Crit Care Nurse 2005 Feb; 25(1): 16-23
Cover Article
CE Article
Assessing and Treating Sleep Problems in Family Caregivers of Intensive Care Unit Patients
Patricia A. Carter, RN, PhD, CNS
Angela P. Clark, RN, PhD, CNS
Patricia A. Carter is an assistant professor at the University of Texas at Austin School of Nursing. During the past 7 years, she has conducted research with family caregivers of patients with chronic illness to explore the relationships between sleep problems and mood changes. Recently, she focused on development and testing of behavioral interventions to promote sleep quality in family caregivers.
Angela P. Clark is an associate professor at the University of Texas at Austin School of Nursing. She is an internationally known nurse researcher in healthcare, family interactions, and nurse interventions to promote coping by families of patients in the intensive care unit. Dr Clark is a fellow of the American Academy of Nursing and the American Heart Association.
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* This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:
- Describe and identify physiologic and emotional responses to sleep loss
- Describe the factors the affect sleep loss
- Discuss the several techniques to reduce sleep loss
Stress is inevitable when a loved one is being treated in an intensive care unit (ICU). Anxiety, fear, and uncertainty all contribute to sleep loss and feelings of exhaustion in the family members of patients before and after the patients’ discharge from the hospital. Research1 has indicated that family caregivers of patients discharged home from ICUs experience increases in anxiety and depression. These increases may occur because patients are often discharged home when they are still experiencing health-related problems that require care from family members.2 To be physically and emotionally prepared to care for patients at home, family caregivers must be well rested. Most factors that create stress for family caregivers while patients are in the ICU and after discharge are not within the caregivers’ control. However, sleep loss is one factor that caregivers can control.
Sleep is a basic physiological need of all beings. Although sleep in family caregivers of ICU patients has been explored in only a few studies, the importance of good sleep in promoting physical and emotional health in family caregivers has been examined in some investigations.3–6
In this article, we describe the impact of sleep loss on the physical and emotional health of individuals and the effect that reduction in stimuli, relaxation, and a healthy sleep routine can have on a caregiver’s ability to reduce sleep loss. A sleep evaluation questionnaire is provided to help critical care nurses determine specific sleep problems, with suggestions for behavioral techniques that can reduce sleep loss. This information can be used to help family caregivers understand the importance of sleep and ways in which they can reduce sleep loss.
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Physiological and Emotional Responses to Sleep Loss
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Short-term sleep loss (2–3 weeks) has been linked to increased heart rate and increased cortisol levels indicative of activation of the sympathetic nervous system.7–9 Long-term sleep loss (>3 weeks) has been linked to impairment of glucose metabolism and decreased immune system function,7,8,10 symptoms of anxiety and depression, poor concentration, and poor quality of life.11–14 The physical and emotional manifestations of long-term sleep loss affect caregivers’ ability to care for their family members.
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Factors That Affect Sleep Loss
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Sleep adequacy is defined as a combination of 3 factors: latency (the time it takes to fall asleep), efficiency ([time spent sleeping ÷ total time in bed] x 100), and duration of sleep15 (see Sidebar). According to the American Academy of Sleep Medicine,16 for adequate sleep, persons should fall asleep within 15 minutes, stay asleep for at least 85% of the time they are in bed, and have a total sleep time of no less than 7 hours.
Many factors may affect the ability of a patient’s family caregiver to obtain adequate sleep (ie, enough sleep to awaken feeling refreshed and rested). These factors include sleep disruptions (eg, reading or watching television in bed), sleep disturbances (eg, noise, anxiety), and physical activity and foods that stimulate wakefulness.17
The sleep evaluation questionnaire in the Appendix
can be used to identify factors that may be affecting sleep adequacy of caregivers. The information gathered can then be used to help family caregivers identify factors within their daily lives that may be adversely affecting their ability to obtain adequate sleep. We think that family caregivers would benefit from gaining knowledge about the factors that affect their sleep. With this knowledge, critical care nurses and family caregivers can begin a discussion on how simple behavioral techniques (Table 1) can be used to make significant improvements in the ability to obtain adequate sleep.24 Additionally, this knowledge of sleep problems and potential solutions can be used by nurses to help caregivers set personal sleep improvement goals (Table 2).
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Behavioral Techniques to Reduce Sleep Loss
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In persons with long-term sleep loss, behavioral techniques to promote sleep (stimulus reduction, relaxation, and healthy sleep routines) can reduce sleep loss while improving overall physical and emotional health.24 The behavioral techniques we discuss take into account the fact that family caregivers may be spending most of their time in the hospital and may not be able to use some of the more complex techniques proposed for noncaregivers. We describe 3 behavioral techniques to promote sleep, provide empirical rationales for their usefulness, and give examples of how each technique can be implemented into a caregiver’s daily life (Table 1
).
