Noise at night in hospital general wards: a mapping of the literature Julie Fillary, Hema Chaplin, Gill Jones, Angela Thompson, Anita Holme and Patricia Wilson
Key words: Noise ■ Sleep ■ Patient satisfaction ■ Nursing interventions ■ Hospital design and construction
T
he King’s Fund Point of Care programme (Coulter et al, 2009) suggests measuring what matters most to patients is essential for a successful strategy to improve quality of patient experience in hospitals. However, following significant failings of care in England at the Mid Staffordshire NHS Foundation Trust, the subsequent public inquiry identified systemic failings in heeding patient experience data and total disregard for ‘predicament of patients’ (Francis, 2013). The Care Quality Commission (CQC) inpatient surveys across the NHS consistently identify areas of care that result in poor patient experience. In particular, noise at night in hospitals and the impact on patients’ sleep Julie Fillary, Senior Research Nurse, Borthwick Diabetes & Research Centre, East and North Herts NHS Trust, Stevenage; Hema Chaplin, previously Research Assistant, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; Gill Jones, Information Skills Librarian, East and North Herts NHS Trust, Stevenage; Angela Thompson, Director of Nursing, East and North Herts NHS Trust, Stevenage; Anita Holme, Lead Research Nurse, Borthwick Diabetes & Research Centre, East and North Herts NHS Trust, Stevenage; Patricia Wilson, previously Reader in Patient Experience, University of Hertfordshire Accepted for publication: May 2015
536
The importance of sleep Sleep has two main functions; conservation and restoration of energy (Moorcroft, 2013). Sleep is necessary for physiologic restoration and maintaining cognitive and emotional wellbeing. During sleep, noise can cause arousal by affecting cortical brain activity and cardiovascular function through elevated heart rate and blood pressure (Buxton et al, 2012). These physiological changes can alter the treatment care pathway for patients as illustrated by Hagerman et al (2005), whose study in an intensive coronary care unit demonstrated a statistically significant increase in the use of beta blockers and rehospitalisation at 3 months. In addition, pain, which is often experienced during illness, can cause sleep fragmentation through increasing cortical arousal. This combined with sleep deprivation can cause hyperalgesic changes and interference with the mode of action of some analgesic medications and a vicious circle can form (Lautenbacher et al, 2006) (Figure 1) Sleep is important during illness owing to its impact on the immune system and defence against infection (Majde and Krueger, 2005). However, the extent of sleep disturbance for hospitalised patients has been highlighted as sleep deteriorates greatly in hospital (Thomas et al, 2012). Although the debate continues as to the different causes, it is internationally recognised that noise is an endemic disruption to sleep at night in hospitals (Lei et al, 2009). In the USA, noise levels at night were identified as the quality-of-care factor that needed the most improvement (Jha et al, 2008). This mirrors the situation in the English NHS with CQC inpatient surveys identifying noise from staff and other patients continuing to be an aspect of care with the least patient satisfaction. While there has been some research focused on improving hospital areas most at risk, such as intensive care owing to noisy equipment necessary to patient care, there has been relatively little work on how to reduce the impact of noise at night in the general ward. For the purpose of this review, ‘general ward’ is defined as bed units accommodating inpatients with medical or surgical conditions requiring routine care.
© 2015 MA Healthcare Ltd
Abstract
English NHS inpatient surveys consistently identify that noise at night in hospitals and its impact on patients’ sleep is a persisting problem that needs addressing. To identify how noise at night in hospital affects patients on general wards and the range of interventions aimed at reducing the problem, a systematic mapping of the literature was undertaken. All primary studies and relevant literature published January 2003–July 2013 were included. Key issues identified in the literature included noise levels and causes, impact on patient experience, and lack of staff awareness. Interventions to reduce noise were targeted at staff education, behaviour modification, care organisation and environmental solutions. The scoping suggested that when compared with specialist units, there is little evidence on effective interventions reducing disturbance from night-time noise on general wards. The available evidence suggests a whole systems approach should be adopted to aid quality sleep and promote recovery.
is a persisting problem. The latest CQC inpatient survey results (2013) identify that the majority of hospitals are not improving patient experience regarding disturbance from noise at night, particularly from other patients, and some are worsening with less than 50% satisfaction rating. Those hospitals that have satisfaction scores of over 70% are predominantly either specialist hospitals or new builds. These new build hospitals have been able to incorporate healthcare design strategies to ensure less disturbance at night.
British Journal of Nursing, 2015, Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
FEATURE Design and methods used for literature mapping The authors adopted a mapping rather than a systematic review approach in order to assess the available evidence and any gaps in research (Trivedi et al, 2009).This review included all types of primary studies and other relevant literature published January 2003 to July 2013. Other literature included policy reviews, guidelines, national quality surveys, and web-based exemplars of innovations. While the focus was on interventions within general wards in UK hospitals, papers from other countries and specialist units were also included to give more insight. The authors searched for English-language publications using the following bibliographic databases: CINAHL, Medline, Embase, Health Business Elite, HMIC (King’s Fund and Department of Health), Cochrane Library and Google Scholar. Keywords and thesaurus terms for the following concepts were used to search all the databases: noise at night, sleep disturbance, reducing noise levels and hospitals. Lateral searches were also conducted through screening reference lists. Figure 2 illustrates the total numbers of articles screened. Abstracts were screened independently by authors GJ and JF for relevance. Included papers were read by JF, HC and PW and coded independently into descriptive themes and they then met to discuss any discrepancies and generate a final set of analytical themes.
Pain
Intensification of pain**
Increased cortical arousals*
Lack of sleep
Difficulty in sleeping
*Young et al, 2008 **Lautenbacher et al, 2006 Figure 1. Relationship between sleep deprivation and pain
Electronic database searches and web searches = 527 (title and abstract screened)
Potentially relevant and full text obtained for screening = 183
Results Four main themes were found from the evidence mapping; noise levels, causes of noise, impact on patient experience, and interventions to reduce noise. Interventions sub-themes comprised staff education and behaviour modification, organisation of care, and environmental.
© 2015 MA Healthcare Ltd
Noise levels Busch-Vishniac et al (2005) found no published results of hospitals meeting the World Health Organization (WHO) sound level guidelines of a maximum of 40 decibels (dB) in patients’ rooms at night. Moreover, they demonstrated an increase in night time noise over the previous 45 years, with average levels increasing from 42 to 60 dB by 2005. However, this 40 dB limit cannot be physically achieved as it is too low for certain hospital settings, such as intensive care (Darbyshire and Young, 2013) which may reflect that WHO guidelines need reviewing to account for the increased use of mechanical equipment in the hospital environment. Although the debate continues as to the exact noise level required for arousal, it has been identified that it can occur from noise above 55 dB (Passchier-Vermeer and Passchier, 2000). Yoder et al (2012) measured sound levels in medical wards and discovered a correlation between higher maximum noise levels and reported disrupted sleep. While the data were only collected on patients over 50 years old, this may not be significant as Wiese and Wang (2011) found in their study that age did not statistically affect patients’ responses to different noises. However, arousal may also be due to the type of noise specifically found in hospitals and not just the level of noise. Buxton et al (2012) exposed healthy subjects to simulated hospital noises and discovered electronic sounds, such as the intravenous infusion alarm,
British Journal of Nursing, 2015, Vol 24, No 10
Included for evidence mapping = 51
Figure 2. Identification of literature for mapping
were more arousing than other sounds of the same volume. Nonetheless, it is not clear whether the responses of healthy individuals are a reasonable proxy for inpatients.
