CE Article and Journal Club Feature

NOCTURNAL CARE INTERACTIONS WITH

PATIENTS IN CRITICAL CARE UNITS
By Linda M. Tamburri, RN, MS, CNS, C, CCRN, Roseann DiBrienza, RN, MS, CNS, C, CCRN, Rochelle Zozula, PhD,
ABSM, and Nancy S. Redeker, RN, PhD, CS. From Robert Wood Johnson University Hospital, New Brunswick,
NJ (LMT, RZ); Newark Beth Israel Medical Center (RD), Newark, NJ; University of Medicine and Dentistry of
New JerseyRobert Wood Johnson Medical School, New Brunswick, NJ (RZ); and University of Medicine
and Dentistry of New Jersey-School of Nursing, Newark, NJ (NSR).
BACKGROUND Sleep deprivation is common in critically ill patients and may have long-term effects on
health outcomes and patients morbidity. Clustering nocturnal care has been recommended to improve
patients sleep.
OBJECTIVES To (1) examine the frequency, pattern, and types of nocturnal care interactions with patients
in 4 critical care units; (2) analyze the relationships among these interactions and patients variables (age,
sex, acuity) and site of admission to the intensive care unit; and (3) analyze the differences in patterns of
nocturnal care activities among the 4 units.
METHODS A randomized retrospective review of the medical records of 50 patients was used to record
care activities from 7 PM to 7 AM in 4 critical care units.
RESULTS Data consisted of interactions during 147 nights. The mean number of care interactions per
night was 42.6 (SD 11.3). Interactions were most frequent at midnight and least frequent at 3 AM. Only 9
uninterrupted periods of 2 to 3 hours were available for sleep (6% of 147 nights studied). Frequency of
interactions correlated significantly with patients acuity scores (r = 0.32, all Ps < .05). A sleep-promoting intervention was documented for only 1 of the 147 nights, and 62% of routine daily baths were provided between 9 PM and 6 AM.
CONCLUSIONS The high frequency of nocturnal care interactions left patients few uninterrupted periods for sleep. Interventions to expand the period around 3 AM when interactions are least common could
increase opportunities for sleep. (American Journal of Critical Care. 2004;13:102-115)

CE

Notice to CE enrollees:

A closed-book, multiple-choice examination

following this article tests your understanding
of the following objectives:
1. Identify common causes of sleep deprivation in critically ill patients
2. Discuss nocturnal care interactions that
impact sleep in the intensive care unit
3. Describe interventions to increase opportunities for sleep in critically ill patients

102

leep deprivation, including short duration and

frequent disruptions, is common in critical care
patients and may have long-term effects on
health outcomes, including immune function,1 wound
healing, cognitive function, emotional distress, functional status,2 and stress levels.3 Environmental factors such as lighting, noise, and frequent nocturnal
interactions for monitoring, treatment, and medications are often associated with sleep deprivation.4,5
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso
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(949) 362-2049; e-mail, reprints@aacn.org.

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Table 1 Activity checklist

7 PM
ID#
Date
Obtaining blood samples
Turning/positioning patients
Measuring vital signs
Giving medications*
Assessing patients
Checking/changing ventilator settings
Suctioning
Providing pain intervention - type
Bathing - routine daily
Bathing - extra
Changing linens
Changing dressings
Responding to patients calls
Obtaining radiographs at bedside
Transporting patients
Performing invasive procedure ||
Family visit
Assessing intake/output
Administering blood products
Feeding - oral
Feeding - tube
Fingerstick glucose
Other - specify
Hourly totals

8 PM 9 PM 10 PM 11 PM 12 AM 1 AM

2 AM 3 AM 4 AM 5 AM 6 AM

Row
total

* All

routes of administration are included. Multiple medications given at one time count as 1 interaction.
physicians, and respiratory therapists.
Bathing in addition to daily bath (ie, diaphoresis, incontinence).
Transport out of unit to another department (ie, radiology, nuclear medicine, cardiac catheterization).
|| Bedside procedure (ie, central catheter insertion, bronchoscopy)
Nurses,

Recognition of the problem of sleep deprivation

in critical care settings has led to the development of
sleep-promoting interventions and protocols.6 Clustering of nocturnal care interactions to allow uninterrupted periods has been recommended to improve
patients sleep.6-8 However, before more widespread
implementation of such programs, more specific
information is needed about the nature and temporal
patterns of patient care activities and the characteristics of patients and critical care units that may influence patterns of care. Therefore, the purposes of this
study were to (1) examine the frequency, pattern, and
types of nocturnal care interactions with patients in 4
critical care units; (2) analyze the relationships among
frequency, temporal patterns, and types of nocturnal
interactions and selected variables related to patients
(age, sex, acuity) and site of admission to the intensive care unit (ICU); and (3) analyze the differences in
patterns of nocturnal care activities among the 4 units.

