Continuing Nursing Education

Objectives and posttest can be found on page 72.

Patient and Parent Sleep

In a Children’s Hospital
Lisa J. Meltzer, Katherine Finn Davis, Jodi A. Mindell

C
omplaints of sleep problems
among hospitalized patients Although sleep complaints during pediatric hospitalization are common, few
are common; however, little studies have examined different aspects of sleep or the impact of pediatric hos-
research has focused on sleep pitalization on parent sleep. This study examined multiple aspects of sleep for 72
patterns, sleep quality, and causes of non-intensive care pediatric inpatients and 58 rooming-in parents who complet-
sleep disruptions in pediatric patients ed a self-report survey of sleep at home and in the hospital, and sleep distur-
and their parents. Because sleep is bances in the hospital. Younger children reported later bedtimes, later wake
linked to immune functioning and times, more night wakings, and shorter total sleep time while hospitalized.
healing in patients (Irwin et al., 1994, Adolescents had later wake times, more night wakings, and longer total sleep
1996; Moldofsky, 1995), as well as the time during hospitalization. Parents reported later bedtimes, later wake times,
mood and functioning of parents and more night wakings when rooming-in. Sleep was significantly disrupted dur-
(Diette et al., 2000; Meltzer & Mindell, ing hospitalization, more so for younger children and parents. Sleep disturbances
2006; Moore, David, Murray, Child, & due to noises, worries, pain, and vital sign checks were related to longer sleep
Arkwright, 2006), it is essential for onset latency, increased night wakings, and earlier wake time. Interventions that
nurses to optimize the sleep quality reduce these disruptions, many of which are amenable to nursing influence, are
and quantity of pediatric inpatients needed to improve child and parent sleep in hospital.
and their parents. Further, while sleep
may be disrupted due to pain, discom-
fort, or other sequelae of a child’s diag-
nosis, there are a number of addition- Literature Review cancer, but the sample size in this
al variables (including noise, light, study was small (N = 29). Together,
delayed bedtime, unfamiliar environ- Although a small number of studies these studies provide preliminary evi-
ment, homesickness) that may have have examined sleep in youth during dence for sleep problems (shortened
the potential to contribute to poor non-intensive care hospitalizations sleep duration, increased sleep disrup-
sleep (such as shortened total sleep and reported shortened sleep duration, tions) in hospitalized youth; however,
time, more sleep disruptions). increased night wakings, and greater each is limited by a restricted age
daytime fatigue, most of these studies range, small sample size, or poor
have been limited by methodology methodology (single-item questions,
(single-item question) and/or sample in-room observation of sleep).
Lisa J. Meltzer, PhD, was a Clinical
Psychologist, Sleep Center, Children’s (limited age range, single disease). As a construct, sleep cannot be
Hospital of Philadelphia, Philadelphia, PA, Hagemann (1981a, b) used an in- measured by a single dimension, but
and an Assistant Professor, Department of room observer in a small sample of rather, needs to include aspects of sleep
Pediatrics, University of Pennsylvania School young children (N = 34, 3 to 8 years) to patterns (bedtime, wake time), sleep
of Medicine, Philadelphia, PA, at the time this determine every five minutes if the continuity (frequency of night wak-
article was written. She is now an Assistant child was awake or asleep. White, ings and sleep duration), and causes of
Professor of Pediatrics, National Jewish Powell, Alexander, Williams, and sleep disruptions (pain, noise) (Meltzer
Health, Denver, CO. Conlon (1988) measured only self- & Davis, 2008). None of the studies
Katherine Finn Davis, PhD, RN, is a Nurse soothing bedtime behaviors related to reviewed here considered these three
Researcher, Center for Pediatric Nursing sleep onset latency, also in a small sam- dimensions together, yet each factor
Research and Evidence-Based Practice, ple of young children (N = 40, 3 to 8 (alone or in combination) can be relat-
Children’s Hospital of Philadelphia, Philadelphia, years). In a study of 27 youth with sick-
PA.
ed to negative daytime functioning,
le cell disease, Jacob and colleagues including fatigue, sleepiness, and poor
Jodi A. Mindell, PhD, is Associate Director of (2006) measured sleep with a single health.
the Sleep Center, Children’s Hospital of question (“How much sleep did you Nurses also need to consider the
Philadelphia, Philadelphia, PA, and Professor have last night?”) that relied on a 10-
of Psychology, Saint Joseph’s University,
parents’ sleep during a child’s hospital-
point Likert scale (“no sleep at all” to ization. Family-centered care has
Philadelphia, PA.
“slept a lot”). Finally, Franck and col- become the standard in pediatric nurs-
Statements of Disclosure: The authors leagues (2007) used three single-item ing, particularly during hospitalization
reported no actual or potential conflict of inter- questions to measure tiredness in the
est in relation to this continuing nursing edu-
when parents are typically present
morning, tiredness in the evening, and throughout their child’s hospital stay
cation activity.
sleep quality. Only Hinds and col- (American Academy of Pediatrics
The Pediatric Nursing journal Editorial Board leagues (2007) used a more compre- [AAP], 2003; Dudley & Carr, 2004;
reported no actual or potential conflict of inter- hensive approach (actigraphy, diary,
est in relation to this continuing nursing edu-
Stremler, Wong, & Parshuram, 2008).
entry checklist on door) to study sleep There are significant benefits of
cation activity.
during hospitalization in youth with parental presence not only for the hos-