Causes of noise in hospitals Christensen (2005a) explored the relationship between the number of staff present and noise levels on a surgical ward over 3 days, concluding that an increase in staff increased noise levels but suggested that patients and visitors could also add to levels. Identification of staff noise as a concern was also recorded by Wiese and Wang (2011), on two separate 4-day periods, where patients identified talking both inside and outside patient rooms among the most common sources of noise, as well as the behaviour of other patients, from visitors or being treated by staff. The CQC inpatient surveys suggest patients are consistently more disturbed by other patients than staff. Patients report that other patients’ mobile phones, computers and televisions can be disturbing, especially at night.
Impact on patient experience Dogan et al (2005) in their study of 150 patients in a variety of hospital settings, identified that patients have worse quality sleep in hospital. This study was strengthened by comparing results with another control group of 50 healthy volunteers. Lei et al (2009) asked 397 patients on medical and surgical wards over a 3-month period to identify sleep-disturbing
537
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
Interventions Interventions focused on three main areas: staff education and behaviour modification, care organisation, and environmental interventions.
Staff education and behaviour modification There are several factors that contribute to the average noise level on the ward including nursing activities and conversation, especially during shift change. Cmiel et al (2004) implemented an educational programme emphasising the need for all staff to speak quietly and use of designated report rooms to talk in instead of at the nurses’ station. Cmiel et al (2004) used followup surveys for over 2 years, which demonstrated a positive trend from patients. This requirement to lessen noise from staff has been recognised by others with the implementation of several different interventions; principally through visually reminding staff about increased noise levels with electronic signs. Bartick et al (2010) used sound meters installed in each nursing area that flashed when 60 dB was reached. Thomas et al (2012) made use of noise-sensitive traffic lights that turn amber when 40 dB is reached and red if noise levels exceed 50 dB. These were installed in the staff break room and at the nurses’ station. When measured through questionnaires and a modified validated Verran and Snyder-Halpern Sleep Scale, these constant reminders were found to help alter behaviours. Behaviour modification programmes have also been used to change nursing and medical routines. One such programme introduced non-disturbance periods in the afternoon and at night, which resulted in reduced sleep disturbance and partly reduced noise levels (Monsén and Edéll-Gustafsson, 2005).This was robustly measured for 14 separate 24-hour periods pre and post-intervention, by noise-level meters and specially designed record forms that took into account technical equipment and activities taking place in rooms. Through combining a ward environment review, staff awareness and educational programme and allowing staff to develop clinical guidelines, Richardson et al (2009) were able to reduce average peak noise levels from 96.48 dB to 77.52 dB on three wards, suggesting that a whole systems approach to reducing noise may be more effective. However, there was no long-term follow up to evaluate sustainability.
Organisation of care Tranmer et al (2003) recommend holistic strategies centred on the individual be regularly revised, as their study, using the
538
Verran and Snyder-Halpern Sleep Scale questionnaires and Factors Influencing Sleep Questionnaire, suggested patients experience different sleeping patterns in hospital at different times. For example, immediately after surgery patients may receive a considerable amount of analgesia, which can help induce sleep, whereas 3 days later they may require less analgesia and find it more difficult to sleep. Ear plugs are widely used in hospital and have been shown to improve rapid eye movement sleep indicating improved sleep quality (Hu et al, 2010). Although Hu et al used simulated intensive care unit noises on healthy subjects, Scotto et al’s (2009) study was conducted in a coronary care unit and found the subjective experience of sleep was improved through ear plug use. However, not all patients were able to complete the study, as the ear plugs were uncomfortable or fell out. Noise was still found to be a sleep-preventing factor in a study investigating the use of ear plugs and eye masks, even though these relatively cheap interventions did improve sleep on a small scale (Richardson et al, 2007). Interventions such as ear plugs have been recommended in situations where noise awareness interventions have failed or it is impractical to reduce noise levels owing to noisy equipment necessary for optimal patient care (Darbyshire and Young, 2013).
Environmental Increase in noise levels on the wards due to modern technology (Busch-Vishniac et al, 2005) has been recognised as an increasing issue. However, Yoder et al (2012) found that patients rated talking as the most common source of noise, rather than noisy equipment. In a study by Bartick et al (2010), when patients’ exposure to staff conversations was reduced, not only did patient satisfaction increase, but there was also a reduction in sedative medication. This could have a cost-saving implication supported by another study that identified that 29% of hypnotic prescriptions were initiated solely to improve sleep quality (Frighetto et al, 2004). The environment also needs to be considered as hard, smooth surfaces amplify and reflect sound, and as a consequence the sound travels over a larger area affecting more patients (Dubbs, 2004). In contrast, ceiling tiles are designed to absorb sound through surface design. Johns Hopkins Hospital, Baltimore found both patients and staff were happier when sound absorbing tiles were added as noise levels reduced by 5 dB and reverberation time dropped by a factor of over 2. In particular staff found it easier to understand each other, whereas previously, they had concerns that they did not always hear conversations and instructions clearly (MacLeod et al, 2007). Sound blocking can be incorporated into structural design through barriers such as closed doors on single rooms. However, this has to be balanced with the need for staff to ensure optimal care is maintained. Therefore to be able to hear and see patients, wards tend to be open plan. To block noise, the Queen Elizabeth Hospital, Birmingham (which opened in 2010) has ensured 44% of its beds are in single rooms and those in bays have an en suite bathroom (University Hospitals Birmingham NHS Trust, 2015). In the US, Boston General Hospital has installed
© 2015 MA Healthcare Ltd
factors and patients reported noise from staff talking and nurses’ shoes squeaking as the main disturbances. This study excluded patients with severe pain that may have skewed the results. Patients have identified that physical and psychological factors, such as bedside manner, degree of control and maintaining dignity, have had an impact on their ability to sleep during hospitalisation (Gellerstedt et al, 2014). Ward environment and layout experienced in large Nightingale wards (without bays or subdivisions) can have an effect on patients’ sleep owing to noise and lack of privacy (Dijkstra et al, 2006). Despite these reports of negative patient experience, it has been highlighted that staff knowledge, irrespective of seniority, was poor on effects of noise (Christensen, 2005b).