Background
Sleep has both circadian and homeostatic properties. Disturbed circadian rhythms in human physiological parameters, including sleep and activity-rest,
have been associated with decrements in well-being

and functioning.9-12 From a homeostatic perspective,

chronic partial sleep deprivation (decreased duration
and increased sleep fragmentation) is associated with
deficits in function through complex biochemical,
autonomic, and neurophysiological mechanisms that
have not been completely explained.13 Frequent care
interactions at night, when physiological sleep propensity is highest, are likely to place patients at highest
risk for sleep deprivation. Therefore, it is important to
examine the factors that may disturb sleep, such as frequency of care interactions at night.
Studies of sleep in acute and critical care settings
conducted during the past 30 years indicated high levels of sleep deprivation in these settings. The consistency in these findings is remarkable, given the wide
variety in the methods used to measure sleep (polysomnography, actigraphy, self-report, observation);
the range of diagnoses, ages, and sexes of the patients
studied; and the use of small samples in the studies.4
Separate polysomnographic studies included small
groups of patients with acute myocardial infarction,
patients undergoing open heart surgery, patients
undergoing noncardiac surgery, patients with neurological and respiratory disorders, and mixed groups
of critically ill adults.14-20 Researchers in these studies

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Table 2 Demographic and clinical characteristics of the sample

Type of clinical unit
Surgical intensive care

Variable
No. of patients
No. of nights

16
48

Age, mean (SD), y

64.8 (16.3)

Sex, No. of patients (%)

Male
Female

10
6

Acuity score, mean

(SD)
Total number of
care interactions,
mean (SD)
Standard
Corrected*
Diagnosis when
admitted to
hospital/reason
for admission to
intensive care unit

(63)
(37)

146.4 (30)

44.8 (10.6)
31.5 (8.6)

Neurosurgical intensive care

9
27
67.8 (12.9)

6
3

(67)
(33)

Medical intensive care

15
45
70

6
9

(13.9)

(40)
(60)

164 (19.8)

144.3 (14.9)

50.4 (9.5)
32.9 (7.4)

37.6 (6.9)
30.6 (8.7)

Brain tumor/craniotomy

Infected renal graft/sepsis

Septic shock/sepsis

Respiratory distress/respiratory distress

Postinfarction angina/
coronary bypass

Hypertensive crisis/Guillain-Barr
syndrome

Perforated colon/
colectomy-colostomy

Ruptured aortic aneurysm/

aneurysm repair

Multiple trauma/
sternal fixation

Coronary artery disease/coronary

bypass-mitral valve replacement

Multiple trauma/
pneumothorax

Coronary artery disease-aortic

stenosis/ coronary bypass-aortic
valve replacement

Unstable angina/
coronary bypass

Aortic stenosis/aortic valve

replacement

Cholecystitis/ruptured appendix

Spinal cord compression/

spinal cord compression

Respiratory arrest-sepsis/
respiratory arrest

Mitral regurgitation/mitral valve

repair

Closed head injury/closed

head injury

Pleural effusion/respiratory failure

Aortic enteric fistula/remove

graft
Thoracic aortic aneurysm/repair
(n = 2)
Esophageal perforation/
endotracheal reintubation
Gangrenous foot/respiratory
arrest
After coronary bypass/
endotracheal reintubation
Multiple trauma/treat trauma

Osteomyelitis/femoral-plantar
bypass

Budd-Chiari syndrome/hypotension
Exacerbation of chronic
obstructive pulmonary disease,
perforated rectum/colectomy
Bladder cancer/radical cystectomy

Respiratory arrest/respiratory failure

Gastrointestinal bleeding/
gastrointestinal bleeding
Myocardial infarction/myocardial
infarction
Pneumonia and renal failure/
respiratory failure
Coronary artery disease, cellulitis/
acute respiratory distress
Coronary artery disease/
coronary artery disease

*Total care interactions corrected for obtaining blood pressure by arterial catheter or outputs by indwelling catheter.