Stimulus Reduction
Stimulants that can affect sleep adequacy can take several forms: environmental, chemical, physical, and emotional. In each instance, the stimulus keeps the family caregiver awake. The bedroom, the traditional environment for sleep, has become a room for watching television, paying bills, eating, reading, and so on. This change may affect a person’s ability to obtain adequate sleep.17 Designating a location for sleep is important. The body and mind must "recognize" that the bedroom is the environment for sleep.17
Persons who have difficulty sleeping must evaluate how stimulants may be affecting their ability to obtain adequate sleep.17 Chemical stimulants (eg, caffeine) must be avoided within 6 hours of going to bed; some persons may need to avoid caffeine as much as 12 hours before going to bed.21 When done early in the day, physical activity can help promote sleep; however, strenuous physical activity within 4 hours of bedtime can stimulate the body and prevent the onset of sleep.23 Emotional stimulants (eg, anxiety, anger, fear) can also affect a person’s ability to fall asleep.25 Practicing relaxation techniques can help decrease these emotional stimulants.
Relaxation
Although anxiety and fear are to be expected when a family member is critically ill, acknowledging these feelings and practicing relaxation techniques can reduce the impact that the feelings have on sleep.26 Often caregivers say it is hard to fall asleep because they cannot stop thinking about things or because thoughts keep running through their mind. In instances such as these, family caregivers can be encouraged to do any of several activities, such as get out of bed and write down their thoughts (journaling); practice thinking about a quiet, comfortable, relaxing place (visual imagery); and repeat the same word over and over (eg, river) while concentrating on making their breathing the same length on inspiration as on exhalation (meditation). Any of these activities will help "quiet" the mind, allowing the caregivers to fall asleep faster.26 Incorporating relaxation techniques into the bedtime routine can condition the mind and body for sleep.
Healthy Sleep Routines
Sleep is a basic physiological need of all beings, and the body responds best if it is on a predictable schedule. Sleep is just one of many biological functions that are regulated by circadian rhythms. The hypothalamus acts as a biological clock to regulate the alteration between sleep and wake states as dictated by internal and external time cues. The light-dark cycle is the most important of these cues. Social interactions, work schedules, and meal times are other extrinsic time cues that contribute to regulating sleep-wake cycles. Internal time cues can also markedly affect sleep. For instance, the time to fall asleep is inversely related to the duration of the previous period of wakefulness. With prolonged sleep loss, an increase occurs in the drive to sleep. This drive to sleep can be overridden, resulting in a disruption of the sleep-wake cycle.15,17
Although most family caregivers want to stay at the hospital "all hours," it is important to encourage them to keep a regular sleep-wake schedule. Family caregivers should be encouraged to go home and sleep in their own beds.17 By reassuring a patient’s family members that they will be notified if any change occurs in the patient and allowing them access to their loved one whenever they are at the hospital, nurses give the family caregivers permission to focus on self-care.27
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A Prescription for Better Sleep
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Behavioral changes are difficult in the best of circumstances, and they may appear impossible when a person is experiencing severe stress. However, caregivers need to know that even the small behavioral techniques described here can dramatically improve the ability to achieve adequate sleep.28 Once the sleep evaluation questionnaire has been administered, it can be scored in the presence of the family caregiver. After problem areas are determined, using the suggestions for sleep promotion behaviors given in Table 1, a nurse can help the caregiver establish sleep goals.
In order to increase the chances for success, personal sleep improvement goals can be set by using goal attainment scaling, as described by Kiresuk et al.29 With goal attainment scaling, a person’s relative success in achieving goals that are individually determined and therefore different perhaps in actual content can be compared. The process involves identifying a goal that is realistic to achieve in a given time. This goal represents the zero point (Table 2), and it must be precise and measurable. Next, a somewhat-better-than-expected outcome is identified, and this outcome becomes the +1 point. A much-better-than-expected outcome becomes the +2 point, a somewhat-less-than-expected outcome becomes the –1 point, and a much-less-than-expected outcome becomes the –2 point. See Table 2 for sample goals. Goal attainment scaling is designed to be an intraindividual measurement method based on the individual’s uniqueness. The 5-point goal attainment scale is more sensitive to small changes than are more traditional dichotomous rating scales,30 and thus caregivers may be able to detect small, yet clinically important changes in the caregivers’ sleep adequacy.
A discussion about the importance of sleep and ways that a caregiver can improve his or her sleep adequacy should be part of this scoring and goal-setting process. Follow-up with the caregiver about his or her sleep adequacy is needed during the patient’s stay in the ICU and after discharge.
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Conclusion
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To be prepared to care for their family member at home and to decrease the risk for physical and emotional illness themselves, caregivers must receive adequate sleep while the patient is in the hospital. Getting adequate sleep is often easier said than done. Family caregivers often experience long-term sleep loss when their family member is receiving treatment in an ICU. The caregivers feel they must be at the bedside the entire time their family member is in the hospital. Critical care nurses need to work to change this perception. Caregivers should be advised to care for themselves, so they will be able to care for their family member when he or she is discharged. We provide nurses information they can use to help family caregivers obtain adequate sleep. Nurses at the bedside are in the best position to encourage family caregivers to practice sleep promotion activities, including reducing stimuli, promoting relaxation, and adopting healthy sleep routines.
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References
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