British Journal of Nursing, 2015, Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
FEATURE sliding glass doors that allow for easy observation while blocking sounds effectively (Mass General Magazine, 2012). However, if not maintained, fittings squeaking or slamming can add to the noise. Therefore a continuous improvement programme is required to ensure fixtures and fittings are as quiet as possible. Covering noise with a constant, but less distracting, sound has been trialled on a small scale in the hospital setting. It has been demonstrated that an elevation of 17.5 dB from the background ambient noise level can cause an arousal from sleep (Stanchina et al, 2005) and masking these peaks of sound that cause arousal and disturb quality of sleep requires consideration. Sound masking works on the principle of raising the background ambient sound with a consistent non-disturbing sound, so that when there is an elevation in noise owing to an activity on the ward, there will be a smaller increase from the background ambient to the peak noise made. Reducing the difference between ambient and peak noises could decrease the risk of waking patients. Sound masking can also reduce the comprehension of voices, so that patients potentially cannot identify what is being said. Considering that nurses’ conversations at their station could be heard and identified by sound recorders in a bay 30 metres from the nurses station (Christensen, 2005a), sound masking could protect confidentiality and disturbance. Sound masking is used regularly in office situations and healthcare treatment rooms to protect confidentiality. However, it is a new concept on wards although it has been tried in some US hospitals where a positive impact on patient experience has been reported anecdotally. Sound masking may be the most effective technique for improving sleep (Xie et al, 2009), however, there are no published results from its use in an NHS hospital.
© 2015 MA Healthcare Ltd
Discussion Ward noise is a main concern for patients (Douglas and Douglas, 2005). This is likely to increase as general NHS wards are caring for more patients with dementia and, even with calming strategies in place, there will be times when patients’ agitation will disturb others. The literature scoping found a lack of research on how to address the challenge of noise. With the use of modern technology in care adding to the sound levels (Buxton et al, 2012), and increased mobile phone use, there is a need to reduce noise. Traditionally, hospitals have looked to nurses as the cause of and solution to noise at night. Although this is appropriate to an extent and improvements have been made with nurses lowering their voices, it would be sensible to include all staff who visit the ward. Therefore, as part of corporate training, it may be appropriate to have guidelines and training at induction to all staff on how to minimise noise at night, with regular refresher sessions. As the strategy of intentional rounding has become a policy indicative of good practice (National Nursing Research Unit, 2012), evening rounding should focus on setting the scene for sleep including reminders of the resources available, such as ear plugs, and facilitation of toileting to reduce disruptions in the night. The aim should be to settle those patients who are early risers first, leaving
British Journal of Nursing, 2015, Vol 24, No 10
Staff
Whole systems approach
Environment
■■ Designated talking areas ■■ Designated quiet times ■■ Electronic warning signs
■■ Ceiling tiles ■■ Sound blocking ■■ Regular maintenance ■■ Sound masking
of fittings
■■ Care
Care Organisation
adjusted to changes in sleep patterns ■■ Intentional rounding ■■ Ear plugs and eye masks
Figure 3. Whole systems approach to noise reduction
those who identify themselves as late risers undisturbed early in the morning. However, as the noisiest time of the day can be early in the morning at shift change (Christensen, 2005a) hospital staff need to minimise noise generated at hand over. Patients’ sleep routines should be identified and those who identify they have sleep issues at home should have full sleep assessments (Gilsenan, 2012). Matrons, ward managers and senior nurses have a particular remit for improving patient experience. In preparation for these roles, nurses need to be enabled to take rapid and effective action on feedback from patients. With a growing emphasis on real-time patient feedback (Nicholls, 2012), there is a stronger likelihood that feedback on night disturbance will be put to effective use through an enhanced sense of nurses having ownership of the data. Richardson et al’s (2009) whole system approach was able to reduce peaks, but still had elevations which they suggested could be owing ‘to patient care activities’. However, technology could be employed to counterbalance the disturbance from noise (Figure 3). One potential intervention that has shown promise in other environments and some US hospitals is sound masking. However, there is
KEY POINTS n Sleep
is necessary for physiologic restoration and maintaining cognitive and emotional wellbeing
n Noise
is an endemic disruption to sleep at night in hospitals, and continues to register as a concern on patient satisfaction surveys
n Noise
from staff talking, other patients and visitors have all been identified as causes of sleep disturbance
n Interventions
identified in this review focused on three main areas: staff education and behaviour modification, care organisation, and environmental interventions
n There
is a lack of high-quality evidence for the effectiveness of sleeppromoting nursing interventions and more research is needed
539
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
Conclusion When compared with specialist units, there is a dearth of evidence on effective interventions to alleviate disturbance from noise at night in the general ward environment. The available evidence indicates the need to incorporate a whole systems approach to develop a comfortable acoustic environment for patients to aid good quality sleep that could then be fully evaluated to improve patient experience. In light of the Francis Report (Francis, 2013) and the Nursing Strategy of providing compassion in care (Department of Health and NHS Commissioning Board, 2012), nurses are being called on to re-evaluate the quality of care provided and effect on patient experience. Recent systematic reviews suggest that there is a lack of highquality evidence for the effectiveness of sleep-promoting nursing interventions (Hellström et al, 2011) and nonpharmacological interventions to improve sleep quality or quantity for general inpatients (Tamrat et al, 2014).Therefore more research is needed before appropriate implementation into clinical practice can occur, thus improving the patients’ BJN experience of noise at night. Conflict of interest: none Acknowledgements: the authors would like to thank Denise Arendse, Pauline Philpot, Sheila Seabrook and Ron Westcott for their administrative help when writing this article. Bartick MC, Thai X, Schmidt T, Altaye A, Solet JM (2010) Decrease in as-needed sedative use by limiting night time sleep disruptions from hospital staff. J Hosp Med 5(3): E20-4 Busch -Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R (2005) Noise levels in Johns Hopkins hospital. J Acoust Soc Am 118(6): 3629-45 Buxton OM, Ellenbogen JM, Wang W et al (2012) Sleep disruption due to hospital noises: a prospective