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Total sample
50
147

Coronary care
10
27
70.9 (16.5)

5
5
131

(50)
(50)
(32.1)

68

(14.7)

27
23

(54)
(46)

144

(25)

42.6 (11.3)
31.3 (8.9)

38.5 (14.2)
30.3 (11.60)
Unstable angina/nonQ wave myocardial
infarction
Shortness of breath/rule out pulmonary
embolus
Congestive heart failure/congestive heart
failure
Atrial fibrillation/respiratory failure
Myocardial infarction /myocardial
infarction (n = 3)
Atrial fibrillation, after myocardial
infarction/congestive heart failure
Unstable angina, congestive heart failure,
diabetes mellitus/same
Status asthmaticus/status asthmaticus

concluded that acutely ill patients have high levels of

sleep fragmentation, a predominance of stage I (light)
sleep, with a reduction of time spent in other sleep
stages (including rapid-eye-movement sleep and slowwave sleep), reduced total sleep time, and decreased
sleep efficiency.
Rates of self-reported sleep disturbance in acute
care units and ICUs range from 22% to 61%.21-25 Frequent awakenings, prolonged latency to sleep onset,
earlier awakening and bedtimes, and generally poor
quality of sleep are common. Patients also report that
their sleep is poorer during hospitalization than at
home24,25 and that sleep disturbance is stressful.3
A review4 of past studies suggests that characteristics of both the patient and the acute/critical care
environment influence sleep disturbance. However,
care activities and diagnostic testing appear to be as
disruptive to sleep as noise.5 The potential significance of care interactions with patients as influences
on sleep in critical care settings was recognized more
than 30 years ago. In early studies, investigators used
observational methods to determine the amount of
time patients were permitted to sleep or rest. Walker26
observed 4 patients at 8-hour intervals for their first 3
postoperative days after cardiotomy. Each patient had
at least 1 interaction with a nurse every hour, with the
maximum number of interactions per hour on postoperative day 1 and a decreasing number of interactions on
days 2 and 3. The longest uninterrupted period was 50
minutes, a period that Walker concluded was not adequate to allow completion of normal 90-minute sleep
cycles. In another small study27 of cardiac surgery
patients, the most frequent types of nurse-patient interactions were direct monitoring (of vital signs, urine
output, and weight), indirect monitoring (checking
intravenous catheters, oxygen therapy), and measures
to promote oxygenation (coughing or suctioning).
In a larger and more recent study,7 a group of 40
patients in a medical ICU had a mean of only 2.2 60minute blocks of undisturbed time to sleep in 7 days.
Only 1 of these blocks fell within conventional sleeping hours, and only 1 procedure was performed in 48%
of the hourly time blocks. Measurements of blood
pressure and body temperature, suctioning, mouth
care, back care, and turning accounted for 76% of the
procedures. The investigators7 used these data to support clustering care interactions in the critical care unit
to allow patients more time for sleep.

Critically ill patients have little opportunity for prolonged, effective sleep.

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Mean number of interactions

4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

Figure 1 Mean number of nocturnal care interactions each hour per patient across all units.

Before such a sleep protocol is implemented across

units where critical care is provided for different types
of patients, more detailed information is needed about
the temporal patterning of specific care activities
across nighttime hours, differences in care interactions with patients among care units, and the impact
of demographic and illness-related factors on patterns
of care interactions. Therefore, the following questions were addressed in this study:
What are the frequency, patterns, and types of
nocturnal care interactions with critically ill patients?
What are the relationships between patients
acuity, age, sex, and the frequency of nocturnal care
interactions among critically ill patients?
What are the differences in the frequency of,
patterns of, and types of nocturnal care interactions
between patients admitted to medical (medical intensive care, coronary care) vs surgical (general surgery
and trauma, neurosurgical) critical care units?

Methods
The study design was based on retrospective review
of patients charts. Approval was obtained from the
institutional review board before the study was started.
Sample and Setting

Data were obtained from the medical records of 50

patients, 21 years and older, who were admitted to 4 critical care units of a university-affiliated tertiary care
medical center in the northeastern United States. The 4
care units included a 16-bed medical ICU, an 8-bed
coronary care unit, a 7-bed neurosurgical ICU, and a 10bed surgical/trauma ICU. The records of patients who
were undergoing treatment with neuromuscular blocking agents, intra-aortic balloon pumps, or continuous
venovenous hemofiltration were not included in the
study because of the continuous bedside care required
by such patients.
106