64 PEDIATRIC NURSING/March-April 2012/Vol. 38/No. 2

pitalized child, but also for their par- from typical sleep at home. Variables the child was not feeling well enough
ents (such as decreased parent/child of interest included bedtime, sleep to complete the questionnaire. No sig-
stress and anxiety, and increased onset latency, night waking frequency, nificant differences were found
parental self-confidence in their par- wake time, and total sleep time. The between youth who did and did not
enting abilities and roles) (Smith, second aim of the study was to exam- participate in terms of age. Parents
Hefley, & Anand, 2007). It has become ine the differences in sleep continuity who roomed-in had younger children
standard practice to allow parents to variables for patients and parents who than parents who did not room-in the
stay at their child’s bedside overnight, experienced sleep disruptions in the previous night (12.7 vs. 15.1 years,
particularly on medical and surgical hospital. Although sleep was found to t(67) = -2.30, p = 0.02).
units (Stremler et al., 2008). Despite differ between adults hospitalized for A member of the research team
the known benefits of constant medical and surgical reasons (Tranmer, approached each patient and his or her
parental presence, little research has Minard, Fox, & Rebelo, 2003), no stud- parents/caregivers between 4:00 p.m.
focused on the impact of rooming-in ies have examined whether the reason and 8:00 p.m. to explain the study and
on parental sleep. for hospitalization (surgery, chronic ill- obtain informed consent and assent.
Only one study examined sleep in ness) is related to sleep in youth. In Participants were then given the Sleep
rooming-in parents of hospitalized addition, although studies have in a Children’s Hospital (SinCH) sur-
youth, reporting an average total sleep demonstrated a “first night effect” in a vey to complete. The timeframe was
time of only 4.6 hours (McCann, sleep laboratory (poor sleep due to selected for several reasons: 1) to
2008). Via an open-ended question, being uncomfortable in a new envi- ensure patients had been hospitalized
parents reported sleep disruptions due ronment) (Scholle et al., 2003), this at least 24 hours; 2) the hospital units
to noise from other children in the effect has been understudied in the tend to be quieter during these hours
room, medical equipment, or conver- pediatric literature. Thus, the third aim because most procedures and rounds
sations in the hallway, as well as an of this study was to examine the differ- are completed prior to this time; 3) by
uncomfortable sleeping arrangement ences in sleep based on the reason for requiring participants to complete the
(for example, a chair). The authors hospitalization, as well as whether or survey that evening, it was ensured
noted that the shortened total sleep not it was the child’s first night of hos- that participants were reporting on the
time is similar to that found in labora- pitalization. previous 24-hours (including the pre-
tory-based studies, resulting in nega- vious night of sleep, as well as sleep
tive changes to mood, performance, during the current day).
and physical well-being (Dinges et al.,
Methods
1997; Haack & Mullington, 2005). Measures
Each of these outcomes is important Participants and Procedure There were no existing measures of
for parents who are trying to provide Participants were drawn from a sleep patterns or sleep quality during
emotional and physical support to large (over 400 inpatient beds), tertiary pediatric hospitalization available for
their hospitalized child, as well as care children’s hospital in the mid- use; thus, the SinCH and the Sleep in a