evaluation. Ann Intern Med 157(3): 170-9. doi: 10.7326/0003-4819-157-3-201208070-00472. Care Quality Commission (2013) National summary of the results for the 2012 Inpatients Survey (September 2012 to January 2013) CQC, Newcastle Upon Tyne http://tinyurl.com/ovkvj5c (accessed 20 May 2015) Christensen M (2005a) Noise levels in a general surgical ward: a descriptive study. J Clin Nurs 14(2): 156-164 Christensen M (2005b) What knowledge do ICU nurses have with regard to the effects of noise exposure in the intensive care unit? Intensive Crit Care Nurs 21(4): 199-207 Cmiel CA, Karr DM, Gasser DM, Oliphant LM, Neveau AJ (2004) Noise control: A nursing team’s approach to sleep promotion: Respecting the silence creates a healthier environment for your patients. Am J Nurs 104(2): 40-8 Coulter A, Fitzpatrick R, Cornwell J (2009) The point of care: Measures of patients’ experience in hospital: purpose, methods and uses.The King’s Fund, London. http://tinyurl.com/qe33yvw (accessed 18 May 2015) Darbyshire JL, Young JD (2013) An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care 17(5): R187. doi: 10.1186/cc12870. Department of Health and NHS Commissioning Board: Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser (2012) Compassion in practice: Nursing, midwifery and care staff our vision and strategy. NHS England. http://tinyurl.com/c5lc4n2 (accessed 18 May 2015) Dijkstra K, Pieterse M, Pruyn A (2006) Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: systematic review. J Adv Nurs 56(2): 166-81 Dogan O, Ertekin D, Dogan S (2005) Sleep quality in hospitalized patients. J Clin Nurs 14(1): 107-13 Douglas CH, Douglas MR (2005) Patient-centred improvements in health-care built environments: perspectives and design indicators Health Expect 8(3): 264-76. doi: 10.1111/j.1369-7625.2005.00336.x Dubbs D (2004) Sound effects: design and operations solutions to hospital noise. Health Facil Manage 17(9): 14–8
540
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust public inquiry. http://tinyurl.com/anb9zme (accessed 19 May 2015) Frighetto L, Marra C, Bandali S, Wilbur K, Naumann T, Jewesson P (2004) An assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult patients. Health Qual Life Outcomes 2: 17. doi: 10.1186/1477-7525-2-17 Gellerstedt L, Medin J, Karlsson MR (2014) Patients’ experiences of sleep in hospital: a qualitative interview study. J Res Nurs 19(3): 176-88 Gilsenan I (2012) Nursing interventions to alleviate insomnia. Nurs Older People 24(4): 14–8. doi: 10.7748/nop2012.05.24.4.14.c9068 Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA, Theorell T (2005) Influence of intensive coronary care acoustics on the quality of care and physiological state of patients. Int J Cardiol 98(2): 267–70. doi: 10.1016/j. ijcard.2003.11.006 Hellström A, Willman A (2011) Promoting sleep by nursing interventions in health care settings: a systematic review. Worldviews Evid Based Nurs 8(3): 128–42. doi: 10.1111/j.1741-6787.2010.00203.x Hu R, Jiang X, Zeng Y, Chen X, Zhang Y (2010) Effects of earplugs and eye masks on nocturnal sleep, melatonin and cortisol in a simulated intensive care unit environment. Crit Care 14(2): R66 (1-9). doi: 10.1186/cc8965 Jha AK, Orav EJ, Zheng J, Epstein AM (2008) Patients’ perception of hospital care in the United States. N Engl J Med 359(18): 1921–31. doi: 10.1056/ NEJMsa0804116 Lautenbacher S, Kundermann B, Krieg J-C (2006) Sleep deprivation and pain perception. Sleep Med Rev 10(5): 357–69. doi: 10.1016/j.smrv.2005.08.001 Lei Z, Qiongjing Y, Qiuli W, Sabrina K, Xiaojing L, Changli W (2009) Sleep quality and sleep disturbing factors of inpatients in a Chinese general hospital. J Clin Nurs 18(17): 2521–9. doi: 10.1111/j.1365-2702.2009.02846.x MacLeod M, Dunn J, Busch-Vishniac IJ, West JE, Reedy A (2007) Quieting Weinberg 5C: a case study in hospital noise control. J Acoust Soc Am 121(6): 3501–8. doi: 10.1121/1.2723655 Majde JA, Krueger JM (2005) Links between the innate immune system and sleep. J Allergy Clin Immunol 116(6): 1188–98. doi: 10.1016/j.jaci.2005.08.005 Mass General Magazine (2012) All’s quiet on the Lunder floors. http://tinyurl. com/o5y5vby Monsén MG, Edéll-Gustafsson UM (2005) Noise and sleep disturbance factors before and after implementation of a behavioural modification programme. Intensive Crit Care Nurs 21(4): 208–19. doi: 10.1016/j.iccn.2004.12.002 Moorcroft WH (2013) Understanding Sleep and Dreaming. 2nd edn. Springer, New York National Nursing Research Unit (2012) Delivering nursing care: Intentional rounding: What is the evidence? Policy+ issue 35 https://www.kcl.ac.uk/ nursing/research/nnru/policy/By-Issue-Number/Policy--Issue-35final.pdf Nicholls J (2012) From Data to Action: The Challenges of Driving Service Improvement. http://tinyurl.com/o9w6rzq (accessed 15 May 2014) Passchier-Vermeer W, Passchier WF (2000) Noise exposure and public health. Environ Health Perspect 108 Suppl 1: 123–31 Richardson A, Allsop M, Coghill E, Turnock C (2007) Earplugs and eye masks: do they improve critical care patients’ sleep? Nurs Crit Care 12(6): 278–86. doi: 10.1111/j.1478-5153.2007.00243.x Richardson A, Thompson A, Coghill E, Chambers I, Turnock C (2009) Development and implementation of a noise reduction intervention programme: a pre- and postaudit of three hospital wards. J Clin Nurs 18(23): 3316–24. doi: 10.1111/j.1365-2702.2009.02897.x Scotto CJ, McClusky C, Spillan S, Kimmel J (2009) Earplugs improve patients’ subjective experience of sleep in critical care. Nurs Crit Care 14(4): 180–4. doi: 10.1111/j.1478-5153.2009.00344.x Stanchina ML, Abu-Hijleh M, Chaudhry BK, Carlisle CC, Millman RP (2005) The influence of white noise on sleep in subjects exposed to ICU noise. Sleep Med 6(5): 423–8. doi: 10.1016/j.sleep.2004.12.004 Tamrat R, Huynh-Le M-P, Goyal M (2014) Non-pharmacologic interventions to improve the sleep of hospitalized patients: a systematic review. J Gen Intern Med 29(5): 788–95. doi: 10.1007/s11606-013-2640-9 Thomas KP, Salas RE, Gamaldo C et al (2012) Sleep rounds: a multidisciplinary approach to optimize sleep quality and satisfaction in hospitalized patients. J Hosp Med 7(6): 508–12. doi: 10.1002/jhm.1934 Tranmer JE, Minard J, Fox LA, Rebelo L (2003) The sleep experience of medical and surgical patients. Clin Nurs Res 12(2): 159–73 Trivedi D, Brooks F, Bunn F, Graham M (2009) Early fatherhood: a mapping of the evidence base relating to pregnancy prevention and parenting support. Health Educ Res 24(6): 999–1028. doi: 10.1093/her/cyp025 University Hospitals Birmingham NHS Trust (2015) Benefits of the new hospital. http://tinyurl.com/nhu744p (accessed 19 May 2015) Wiese CH, Wang LM (2011) LV-11-C031: Measured levels of hospital noise before, during, and after renovation of a hospital wing, and a survey of resulting patient perception. http://tinyurl.com/ml6mev6 (accessed 19 May 2015) Xie H, Kang J, Mills GH (2009) Clinical review: The impact of noise on patients’ sleep and the effectiveness of noise reduction strategies in intensive care units. Crit Care 13(2): 208. doi: 10.1186/cc7154 Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM (2012) Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med 172(1): 68–70. doi: 10.1001/archinternmed.2011.603 Young JS, Bourgeois JA, Hilty DM, Hardin KA (2008) Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med 3(6): 473–82. doi: 10.1002/jhm.372
© 2015 MA Healthcare Ltd
a lack of robust evidence and further research is required to evaluate impact on patient experience.