Instruments

An activity checklist we developed was used to

record care activities that involved interaction with a
healthcare provider (nurse, respiratory therapist, nursing assistant, physician) between 7 PM and 7 AM. This
period was chosen because most nurses in the ICUs
work 12-hour shifts and because this window of time
coincides most closely with typical sleeping hours
and circadian sleep propensity. The checklist included
22 typical activities related to patient care (Table 1).
The categories of activities were derived from the literature and our clinical experience. Activities were
selected that involved touching patients or equipment
directly connected to patients or involved the presence of the healthcare provider at the bedside. The
checklist was reviewed for completeness and clinical
relevance by a group of experts in critical care nursing, including staff nurses and advanced practice
nurses. Space was available at the bottom of the form
for recording additional care activities and notes of
the chart reviewer. Two of us (L.M.T. and R.D.), clinical nurse specialists in critical care, extracted data
from each medical record.
Patient acuity was measured by using the Navy
Workload Management System 28 because it is the
standard acuity measure used to determine nursing
workload in this hospital. This system is used to identify care requirements on the basis of a series of care
indicators, including vital signs, monitoring, activities
of daily living, feeding, intravenous therapy/medications, respiratory therapy, treatments/procedures,
teaching, emotional support, and continuous care.
Staff nurses prospectively evaluate the care requirements of their patients for the ensuing 24 hours.
Scores are used to classify patients as requiring minimal care (0-12 points), moderate care (13-31
points), acute care (32-63 points), intensive care
(64-95 points), continuous care (96-145 points),

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100

Percentage

80
60
40
20
0
7 PM

9 PM
Surgical ICU

11 PM
Neurosurgical ICU

1 AM
Medical ICU

3 AM

5 AM

Coronary care unit

Total

Figure 2 Percentage of hourly intervals within which 1 or more care interactions occurred, by intensive care unit (ICU).

and critical care (146 or more points). These categories were defined and validated by the developers
of the Navy system and were labeled according to the
intensity of care.28 Data were also collected from the
medical records on the age, sex, diagnoses, care unit,
and procedures performed on each of the patients
whose charts were reviewed.
Procedures

The chart reviewers randomly chose days during

which they reviewed open medical records for patients
who stayed for at least 4 consecutive nights in a unit. A
patients first night in the critical care unit was not
included because of the expectation that his or her condition would be more unstable during the first 24 hours
after admission. Care activities that occurred between
the hours of 7 PM and 7 AM were determined from the
medical records and were recorded on the checklist.
Data Analysis

Data were entered into a personal computer by

using the SPSS (version 10) statistical program
(SPSS Inc, Chicago, Ill). Descriptive statistics were
used to analyze the frequencies of specific nocturnal
care interactions. Care interactions were totaled for
the entire night and for each hourly interval. The data
were recorded in hourly time blocks and were graphed
to enable visual examination of the temporal patterns
for the hours from 7 PM to 7 AM. Pearson correlations
were computed to examine the relationships between
age, acuity, and number of care interactions. Analysis
of variance was used to compare the 4 critical care units
with respect to number of nighttime activities, patients
age, and acuity.

Results
Review of the records of 50 patients produced
147 nights of data. We had 3 nights of data on 47
patients, and 2 nights of data on 3 patients. The patients
with only 2 nights of data were admitted to the coronary
care unit, where length of stay tends to be shorter than
in the other units. These records were used because the
number of records with 3 nights of data available was
insufficient. Demographic and clinical data for the
samples obtained in each clinical unit appear in Table 2.
The sample included 27 men (54%). The mean age was
68 (SD 14.7) years. Mean acuity level for the entire
group was 144 (SD 25). Patients diagnoses were heterogeneous within and between units. Because of the
frequently high numbers of critically ill patients in
this hospital, patients are sometimes admitted to units
with available beds. For example, patients with medical diagnoses are sometimes sent to surgical units and
vice versa. The samples represented the surgical/trauma
ICU (n = 16), the neurosurgical ICU (n = 9), the medical ICU (n = 15), and the coronary care unit (n = 10).
Patients admitted to the various care units did not differ significantly in age.
A mean of 42.6 (SD 11.3) care interactions
occurred per night (Table 2). As seen in Figure 1, interactions were most frequent at 8 PM, midnight, and 6 AM.
Overall, interactions were most frequent at midnight
and least frequent at 3 AM, at which time 33% of patients
had no interactions with healthcare providers. The
number of nocturnal interactions did not differ significantly within subjects across the 3 nights of the study.
Over all nights of the study, there were 197 (11%
of total intervals) 1-hour intervals when no care interactions took place. The temporal patterning of the

