Evidence Based Practice

Self-Learning Module

Baindu Gbow, Briana MacCrone, Felicia McKenna &

Holly McKonly

Mission Moment“ A single dream is more powerful than a thousand realities.”

-J.R.R. Tolkien

Learning Objectives - The reader will identify five reasons for which patients lose sleep in

the hospital setting.- The reader will be able to list important techniques to assist with

ensuring a quiet environment to promote sleep among patients in the unit.

- The reader will describe the differences between the two stages of sleep: Rapid eye movement (REM), and Non-rapid eye movement (NREM), and the effect of noise on these stages.

- The reader will be able to recognize both physiological and psychological impacts that result from a lack of sleep.

What is Quiet Time?

“ A period of reduced controllable noise and light to promote rest and

healing.”(Maidl, Leske & Garcia, 2014)

What are Patient Outcomes?● Improved satisfaction levels as evidenced by patient satisfaction surveys

(Gardner et al., 2009)

● Increased sleep and decreased anxiety among patients as evidenced by

Richards-Campbell Sleep Questionnaire scores (Maidl, Leske & Garcia, 2009)

● Decreased heart rate (Buxton, 2012)

● Swift healing time, more energy and improved immune system (Bergner, 2014)

PICO Question● Population:

○ Adult critical care patients

● Intervention:○ Implementing a scheduled quiet time

● Comparison:○ Not implementing a scheduled quiet time

● Outcome:○ Improved patient outcomes

PICO Question● In adult critical care patients, how

does a scheduled quiet time, compared with not implementing a

scheduled quiet time, improve patient outcomes?

Literature Reviewed ● Articles Reviewed: 9 ● Articles Appraised: 8● Databases searched: Cochrane Library, CINHAL, PubMed,

HealthEBSCO, Alvernia Interlibrary Loan● Keywords: Therapeutic, quiet time, patient satisfaction,

critical care, reduced noise, intervention, patient outcomes● Year limits: 2008-2016● Search limits: Peer reviewed, abstract available, scholarly

journals

Significance: Importance of Adequate Sleep

● Sleep is an essential aspect to human survival (Richardson et al., 2009)

● Sleep has been shown to be therapeutic for health, healing and recovery (Gardner et al., 2009)

● Lack of adequate sleep may negatively impact all body systems (Richardson et al., 2009)

● Noise is a significant barrier to sleep for hospitalized patients (Gardner et al., 2009)

Significance: Current Noise Levels

● The noise level recommended by the US Environmental Protection Agency (EPA) for safe indoor

activity is 45 decibels (dB)(United States Environmental Protection Agency, 1974)

● Recent research has found that US hospitals reach a noise levels of approximately 72 dB during the daytime

and almost 60 dB at night(Gardner et al., 2009)

Current Practice: Reading Hospital R3S

● R3S does not currently have a scheduled

quiet time implemented on their unit.

Current Practice: Sleep Cycle

REM: The rapid side-to-side intermittent movement of the closed eyes

● Occurs in cycles of about 90-120 minutes throughout the night, which accounts for about 20-25% of total sleep in adults

● The brain’s oxygen consumption is high and breathing becomes more rapid and irregular

NREM: A progression from deep levels of drowsiness to deep sleep. It is divided into three stages:

● Stage 1- A quick transition from wakefulness and sleep● Stage 2- The stage with the most ample amount of sleep in adults● Stage 3- The deepest level of sleep

REM vs. NREM: Can be distinguished through distinct patterns seen on Electroencephalograms (EEGs) (Buxton et al., 2012)

Current Practice: Impact of Noise on Sleep Cycle

● Noise causes arousal in all stages of the sleep cycle

○ Can result in heart rate elevation of approximately 10 beats/min (Buxton, 2012)

● Greater impact and quicker onset of heart rate acceleration seen during REM

○ Much lesser effect in stages 1 and 2 in NREM (Buxton, 2014)

● Disrupted sleep patterns are known to be associated with cardiovascular and coronary

heart disease (Buxton, 2014)

● Sleep disturbances reduce the amount of rapid eye movement (REM) sleep

○ Can lead to psychological symptoms such as confusion, depression, hallucinations

and memory impairment (Bergner, 2014)

● A lack of non-rapid eye movement (NREM) reduces growth hormone (GH) secretion

● A lack of GH decreases anabolic activity

○ Can result in immunosuppression, slower healing and fatigue (Bergner, 2014)

Current Practice: Physiological & Psychological Impact From Inadequate Sleep

● Cardiovascular stimulation

● Hearing loss

● Increased gastric secretion

● Pituitary and adrenal gland stimulation

● Suppression of the immune response to infection

● Suppression of female reproduction and fertility

● Increased anxiety and pain

● Headache

● Emotional stress (Xie, Kang & Mills, 2009)