British Journal of Nursing, 2015, Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
Key words: Noise ■ Sleep ■ Patient satisfaction ■ Nursing interventions ■ Hospital design and construction
T
he King’s Fund Point of Care programme (Coulter et al, 2009) suggests measuring what matters most to patients is essential for a successful strategy to improve quality of patient experience in hospitals. However, following significant failings of care in England at the Mid Staffordshire NHS Foundation Trust, the subsequent public inquiry identified systemic failings in heeding patient experience data and total disregard for ‘predicament of patients’ (Francis, 2013). The Care Quality Commission (CQC) inpatient surveys across the NHS consistently identify areas of care that result in poor patient experience. In particular, noise at night in hospitals and the impact on patients’ sleep Julie Fillary, Senior Research Nurse, Borthwick Diabetes & Research Centre, East and North Herts NHS Trust, Stevenage; Hema Chaplin, previously Research Assistant, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; Gill Jones, Information Skills Librarian, East and North Herts NHS Trust, Stevenage; Angela Thompson, Director of Nursing, East and North Herts NHS Trust, Stevenage; Anita Holme, Lead Research Nurse, Borthwick Diabetes & Research Centre, East and North Herts NHS Trust, Stevenage; Patricia Wilson, previously Reader in Patient Experience, University of Hertfordshire Accepted for publication: May 2015
536
The importance of sleep Sleep has two main functions; conservation and restoration of energy (Moorcroft, 2013). Sleep is necessary for physiologic restoration and maintaining cognitive and emotional wellbeing. During sleep, noise can cause arousal by affecting cortical brain activity and cardiovascular function through elevated heart rate and blood pressure (Buxton et al, 2012). These physiological changes can alter the treatment care pathway for patients as illustrated by Hagerman et al (2005), whose study in an intensive coronary care unit demonstrated a statistically significant increase in the use of beta blockers and rehospitalisation at 3 months. In addition, pain, which is often experienced during illness, can cause sleep fragmentation through increasing cortical arousal. This combined with sleep deprivation can cause hyperalgesic changes and interference with the mode of action of some analgesic medications and a vicious circle can form (Lautenbacher et al, 2006) (Figure 1) Sleep is important during illness owing to its impact on the immune system and defence against infection (Majde and Krueger, 2005). However, the extent of sleep disturbance for hospitalised patients has been highlighted as sleep deteriorates greatly in hospital (Thomas et al, 2012). Although the debate continues as to the different causes, it is internationally recognised that noise is an endemic disruption to sleep at night in hospitals (Lei et al, 2009). In the USA, noise levels at night were identified as the quality-of-care factor that needed the most improvement (Jha et al, 2008). This mirrors the situation in the English NHS with CQC inpatient surveys identifying noise from staff and other patients continuing to be an aspect of care with the least patient satisfaction. While there has been some research focused on improving hospital areas most at risk, such as intensive care owing to noisy equipment necessary to patient care, there has been relatively little work on how to reduce the impact of noise at night in the general ward. For the purpose of this review, ‘general ward’ is defined as bed units accommodating inpatients with medical or surgical conditions requiring routine care.
© 2015 MA Healthcare Ltd
Abstract
English NHS inpatient surveys consistently identify that noise at night in hospitals and its impact on patients’ sleep is a persisting problem that needs addressing. To identify how noise at night in hospital affects patients on general wards and the range of interventions aimed at reducing the problem, a systematic mapping of the literature was undertaken. All primary studies and relevant literature published January 2003–July 2013 were included. Key issues identified in the literature included noise levels and causes, impact on patient experience, and lack of staff awareness. Interventions to reduce noise were targeted at staff education, behaviour modification, care organisation and environmental solutions. The scoping suggested that when compared with specialist units, there is little evidence on effective interventions reducing disturbance from night-time noise on general wards. The available evidence suggests a whole systems approach should be adopted to aid quality sleep and promote recovery.
is a persisting problem. The latest CQC inpatient survey results (2013) identify that the majority of hospitals are not improving patient experience regarding disturbance from noise at night, particularly from other patients, and some are worsening with less than 50% satisfaction rating. Those hospitals that have satisfaction scores of over 70% are predominantly either specialist hospitals or new builds. These new build hospitals have been able to incorporate healthcare design strategies to ensure less disturbance at night.
British Journal of Nursing, 2015, Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
FEATURE Design and methods used for literature mapping The authors adopted a mapping rather than a systematic review approach in order to assess the available evidence and any gaps in research (Trivedi et al, 2009).This review included all types of primary studies and other relevant literature published January 2003 to July 2013. Other literature included policy reviews, guidelines, national quality surveys, and web-based exemplars of innovations. While the focus was on interventions within general wards in UK hospitals, papers from other countries and specialist units were also included to give more insight. The authors searched for English-language publications using the following bibliographic databases: CINAHL, Medline, Embase, Health Business Elite, HMIC (King’s Fund and Department of Health), Cochrane Library and Google Scholar. Keywords and thesaurus terms for the following concepts were used to search all the databases: noise at night, sleep disturbance, reducing noise levels and hospitals. Lateral searches were also conducted through screening reference lists. Figure 2 illustrates the total numbers of articles screened. Abstracts were screened independently by authors GJ and JF for relevance. Included papers were read by JF, HC and PW and coded independently into descriptive themes and they then met to discuss any discrepancies and generate a final set of analytical themes.
Pain
Intensification of pain**
Increased cortical arousals*
Lack of sleep
Difficulty in sleeping
*Young et al, 2008 **Lautenbacher et al, 2006 Figure 1. Relationship between sleep deprivation and pain
Electronic database searches and web searches = 527 (title and abstract screened)
Potentially relevant and full text obtained for screening = 183
Results Four main themes were found from the evidence mapping; noise levels, causes of noise, impact on patient experience, and interventions to reduce noise. Interventions sub-themes comprised staff education and behaviour modification, organisation of care, and environmental.
© 2015 MA Healthcare Ltd
Noise levels Busch-Vishniac et al (2005) found no published results of hospitals meeting the World Health Organization (WHO) sound level guidelines of a maximum of 40 decibels (dB) in patients’ rooms at night. Moreover, they demonstrated an increase in night time noise over the previous 45 years, with average levels increasing from 42 to 60 dB by 2005. However, this 40 dB limit cannot be physically achieved as it is too low for certain hospital settings, such as intensive care (Darbyshire and Young, 2013) which may reflect that WHO guidelines need reviewing to account for the increased use of mechanical equipment in the hospital environment. Although the debate continues as to the exact noise level required for arousal, it has been identified that it can occur from noise above 55 dB (Passchier-Vermeer and Passchier, 2000). Yoder et al (2012) measured sound levels in medical wards and discovered a correlation between higher maximum noise levels and reported disrupted sleep. While the data were only collected on patients over 50 years old, this may not be significant as Wiese and Wang (2011) found in their study that age did not statistically affect patients’ responses to different noises. However, arousal may also be due to the type of noise specifically found in hospitals and not just the level of noise. Buxton et al (2012) exposed healthy subjects to simulated hospital noises and discovered electronic sounds, such as the intravenous infusion alarm,
British Journal of Nursing, 2015, Vol 24, No 10
Included for evidence mapping = 51
Figure 2. Identification of literature for mapping
were more arousing than other sounds of the same volume. Nonetheless, it is not clear whether the responses of healthy individuals are a reasonable proxy for inpatients.