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Table 3 Number of interventions per hour on patients with uninterrupted time of 2 hours or more between 10 PM and 6 AM*
Patient
45
Unit: coronary care unit
67-year-old man with myocardial infarction
45
7
Unit: surgical intensive care unit
81-year-old man after coronary artery
bypass, reintubation
7
33
Unit: coronary care unit
86-year-old woman with unstable angina

9
Unit: surgical intensive care unit
67-year-old man with diverticulosis after
colectomy
12
Unit: surgical intensive care unit
32-year-old man with multiple trauma
17
Unit: surgical intensive care unit
58-year-old man after coronary artery
bypass reexploration, intubation
48
Unit: neurosurgical intensive care unit
86-year-old woman with pleural effusion
and respiratory failure

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

3
3

0
0

3
3

1
1

1
0

0
0

0
2

0
2

2
3

1
1

0
1

4
3

0
0

0
1

1
0

2
0

0
0

4
4

* Zeros indicate blocks of time with no interventions; shaded areas, blocks of 2 hours or more with no interventions.
Study night 1.

Study night 2.

Study night 3.

remaining 89% of the time periods is plotted in Figure 2. Episodes with no interactions were most frequent at 7 PM, 9 PM, 11 PM, 1 AM, 3 AM, and 5 AM, with
the maximum number occurring at 3 AM. Because our
primary interest was assessment of time available for
90-minute sleep cycles, data sets for each patient
were examined to determine the presence of blocks of
time of 2 hours or more during which no care interactions occurred for individual patients.
We found 9 intervals of 2 hours or more with no
interventions (6% of 147 nights assessed; Table 3).
The intervals included 6 2-hour intervals and 3 3hour intervals. Four (44%) of these episodes occurred
in the same 2 patients. Therefore, a total of 7 patients
(14%) had uninterrupted time available for sleep during their 2- to 3-night stay in the ICU, and 6 of these
patients had only a single 2-hour episode. We found
no uninterrupted time intervals longer than 3 hours
among the 147 nights of data collected.

Patients experienced 2 to 3 hours

without interruption on only 6%
of the nights studied.
Table 4 presents the reasons for nighttime care
interactions, listed in descending frequency of occurrence. The most frequent reasons were measurement of
vital signs and intake and output; next, in order were
108

administration of medications, assessments, turning,

checking/changing ventilator settings, administering
respiratory medications such as bronchodilators through
ventilator tubing, obtaining blood samples, and bathing.

During 147 nights, only 1 instance of a

sleep intervention was documented.
The most frequent interventions were performed
hourly or every 2 hours (Table 4). Blood pressures
were measured with a standard blood pressure cuff for
100 study nights (68%). Of these, pressures were monitored hourly on 46 nights and every 2 hours or more
on 49 nights. A mean of 9.9 cuff readings (SD 2.9)
were done each night. Arterial catheters were used to
monitor blood pressure for 51 study nights. A mean of
10 (SD 2.81) readings were done per night. Twentynine (58%) of these patients had readings obtained at
least hourly. Administration of medication occurred a
mean of 4.8 times per study night. The most frequent
care interactions generally occurred at 2-hour intervals.
For example, Figure 3 illustrates the pattern of assessment of vital signs.
Routine daily baths were performed on 62% of
study nights between 9 PM and 6 AM. Of these, 61%
occurred between 2 AM and 5 AM. The temporal patterning of baths is plotted in Figure 4.

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Table 4 Types of care interactions with patients during each hour from 7 PM to 6 AM
Care interaction

7 PM

8 PM

9 PM 10 PM 11 PM 12 AM 1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

Measuring vital signs

109

144

119

144

112

142

113

138

107

141

107

136

Measuring vital signs via arterial catheters

42

48

41

48

41

48

39

46

37

48

40

45

Assessing intake/output

90

118

95

126

95

111

96

115

93

117

95

129

Assessing intake/output via catheter

84

100

84

104

86

97

87

99

84

101

86

102

Giving medications

25

52

34

121

50

98

44

61

27

45

34

120

Assessing patient

38

97

19

40

16

87

17

40

11

61

21

54

37

22

43

18

32

15

37

32

11

33

11

41

26

23

14

46

18

20

36

30

14

Administering medications via ventilator

36

20

31

13

18

24

19

23

Obtaining blood samples

39

18

14

19

13

17

27

Bathing patient

12

20

23

12

Turning patient
Checking ventilator

Values are numbers of interactions.