Current Practice: Sources of Noise & Disturbances

● Staff conversation and alarm noises have been found to cause the most disturbances and result in a lack of sleep in the hospital setting (Xie, Kang & Mills, 2009)

● Other sources of noise & disturbances:○ Telephones, pagers, overhead speakers○ Fellow patients and visitors ○ Telemetry monitors○ Call bells○ Lights○ Doors opening and closing○ Nursing and medical routines○ Ventilators, suctioning○ Television (Konkani, 2014) & (Xie, Kang & Mills, 2009)

Considerations● Reasonably cost effective

○ May be some expenses to alternate volume on equipment and environment i.e. doors, call bells and acoustics

● Can have implications on patient care due to time restraints

● Research reveals an overall satisfaction with quiet time by patients and nurses

Summary of Evidence ● The literature revealed a variety of resources that came to the same

conclusion of an improved satisfaction level, among both patients and

nurses, with a scheduled quiet time. (Richardson, 2009)

● Improved sleep has been associated with decreased noise (Maidl, Leske &

Garcia, 2009)

● Sound-masking is one of the most effective techniques in promoting

rest (Xie, Kang & Mills, 2009)

● Staff conversations and alarm sounds tend to cause the most noise

disturbance (Xie, Kang & Mills, 2009)

Recommendations for Nursing Practice

In order for nurses and staff to understand the importance of quiet time, it is essential for them to be fully aware of the patient environment and

disruptive factors.

Ways to increase awareness:

● Educate staff, patients, visitors and family○ Effects on health & positive outcomes

● Posting signs to reinforce quiet time● Routine meetings to discuss issues,

outcomes & recommendations for practice

Strategies to Promote Quiet Time

● Close the doors to patients rooms (except those with a high fall risk)● Lights in the hallways and room dimmed or turned off● TV’s turned off or silenced● Sound-masking● Posting signs to increase awareness of quiet time● Providing patients with earplugs and/or eye masks● Maintain conversations at a low noise level● Phones and beepers silenced or placed on vibrate● Limit procedures or treatments during scheduled time frame● Provide comfort with positioning and pain relief prior to quiet time● Decrease volume on equipment alarms

(Scotto et al., 2009), (Gardner et al., 2009) & (Richardson, 2009)

References ● Bergner, T. (2014). Promoting rest using a quiet time innovation in an adult neuroscience step down unit.

Canadian Journal of Neuroscience Nursing, 36(3), 5-8. Retrieved from http://cann.ca/canadian-nursing

● Buxton, O., Ellenbogen, J., Wang, W., Carballeira, A., O'Connor, S., Cooper, D., & Solet, J. (2012). Sleep disruption

due to hospital noises: A prospective evaluation. Annals of Internal Medicine, 157(3), 170-179. http://dx.doi.

org/10.7326/0003-4819-157-3- 201208070-00472

● Gardner, G., Collins, C., Osborne, S., Henderson, A., & Eastwood, M. (2009). Creating a therapeutic environment:

A non-randomised controlled trial of a quiet time intervention for patients in acute care. International

Journal of Nursing Studies, 46(6), 778-786. http://dx.doi.org/10.1016/j.ijnurstu.2008.12.009

● Konkani, A., Oakley, B., & Penprase, B. (2014). Reducing hospital ICU noise: A behavior-based approach.

Journal of Healthcare Engineering, 5(2), 229-246. http://dx.doi.org/10.1260/2040-2295.5.2.229

References continued● Maidl, C. A., Leske, J. S., & Garcia, A. E. (2014). The influence of “quiet time” for patients in critical care. Clinical

Nursing Research, 23(5), 544-559. http://dx.doi.org/10.1177/ 1054773813493000

● Richardson, A., Thompson, A., Coghill, E., Chambers, I., & Turnock, C. (2009). Development and implementation of a

noise reduction intervention programme: A pre- and post audit of three hospital wards. Journal of Clinical Nursing,

18(23), 3316-3324. http://dx.doi.org/10.1111/j.1365-2702.2009.02897.x

● Scotto, C., McClusky, C., Spillan, S., & Kimmel, J. (2009). Earplugs improve patients' subjective experience of sleep in

critical care. Nursing In Critical Care, 14(4), 180-184. http://dx.doi.org/10.1111/j.1478-5153.2009.00344.x

● United States Environmental Protection Agency. (1974). Noise levels affecting health and welfare. Retrieved from

https://www3.epa.gov/

● Xie, H., Kang, J., & Mills, G. (2009). Clinical review: The impact of noise on patients' sleep and the effectiveness of

noise reduction strategies in intensive care units. Critical Care, (13)2, 208. http://dx.doi.org/10.1186/cc7154