Causes of noise in hospitals Christensen (2005a) explored the relationship between the number of staff present and noise levels on a surgical ward over 3 days, concluding that an increase in staff increased noise levels but suggested that patients and visitors could also add to levels. Identification of staff noise as a concern was also recorded by Wiese and Wang (2011), on two separate 4-day periods, where patients identified talking both inside and outside patient rooms among the most common sources of noise, as well as the behaviour of other patients, from visitors or being treated by staff. The CQC inpatient surveys suggest patients are consistently more disturbed by other patients than staff. Patients report that other patients’ mobile phones, computers and televisions can be disturbing, especially at night.
Impact on patient experience Dogan et al (2005) in their study of 150 patients in a variety of hospital settings, identified that patients have worse quality sleep in hospital. This study was strengthened by comparing results with another control group of 50 healthy volunteers. Lei et al (2009) asked 397 patients on medical and surgical wards over a 3-month period to identify sleep-disturbing
537
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
Interventions Interventions focused on three main areas: staff education and behaviour modification, care organisation, and environmental interventions.
Staff education and behaviour modification There are several factors that contribute to the average noise level on the ward including nursing activities and conversation, especially during shift change. Cmiel et al (2004) implemented an educational programme emphasising the need for all staff to speak quietly and use of designated report rooms to talk in instead of at the nurses’ station. Cmiel et al (2004) used followup surveys for over 2 years, which demonstrated a positive trend from patients. This requirement to lessen noise from staff has been recognised by others with the implementation of several different interventions; principally through visually reminding staff about increased noise levels with electronic signs. Bartick et al (2010) used sound meters installed in each nursing area that flashed when 60 dB was reached. Thomas et al (2012) made use of noise-sensitive traffic lights that turn amber when 40 dB is reached and red if noise levels exceed 50 dB. These were installed in the staff break room and at the nurses’ station. When measured through questionnaires and a modified validated Verran and Snyder-Halpern Sleep Scale, these constant reminders were found to help alter behaviours. Behaviour modification programmes have also been used to change nursing and medical routines. One such programme introduced non-disturbance periods in the afternoon and at night, which resulted in reduced sleep disturbance and partly reduced noise levels (Monsén and Edéll-Gustafsson, 2005).This was robustly measured for 14 separate 24-hour periods pre and post-intervention, by noise-level meters and specially designed record forms that took into account technical equipment and activities taking place in rooms. Through combining a ward environment review, staff awareness and educational programme and allowing staff to develop clinical guidelines, Richardson et al (2009) were able to reduce average peak noise levels from 96.48 dB to 77.52 dB on three wards, suggesting that a whole systems approach to reducing noise may be more effective. However, there was no long-term follow up to evaluate sustainability.
Organisation of care Tranmer et al (2003) recommend holistic strategies centred on the individual be regularly revised, as their study, using the
538
Verran and Snyder-Halpern Sleep Scale questionnaires and Factors Influencing Sleep Questionnaire, suggested patients experience different sleeping patterns in hospital at different times. For example, immediately after surgery patients may receive a considerable amount of analgesia, which can help induce sleep, whereas 3 days later they may require less analgesia and find it more difficult to sleep. Ear plugs are widely used in hospital and have been shown to improve rapid eye movement sleep indicating improved sleep quality (Hu et al, 2010). Although Hu et al used simulated intensive care unit noises on healthy subjects, Scotto et al’s (2009) study was conducted in a coronary care unit and found the subjective experience of sleep was improved through ear plug use. However, not all patients were able to complete the study, as the ear plugs were uncomfortable or fell out. Noise was still found to be a sleep-preventing factor in a study investigating the use of ear plugs and eye masks, even though these relatively cheap interventions did improve sleep on a small scale (Richardson et al, 2007). Interventions such as ear plugs have been recommended in situations where noise awareness interventions have failed or it is impractical to reduce noise levels owing to noisy equipment necessary for optimal patient care (Darbyshire and Young, 2013).
Environmental Increase in noise levels on the wards due to modern technology (Busch-Vishniac et al, 2005) has been recognised as an increasing issue. However, Yoder et al (2012) found that patients rated talking as the most common source of noise, rather than noisy equipment. In a study by Bartick et al (2010), when patients’ exposure to staff conversations was reduced, not only did patient satisfaction increase, but there was also a reduction in sedative medication. This could have a cost-saving implication supported by another study that identified that 29% of hypnotic prescriptions were initiated solely to improve sleep quality (Frighetto et al, 2004). The environment also needs to be considered as hard, smooth surfaces amplify and reflect sound, and as a consequence the sound travels over a larger area affecting more patients (Dubbs, 2004). In contrast, ceiling tiles are designed to absorb sound through surface design. Johns Hopkins Hospital, Baltimore found both patients and staff were happier when sound absorbing tiles were added as noise levels reduced by 5 dB and reverberation time dropped by a factor of over 2. In particular staff found it easier to understand each other, whereas previously, they had concerns that they did not always hear conversations and instructions clearly (MacLeod et al, 2007). Sound blocking can be incorporated into structural design through barriers such as closed doors on single rooms. However, this has to be balanced with the need for staff to ensure optimal care is maintained. Therefore to be able to hear and see patients, wards tend to be open plan. To block noise, the Queen Elizabeth Hospital, Birmingham (which opened in 2010) has ensured 44% of its beds are in single rooms and those in bays have an en suite bathroom (University Hospitals Birmingham NHS Trust, 2015). In the US, Boston General Hospital has installed
© 2015 MA Healthcare Ltd
factors and patients reported noise from staff talking and nurses’ shoes squeaking as the main disturbances. This study excluded patients with severe pain that may have skewed the results. Patients have identified that physical and psychological factors, such as bedside manner, degree of control and maintaining dignity, have had an impact on their ability to sleep during hospitalisation (Gellerstedt et al, 2014). Ward environment and layout experienced in large Nightingale wards (without bays or subdivisions) can have an effect on patients’ sleep owing to noise and lack of privacy (Dijkstra et al, 2006). Despite these reports of negative patient experience, it has been highlighted that staff knowledge, irrespective of seniority, was poor on effects of noise (Christensen, 2005b).