Only 1 record out of the 147 nights of data indicated an intervention for sleep. The nurse noted that
she had given the patient a back rub to promote sleep.
Neither frequency of care interactions nor acuity
scores varied significantly with patients age or sex.
Acuity score was moderately and positively correlated with frequency of care interactions for each of
the 3 nights of the study (r = 0.32-0.56, P < .05).
A nonsignificant trend toward a difference in levels of patient acuity was detected among the 4 care
units, F3,47 = 2.68, P = .06; mean levels of acuity were
higher in the neurosurgical ICU and lower in the
coronary care unit (Table 2). The frequency of nocturnal care interactions differed significantly among the
4 units, F3,146 = 10.99, P < .001. Post hoc comparisons
indicated that care interactions were significantly
more frequent in patients admitted to the surgical/
trauma ICU and the neurosurgical ICU than in patients
admitted to the medical ICU and the coronary care
unit (Scheff tests, all Ps < .05). Because many of the
patients in the surgical units had arterial catheters and
urinary catheters that might allow assessment of vital
signs and urinary output without waking the patients,
totals were recalculated to exclude vital signs on
patients who had arterial catheters and exclude urinary outputs on patients who had urinary catheters.
Reanalysis of differences between units in the frequency of care interactions revealed no significant
differences in the frequency when the use of arterial

catheters and indwelling urinary catheters for assessment of vital signs and outputs was considered. The
temporal patterns of care interactions were similar
between the units, with peaks at 8 PM, midnight, and
6 AM. Because most of the nurses worked 12-hour
shifts (7 PM to 7 AM) and a few worked 8-hour shifts
(3 PM to 11 PM, 11 PM to 7 AM), these time frames
appear to correspond to shift changes. By visual analysis, the increased frequency of interactions occurred
on the even hours and a decrease in the number of
interactions at 3 AM (Figure 2).

Discussion
Our results indicate the frequent and repetitive
nature of care interactions with patients in the critical
care units studied and suggest that this patterning
leaves little opportunity for patients to sleep. By
exploring the temporal patterning of nocturnal care
interactions and comparing critical care units with
different specialties, we extended the work of earlier
researchers7,26,29 who also noted that care interactions
provide patients little opportunity for sleep. Although
we did not measure sleep, the absence of 2 or more
consecutive blocks of uninterrupted time on 94% of
the study nights makes it extremely unlikely that
patients had an opportunity to sleep. The maximum
uninterrupted time was 3 hours, a time inadequate to
obtain a sufficient quantity of daily sleep. Although
we did not evaluate care interactions during daytime

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109

Number of times vital signs assessed

160
140
120
100
80
60
40
20
0
7 PM

9 PM

11 PM

1 AM

3 AM

5 AM

Figure 3 Frequency of vital signs assessment each hour during the night.

hours, most likely care interactions, noise, and other

sleep-disturbing factors were even more frequent during the daytime. Future studies should evaluate interactions that occur throughout the 24-hour day and
how the interactions correspond with objectively and
subjectively recorded sleep.
Not surprisingly, care interactions were most frequent on the even hours and appear to reflect practice
protocols that require assessments every 2 hours, such
as monitoring vital signs and intake and output. Peaks
in interactions also occurred at 8 PM, midnight, and 6
AM, perhaps reflecting shift work patterns in this institution, in which the majority of nurses work 12-hour
shifts (night shift, 7 PM to 7 AM), but a few work 8hour shifts. The nadir in frequency of care interactions at 3 AM corresponds to the physiological nadir
in sleep, temperature, and alertness rhythms for both
patients and nurses. However, it is unclear whether
this nadir reflected the nurses intention to allow
patients time for sleep or whether it reflected a lull in
the work flow in the unit. Given the coincidence of
this period with natural circadian periodicity, interventions designed to promote sleep might focus on
widening this 1-hour window to make more time
available for sleep.
The nocturnal interactions in this study most
likely indicate the need for monitoring and for managing life-threatening physiological alterations. Protocols, such as hourly monitoring of vital signs, have
been developed to ensure detection of life-threatening
problems in a timely manner. Although technological
advancements, such as arterial catheters, may ensure
this level of continuous monitoring without disturbing
110