make important decisions about their Atlantic region of the United States. Children’s Hospital – Parent Version
child’s medical care. Families were eligible to participate if (SinCH-P) surveys were created for this
A negative relationship between the child/adolescent was 1) 8 to 21 study using validated recall methodol-
sleep loss and daytime functioning years of age (inclusive), 2) had been ogy (Meltzer, Mindell, & Levandoski,
has been documented in parents of admitted to the hospital no later than 2007; Monk et al., 2003; Olds, Maher,
children with chronic illnesses (Diette 4:00 p.m. the previous day (ensuring at Blunden, & Matricciani, 2010). The
et al., 2000; Meltzer & Mindell, 2006; least 24 hours of hospitalization), 3) SinCH and SinCH-P are each a 75-item
Moore et al., 2006) but has not been did not have surgery in the previous 24 self-report measure of sleep (bedtime,
studied during times of hospitaliza- hours, and 4) did not have sedation for wake time, sleep onset latency) and
tion. Therefore, although parental a medical procedure (such as an MRI) sleep disturbances during hospitaliza-
presence during hospitalization is in the previous 24 hours. Parents of tion (noise, light, pain, vital sign
emotionally beneficial for the parent patients were eligible to participate if checks). Sleep questions were taken
and child, ultimately, parental health, 1) their child met the above criteria, from validated self-report measures of
well-being, and the ability to function and 2) the parent had stayed with the sleep in children and adolescents
as an advocate for the child may be child the previous night (roomed-in). (Meltzer & Davis, 2008; Wolfson &
negatively impacted (Dudley & Carr, Participation by both the patient and Carskadon, 1998; Wolfson et al., 2003)
2004; Hopia, Tomlinson, Paavilainen, the parent was not required (for exam- and adults (Meltzer et al., 2007). Sleep
& Astedt-Kurki, 2005). Thus, more ple, the adolescent participated but the disturbance questions were selected
information is needed about rooming- parent did not room-in the previous from two validated measures of sleep
in parents’ sleep during pediatric hos- night). for the hospitalized adult: the
pitalization. This study was approved by the Disturbances Due to Hospital Noises
hospital’s Institutional Review Board. Scale (Topf, 1985) and the Sleep in the
Parent written consent and youth ver- Intensive Care Unit Questionnaire
Study Objectives bal assent were obtained for all partici- (Freedman, Kotzer, & Schwab, 1999).
To address the gaps in the existing pants. During a one-week period, the These questions were modified as
literature related to sleep in pediatric charge nurse for each non-critical care needed for this population based on
patients and their parents during hos- inpatient unit in the hospital identi- the clinical experience of the research
pitalization, the goal of this study was fied potential participants using the team and a group of 15 youth who had
to capture multiple aspects of sleep for inclusion criteria described. Partici- chronic illnesses and a history of mul-
patients and parents during a night in pation rates were 78% for patients and tiple hospitalizations.
a children’s hospital. The first aim was 79% for parents. The two primary rea- Youth were given a preliminary ver-
to examine whether the previous sons given for not wanting to partici- sion of the SinCH survey. Feedback
night of sleep in the hospital differed pate included 1) not interested and 2) about content and question format

PEDIATRIC NURSING/March-April 2012/Vol. 38/No. 2 65

Patient and Parent Sleep in a Children’s Hospital

(including wording, length, and age Figure 1.