British Journal of Nursing, 2015, Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
FEATURE sliding glass doors that allow for easy observation while blocking sounds effectively (Mass General Magazine, 2012). However, if not maintained, fittings squeaking or slamming can add to the noise. Therefore a continuous improvement programme is required to ensure fixtures and fittings are as quiet as possible. Covering noise with a constant, but less distracting, sound has been trialled on a small scale in the hospital setting. It has been demonstrated that an elevation of 17.5 dB from the background ambient noise level can cause an arousal from sleep (Stanchina et al, 2005) and masking these peaks of sound that cause arousal and disturb quality of sleep requires consideration. Sound masking works on the principle of raising the background ambient sound with a consistent non-disturbing sound, so that when there is an elevation in noise owing to an activity on the ward, there will be a smaller increase from the background ambient to the peak noise made. Reducing the difference between ambient and peak noises could decrease the risk of waking patients. Sound masking can also reduce the comprehension of voices, so that patients potentially cannot identify what is being said. Considering that nurses’ conversations at their station could be heard and identified by sound recorders in a bay 30 metres from the nurses station (Christensen, 2005a), sound masking could protect confidentiality and disturbance. Sound masking is used regularly in office situations and healthcare treatment rooms to protect confidentiality. However, it is a new concept on wards although it has been tried in some US hospitals where a positive impact on patient experience has been reported anecdotally. Sound masking may be the most effective technique for improving sleep (Xie et al, 2009), however, there are no published results from its use in an NHS hospital.
© 2015 MA Healthcare Ltd
Discussion Ward noise is a main concern for patients (Douglas and Douglas, 2005). This is likely to increase as general NHS wards are caring for more patients with dementia and, even with calming strategies in place, there will be times when patients’ agitation will disturb others. The literature scoping found a lack of research on how to address the challenge of noise. With the use of modern technology in care adding to the sound levels (Buxton et al, 2012), and increased mobile phone use, there is a need to reduce noise. Traditionally, hospitals have looked to nurses as the cause of and solution to noise at night. Although this is appropriate to an extent and improvements have been made with nurses lowering their voices, it would be sensible to include all staff who visit the ward. Therefore, as part of corporate training, it may be appropriate to have guidelines and training at induction to all staff on how to minimise noise at night, with regular refresher sessions. As the strategy of intentional rounding has become a policy indicative of good practice (National Nursing Research Unit, 2012), evening rounding should focus on setting the scene for sleep including reminders of the resources available, such as ear plugs, and facilitation of toileting to reduce disruptions in the night. The aim should be to settle those patients who are early risers first, leaving
British Journal of Nursing, 2015, Vol 24, No 10
Staff
Whole systems approach
Environment
■■ Designated talking areas ■■ Designated quiet times ■■ Electronic warning signs
■■ Ceiling tiles ■■ Sound blocking ■■ Regular maintenance ■■ Sound masking
of fittings
■■ Care
Care Organisation
adjusted to changes in sleep patterns ■■ Intentional rounding ■■ Ear plugs and eye masks
Figure 3. Whole systems approach to noise reduction
those who identify themselves as late risers undisturbed early in the morning. However, as the noisiest time of the day can be early in the morning at shift change (Christensen, 2005a) hospital staff need to minimise noise generated at hand over. Patients’ sleep routines should be identified and those who identify they have sleep issues at home should have full sleep assessments (Gilsenan, 2012). Matrons, ward managers and senior nurses have a particular remit for improving patient experience. In preparation for these roles, nurses need to be enabled to take rapid and effective action on feedback from patients. With a growing emphasis on real-time patient feedback (Nicholls, 2012), there is a stronger likelihood that feedback on night disturbance will be put to effective use through an enhanced sense of nurses having ownership of the data. Richardson et al’s (2009) whole system approach was able to reduce peaks, but still had elevations which they suggested could be owing ‘to patient care activities’. However, technology could be employed to counterbalance the disturbance from noise (Figure 3). One potential intervention that has shown promise in other environments and some US hospitals is sound masking. However, there is
KEY POINTS n Sleep
is necessary for physiologic restoration and maintaining cognitive and emotional wellbeing
n Noise
is an endemic disruption to sleep at night in hospitals, and continues to register as a concern on patient satisfaction surveys
n Noise
from staff talking, other patients and visitors have all been identified as causes of sleep disturbance
n Interventions
identified in this review focused on three main areas: staff education and behaviour modification, care organisation, and environmental interventions
n There
is a lack of high-quality evidence for the effectiveness of sleeppromoting nursing interventions and more research is needed
539
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
Conclusion When compared with specialist units, there is a dearth of evidence on effective interventions to alleviate disturbance from noise at night in the general ward environment. The available evidence indicates the need to incorporate a whole systems approach to develop a comfortable acoustic environment for patients to aid good quality sleep that could then be fully evaluated to improve patient experience. In light of the Francis Report (Francis, 2013) and the Nursing Strategy of providing compassion in care (Department of Health and NHS Commissioning Board, 2012), nurses are being called on to re-evaluate the quality of care provided and effect on patient experience. Recent systematic reviews suggest that there is a lack of highquality evidence for the effectiveness of sleep-promoting nursing interventions (Hellström et al, 2011) and nonpharmacological interventions to improve sleep quality or quantity for general inpatients (Tamrat et al, 2014).Therefore more research is needed before appropriate implementation into clinical practice can occur, thus improving the patients’ BJN experience of noise at night. Conflict of interest: none Acknowledgements: the authors would like to thank Denise Arendse, Pauline Philpot, Sheila Seabrook and Ron Westcott for their administrative help when writing this article. Bartick MC, Thai X, Schmidt T, Altaye A, Solet JM (2010) Decrease in as-needed sedative use by limiting night time sleep disruptions from hospital staff. J Hosp Med 5(3): E20-4 Busch -Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R (2005) Noise levels in Johns Hopkins hospital. J Acoust Soc Am 118(6): 3629-45 Buxton OM, Ellenbogen JM, Wang W et al (2012) Sleep disruption due to hospital noises: a prospective evaluation. Ann Intern Med 157(3): 170-9. doi: 10.7326/0003-4819-157-3-201208070-00472. Care Quality Commission (2013) National summary of the results