patients, numerous care activities must be performed

to maintain physiological homeostasis in the critically
ill. Patients whose conditions are more physiologically stable may require less frequent interventions and
therefore may be allowed more uninterrupted time to
sleep. Studies should be conducted to determine the
safety and efficacy of reducing the frequency of nocturnal interventions and assessments to promote patients
sleep. Clustering activities can provide extended blocks
of uninterrupted time and improve patients chances for
sleep. The physiological need for sleep must be carefully balanced against the need for frequent assessment of vital signs and the other care activities.
Nurses provided routine daily baths for patients
on 55 of the 147 study nights between 2 AM and 5 AM.
Bathing is not time sensitive and does not affect
patients safety. Therefore, baths are most appropriately scheduled when they are most likely to maximize comfort and sleep. Bathing can be a therapeutic
and relaxing process that may actually promote sleep
if performed in the evening. Recent research30 suggests that warm baths may enhance slow-wave sleep.
However, the extent to which such enhancement occurs
with the sponge baths typically performed in critical
care units is unknown. The practice of bathing patients
at night to enhance the work flow during the day
when patients are undergoing procedures or diagnostic testing may be contrary to patients needs for sleep
if it arouses them.

Strategies to reduce interruptions and

improve patients sleep have yet to be
successfully implemented.
Only a single care intervention for sleep was documented during the 147 nights of the study. Given the
frequency of publications on the topic of sleep in the
acute care setting and attention given to the topic by
the American Association of Critical-Care Nurses in
their published protocol, Promoting Sleep in Acute
and Critical Care,6 this finding was surprising and
suggests the need to increase awareness of the problem of sleep deprivation in the ICU.
Age and sex were not significantly related to the
number of care interactions or acuity levels. However,
intensity of patients care needs was associated with our
count of the frequency of care interactions. The Navy
Workload Index was used in this study because it was
the measure of patient acuity in this acute care hospital setting. However, given the use of care activities to
determine the Navy index, the finding of a relation-

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Percentage of patients

30
25
20
15
10
5
0
7 PM

9 PM
Surgical ICU

11 PM
Neurosurgical ICU

1 AM

5 AM

3 AM

Coronary care unit

Medical ICU

Figure 4 Percentage of patients bathed during nocturnal hours, by intensive care unit (ICU).

ship between it and our count of care activities is not

surprising. Future studies should use a measure that is
more reflective of physiological status, such as the
Acute Physiology and Chronic Health Evaluation.31

Study Limitations
This study was designed to provide baseline data to
support the development of a sleep promotion protocol.
Its retrospective design precluded measurement of
variables that were not available in the medical records,
and the findings are therefore limited by the quality of
the available data. Sleep was not measured; we assumed
that critically ill patients would sleep if given ample
opportunity. This assumption should be tested in future
research. Our results reflect practice in a single institution, but practices in this institution are likely to be similar to those in other tertiary care settings. Nevertheless,
findings should be generalized with caution.

Implications for Further Research

The primary impetus for this study was the evaluation of time available for patients to sleep in the critical care setting, but sleep was not directly measured.
Further study of the impact of the effects of repatterning care interactions on sleep in which objective
methods are used to measure sleep is needed. Polysomnography, the reference standard for measuring
sleep, would provide the most detailed data on the
physiological attributes of sleep. However, its expense
and intrusiveness limit its usefulness in the critical
care setting for extended periods of monitoring. Actigraphy is an alternative behavioral measure of sleep
that may be most useful in this setting.4 Past studies
indicated that a large proportion of total sleep occurs
during daytime hours, so 24-hour monitoring would
be most useful.32 Future prospective studies should be

designed to address the multifactorial nature of the

problem of sleep disturbance and include more
detailed evaluation of the effects of demographic,
psychological, and physiological characteristics of
patients, as well as environmental characteristics of
the critical care setting.

Conclusion
The multifactorial problem of sleep disturbance
in the critical care setting is well known. This problem persists, with little improvement, despite recognition of the problem for more than 30 years. The
findings of this study suggest the significant role of
care practices, specifically frequent interactions for
patients care. The findings suggest that many possibilities exist to increase ICU patients opportunities
for sleep. They also raise questions as to whether
common care activities performed at night are done
because of patients needs, work flow convenience,
traditional practice, unit culture, or a combination of
factors. The results of this study are being used to
refine a protocol to promote patients sleep in critical
care units. An important feature of the protocol is
repatterning of nocturnal activities. In addition, focus
groups and educational activities are being conducted
to elicit nurses ideas about how to improve patients
sleep and to raise awareness of the problem.
ACKNOWLEDGMENT
This study was funded by a Data-Driven Clinical Practice Grant awarded by the
American Association of Critical-Care Nurses.
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JOURNAL CLUB ARTICLE DISCUSSION POINTS

