 3, 6, and 12 post- implementation. At each

168  |    IMPROVING CRITICAL CARE PATIENTS’ SLEEP QUALITY IN SURGICAL HIGH DEPENDENCY

data collection point, a GRIP analysis was performed, barriers were identified, and strategies to facilitate the practice change were developed.

OUTCOMES

A total of 120 patients were surveyed, and 150 observation audits were conducted over 1 year. Sleep quality as measured using the RCSQ was similar between pre- audit (mean 53, SD = 19.89) and month 1 (mean 54, SD = 24.40). Sleep quality improved at month 3 (mean 64, SD 19.34) and was sustained at months 6 (mean 64, SD = 24.13) and 12 (mean 64, SD = 19.4). The effect of the interven- tion was calculated from pre- audit to 3 months and was shown to have a medium effect at 0.49. The effect continued to improve at 12 months, reflected in an effect size of 0.56.

Nurse adherence to the EBP generally improved, and the thresh- olds of 80% were exceeded by month 12. There was a decrease in adherence in one of the components at month 6, which was possibly related to nurse turnover. This decrease in adherence was addressed by reconducting the in- service sessions and including the education as part of the orientation for new nurses.

DISSEMINATION

Dissemination plans include sharing the results internally and integrat- ing this best practice in other units. To promote this EBP change, the intervention will be tailored to fit the unique practice and culture of the other units.

LINKING E VIDENCE TO AC TION

• Sleep is an essential basic need and can be improved through sim- ple evidence- based interventions.

• Best practice for promoting sleep includes grouping nursing ac- tivities and reducing light and noise at night.

ACKNOWLEDG MENTS We would like to thank APN Cindy Chua, SNM Tan Chai Eng, Ruzaini, Susan, Lili, Xiao Ming and the nurses of the National University Hospital, Ward 27, for their contributions to this project.

ORCID Keh Kiong Ong https://orcid.org/0000-0002-6648-4189

R E FE R E N C E S Joanna Briggs Institute (n.d.- a). The JBI approach. Retrieved from http://

joannabriggs.org/jbi-approach.html Joanna Briggs Institute (n.d.- b). JBI Practical Application of Clinical Evidence

System (PACES). Retrieved from http://paces.jbiconnectplus.org/ Kamdar, B.B., Needham, D.M. & Collop, N.A. (2012) Sleep depriva-

tion in critical illness: its role in physical and psychological recov- ery. Journal of Intensive Care Medicine, 27(2), 97– 111. https://doi. org/10.1177/08850 66610 394322

Marin, T. & Fong, E. (2021) Evidence Summary. Promoting Sleep and Rest During Hospitalization: Non- pharmacological Interventions. The JBI EBP Database, JBI- ES- 2529- 2.

Ploeg, J., Skelly, J., Rowan, M., Edwards, N., Davies, B., Grinspun, D. et al. (2010) The role of nursing best practice champi- ons in diffusing practice guidelines: a mixed methods study. Worldviews on Evidence- Based Nursing, 7(4), 238– 251. https://doi. org/10.1111/j.1741- 6787.2010.00202.x

Richards, K.C., O'Sullivan, P.S. & Phillips, R.L. (2000) Measurement of sleep in critically ill patients. Journal of Nursing Measurement, 8(2), 131– 144.

Xie, H., Kang, J. & Mills, G.H. (2009) Clinical review: The impact of noise on patients’ sleep and the effectiveness of noise reduction strat- egies in intensive care units. Critical Care, 13(2), 208. https://doi. org/10.1186/cc7154

How to cite this article: Ong, K.K., Khoo, L.M., Zhou, Y. & Tho, P.C. (2022) Improving critical care patients' sleep quality in a surgical high- dependency unit: An evidence- based practice project. Worldviews on Evidence- Based Nursing, 19, 166– 168. https://doi.org/10.1111/wvn.12558

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Copyright of Worldviews on Evidence-Based Nursing (John Wiley & Sons, Inc.) is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.