for the 2012 Inpatients Survey (September 2012 to January 2013) CQC, Newcastle Upon Tyne http://tinyurl.com/ovkvj5c (accessed 20 May 2015) Christensen M (2005a) Noise levels in a general surgical ward: a descriptive study. J Clin Nurs 14(2): 156-164 Christensen M (2005b) What knowledge do ICU nurses have with regard to the effects of noise exposure in the intensive care unit? Intensive Crit Care Nurs 21(4): 199-207 Cmiel CA, Karr DM, Gasser DM, Oliphant LM, Neveau AJ (2004) Noise control: A nursing team’s approach to sleep promotion: Respecting the silence creates a healthier environment for your patients. Am J Nurs 104(2): 40-8 Coulter A, Fitzpatrick R, Cornwell J (2009) The point of care: Measures of patients’ experience in hospital: purpose, methods and uses.The King’s Fund, London. http://tinyurl.com/qe33yvw (accessed 18 May 2015) Darbyshire JL, Young JD (2013) An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care 17(5): R187. doi: 10.1186/cc12870. Department of Health and NHS Commissioning Board: Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser (2012) Compassion in practice: Nursing, midwifery and care staff our vision and strategy. NHS England. http://tinyurl.com/c5lc4n2 (accessed 18 May 2015) Dijkstra K, Pieterse M, Pruyn A (2006) Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: systematic review. J Adv Nurs 56(2): 166-81 Dogan O, Ertekin D, Dogan S (2005) Sleep quality in hospitalized patients. J Clin Nurs 14(1): 107-13 Douglas CH, Douglas MR (2005) Patient-centred improvements in health-care built environments: perspectives and design indicators Health Expect 8(3): 264-76. doi: 10.1111/j.1369-7625.2005.00336.x Dubbs D (2004) Sound effects: design and operations solutions to hospital noise. Health Facil Manage 17(9): 14–8
540
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust public inquiry. http://tinyurl.com/anb9zme (accessed 19 May 2015) Frighetto L, Marra C, Bandali S, Wilbur K, Naumann T, Jewesson P (2004) An assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult patients. Health Qual Life Outcomes 2: 17. doi: 10.1186/1477-7525-2-17 Gellerstedt L, Medin J, Karlsson MR (2014) Patients’ experiences of sleep in hospital: a qualitative interview study. J Res Nurs 19(3): 176-88 Gilsenan I (2012) Nursing interventions to alleviate insomnia. Nurs Older People 24(4): 14–8. doi: 10.7748/nop2012.05.24.4.14.c9068 Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA, Theorell T (2005) Influence of intensive coronary care acoustics on the quality of care and physiological state of patients. Int J Cardiol 98(2): 267–70. doi: 10.1016/j. ijcard.2003.11.006 Hellström A, Willman A (2011) Promoting sleep by nursing interventions in health care settings: a systematic review. Worldviews Evid Based Nurs 8(3): 128–42. doi: 10.1111/j.1741-6787.2010.00203.x Hu R, Jiang X, Zeng Y, Chen X, Zhang Y (2010) Effects of earplugs and eye masks on nocturnal sleep, melatonin and cortisol in a simulated intensive care unit environment. Crit Care 14(2): R66 (1-9). doi: 10.1186/cc8965 Jha AK, Orav EJ, Zheng J, Epstein AM (2008) Patients’ perception of hospital care in the United States. N Engl J Med 359(18): 1921–31. doi: 10.1056/ NEJMsa0804116 Lautenbacher S, Kundermann B, Krieg J-C (2006) Sleep deprivation and pain perception. Sleep Med Rev 10(5): 357–69. doi: 10.1016/j.smrv.2005.08.001 Lei Z, Qiongjing Y, Qiuli W, Sabrina K, Xiaojing L, Changli W (2009) Sleep quality and sleep disturbing factors of inpatients in a Chinese general hospital. J Clin Nurs 18(17): 2521–9. doi: 10.1111/j.1365-2702.2009.02846.x MacLeod M, Dunn J, Busch-Vishniac IJ, West JE, Reedy A (2007) Quieting Weinberg 5C: a case study in hospital noise control. J Acoust Soc Am 121(6): 3501–8. doi: 10.1121/1.2723655 Majde JA, Krueger JM (2005) Links between the innate immune system and sleep. J Allergy Clin Immunol 116(6): 1188–98. doi: 10.1016/j.jaci.2005.08.005 Mass General Magazine (2012) All’s quiet on the Lunder floors. http://tinyurl. com/o5y5vby Monsén MG, Edéll-Gustafsson UM (2005) Noise and sleep disturbance factors before and after implementation of a behavioural modification programme. Intensive Crit Care Nurs 21(4): 208–19. doi: 10.1016/j.iccn.2004.12.002 Moorcroft WH (2013) Understanding Sleep and Dreaming. 2nd edn. Springer, New York National Nursing Research Unit (2012) Delivering nursing care: Intentional rounding: What is the evidence? Policy+ issue 35 https://www.kcl.ac.uk/ nursing/research/nnru/policy/By-Issue-Number/Policy--Issue-35final.pdf Nicholls J (2012) From Data to Action: The Challenges of Driving Service Improvement. http://tinyurl.com/o9w6rzq (accessed 15 May 2014) Passchier-Vermeer W, Passchier WF (2000) Noise exposure and public health. Environ Health Perspect 108 Suppl 1: 123–31 Richardson A, Allsop M, Coghill E, Turnock C (2007) Earplugs and eye masks: do they improve critical care patients’ sleep? Nurs Crit Care 12(6): 278–86. doi: 10.1111/j.1478-5153.2007.00243.x Richardson A, Thompson A, Coghill E, Chambers I, Turnock C (2009) Development and implementation of a noise reduction intervention programme: a pre- and postaudit of three hospital wards. J Clin Nurs 18(23): 3316–24. doi: 10.1111/j.1365-2702.2009.02897.x Scotto CJ, McClusky C, Spillan S, Kimmel J (2009) Earplugs improve patients’ subjective experience of sleep in critical care. Nurs Crit Care 14(4): 180–4. doi: 10.1111/j.1478-5153.2009.00344.x Stanchina ML, Abu-Hijleh M, Chaudhry BK, Carlisle CC, Millman RP (2005) The influence of white noise on sleep in subjects exposed to ICU noise. Sleep Med 6(5): 423–8. doi: 10.1016/j.sleep.2004.12.004 Tamrat R, Huynh-Le M-P, Goyal M (2014) Non-pharmacologic interventions to improve the sleep of hospitalized patients: a systematic review. J Gen Intern Med 29(5): 788–95. doi: 10.1007/s11606-013-2640-9 Thomas KP, Salas RE, Gamaldo C et al (2012) Sleep rounds: a multidisciplinary approach to optimize sleep quality and satisfaction in hospitalized patients. J Hosp Med 7(6): 508–12. doi: 10.1002/jhm.1934 Tranmer JE, Minard J, Fox LA, Rebelo L (2003) The sleep experience of medical and surgical patients. Clin Nurs Res 12(2): 159–73 Trivedi D, Brooks F, Bunn F, Graham M (2009) Early fatherhood: a mapping of the evidence base relating to pregnancy prevention and parenting support. Health Educ Res 24(6): 999–1028. doi: 10.1093/her/cyp025 University Hospitals Birmingham NHS Trust (2015) Benefits of the new hospital. http://tinyurl.com/nhu744p (accessed 19 May 2015) Wiese CH, Wang LM (2011) LV-11-C031: Measured levels of hospital noise before, during, and after renovation of a hospital wing, and a survey of resulting patient perception. http://tinyurl.com/ml6mev6 (accessed 19 May 2015) Xie H, Kang J, Mills GH (2009) Clinical review: The impact of noise on patients’ sleep and the effectiveness of noise reduction strategies in intensive care units. Crit Care 13(2): 208. doi: 10.1186/cc7154 Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM (2012) Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med 172(1): 68–70. doi: 10.1001/archinternmed.2011.603 Young JS, Bourgeois JA, Hilty DM, Hardin KA (2008) Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med 3(6): 473–82. doi: 10.1002/jhm.372
© 2015 MA Healthcare Ltd
a lack of robust evidence and further research is required to evaluate impact on patient experience.
British Journal of Nursing, 2015, Vol 24, No 10
British Journal of Nursing. Downloaded from magonlinelibrary.com by 129.011.021.002 on May 18, 2016. For personal use only. No other uses without permission. . All rights reserved.
![[Disturbance due to traffic noise at night].](/assets/img/hold.png)