In a journal club, research articles are reviewed and critiqued. General and specific questions help to aid journal club
participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of
the conclusions, and the implications for practice.
When critically appraising this issues AJCC journal club article, Nocturnal Care Interactions With Patients in Critical
Care Units, consider the questions and discussion points listed below.
Study Synopsis: The purpose of this study was to explore
the frequency, pattern, and type of interactions that occurred
during the night for 50 critically ill patients. A randomized, retrospective review of medical records was used to record nocturnal care activities in 4 intensive care units (ICUs) for a total of
147 nights. It was found that, on average, the number of care
interactions per night was 42.6. Nocturnal care interactions
were most frequent at midnight and the least frequent at 3 AM.
There were only 9 uninterrupted periods of 2 to 3 hours that
were available for sleep during the study time frame of 7 PM to
7 AM. There was an association with the frequency of interactions and severity of illness, in that patients with higher acuity
scores had more frequent interactions. The study has direct
implications for critical care nursing care. As sleep deprivation
is common in critically ill patients and can contribute to health
outcomes, changing nursing care practices to facilitate sleep for
the critically ill becomes especially important.
A.

Description of the Study

What was the purpose of the study?
Why is it important to study nocturnal care
interactions with critically ill patients?

B.

Literature Evaluation
What is reflected in the literature about sleep
disturbances during critical illness in the ICU?
What have previous studies found regarding
nursing care interactions that disrupt sleep?

C.

Sample
Data were obtained from what types of patients?

D.

Methods and Design

Describe the study methods.
How were care activities recorded?

E.

Results
What were the findings in terms of the frequency
and pattern of care interactions?
What were common reasons for nighttime care
interactions?
Did the findings differ significantly among
subjects across the nights of the study?
What time intervals were found to have no
care interventions?

F.

Clinical Significance

What are implications of the study for ICU

nursing care?

What are implications for the development of

sleep protocols in the ICU?

Information From the Authors: Linda Tamburri, RN, MS,

lead author of this journal club article, provided
additional information about the study. Tamburri explained that
the research team chose to study nocturnal care interactions as a
means of identifying nursing practice changes. She related,
Two of the investigators on our team had previously conducted a study that examined the sleep patterns of cardiac
patients on medical telemetry units. We wanted to extend that
work and look at sleep in ICU patients. Because there is limited
data on sleep in the ICU, we decided to explore the source of
nocturnal interruptions for this population. Another driving factor was that we were eager to conduct a study that could identify opportunities for practical changes in nursing practice.
Tamburri related that while it was expected that the study
would find that patients had many care interventions during the
night, the research team was most surprised by the number.
She shared, We expected the data to show that a number of
patients would have insufficient time for sleep, but we did not
anticipate it would be such a large percentage of the nights
studied. The high number of patients who received their routine
daily bath between 2 AM and 5 AM was also interesting, and
raises questions regarding the reasons for this practice.
When asked about the finding that only 1 sleep-promoting
intervention was charted and whether this may have been due
to lack of documentation, Tamburri replied, We do not know
if sleep-promoting interventions were absent from the medical
record because they were not provided or because the documentation may not have been complete. It is likely that these
interventions are often provided, but nurses may not see them
as being significant enough to warrant noting them in the medical record.
CNS, C, CCRN,

Implications for Practice: The findings of the study

demonstrate that critically ill patients have a significant amount
of care interactions that impact their ability to sleep. This has
direct implications for nursing care as well as in terms of activities such as routine bathing on the night shift. Tamburri shared,
The direct implications from this study are that we have many
opportunities to increase the time our patients have available
for sleep. While this may not always be possible in the most
unstable patients, there are many instances in which we can
individualize care for each patient. We need to closely examine
our nursing practice and hospital systems to be sure our actions
are driven by the needs of our patients. For example, do we
measure vital signs every 1 to 2 hours because that is our policy, because it is traditional practice, or because it is what the
patients condition truly warrants? Clustering nursing activities
and those of other caregivers to provide greater lengths of uninterrupted time for sleep is another change that can easily be
implemented.
Journal Club feature commentary is provided by Ruth Kleinpell.

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113

Nocturnal Care Interactions with Patients in Critical Care Units

Linda M. Tamburri, Roseann DiBrienza, Rochelle Zozula and Nancy S. Redeker
Am J Crit Care 2004;13:102-113
2004 American Association of Critical-Care Nurses
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research
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