appropriateness) were integrated into Sample Items from the Sleep in a Children’s Hospital Survey
the final version. There are no summa-
ry scales (only descriptive self-report
A. Typical Sleep Questions – Weekday
information) provided by this survey,
so no psychometric data are provided. The next set of questions has to do with your usual schedule on days when you are
However, the face validity of this sur- at home and you go to school.
vey is appropriate for this type of
1. What time do you usually go to bed on school nights?
exploratory study, with the self-report- ____:____ PM AM
(List ONE time, not a range)
ed sleep patterns and sleep distur-
bances utilized in this measure a well- 2. Once you turn your light off on school nights, how long
established and accepted methodolo- _________ Minutes
does it usually take you to fall asleep?
gy. Similar scales with a similar
methodology of using 24-hour recall 3. After you have gone to sleep, how many times do you
_________ Times
of sleep patterns and sleep problems usually wake up during the night?
have been used in a variety of popula- 4. What time do you usually wake up on school days?
tions, including studies the authors ____:____ PM AM
(List ONE time, not a range)
conducted with children and adoles-
cents of similar ages (Meltzer & Davis, B. Sleep the Previous Night in Hospital
2008; Monk et al., 2003; Olds et al., Now we’d like to ask you about how you sleep while you are here in the hospital.
2010). Further, studies have demon- Please think back to LAST NIGHT when you answer these questions.
strated that children as young as 8
years of age can provide self-reported 1. What time did you try to fall asleep last night?
____:____ PM AM
health information, including sleep (List ONE time, not a range)
patterns and sleep disturbances 2. Once you turn your light off, about how long did it take
(Meltzer & Davis, 2008; Riley, 2004; _________ Minutes
you to fall asleep last night?
Varni, Limbers, & Burwinkle, 2007).
The surveys included the following 3. After you went to sleep last night, how many times did
_________ Times
sections: 1) demographic information, you wake up during the night?
2) typical sleep patterns on weekdays 4. What time did you wake up today?
and weekends at home, 3) sleep the ____:____ PM AM
(List ONE time, not a range)
previous night in the hospital, 4) nois-
es and worries that may have bothered C. Noises and Worries that May Have Bothered Participants the Previous Night
participants the previous night, and 5) Some kids find it hard to sleep in the hospital, while others do not. Please think about
specific sleep disruptors (such as LAST NIGHT when answering the following questions about things that may have
child’s pain, vital sign checks) that made it hard for you to fall asleep or stay asleep. Please circle one answer for each
may have disturbed sleep onset or question.
sleep maintenance (see Figure 1). Each
Last night, how bothered were you by the following noises…
child and parent participant complet-
ed the appropriate SinCH survey 1. People talking outside your room Not at all A little Somewhat A lot
reporting on his or her own sleep. The
SinCH was read aloud to children 8 to 2. Doors opening, closing, slamming Not at all A little Somewhat A lot
10 years of age, while children over 10 Last night, how bothered were you by the following…
years of age completed the SinCH
independently. It took approximately 1. Your bed was uncomfortable Not at all A little Somewhat A lot
15 minutes for participants to com- 2. Thoughts or worries about missing school Not at all A little Somewhat A lot
plete the survey.
D. Specific Sleep Disruptors that May Have Disturbed Sleep Onset or Sleep
Statistical Analyses Maintenance
Descriptive statistics (means, fre-
quencies) were used to describe the Last night, in the middle of the night, were you bothered by…
study sample. Reported sleep variables 1. Pain Yes No
included bedtime (time attempted to
fall asleep), sleep onset latency (SOL) 2. Noise in your room Yes No
(minutes to fall asleep at bedtime),
3. Nurse taking your temperature or blood pressure Yes No
night waking frequency, and wake
time. Total sleep time (TST) was calcu-
lated (time from bedtime to wake
time, less SOL). Because developmen- ries, and other causes of sleep disrup- Results
tal differences in sleep may be masked tions. T-tests were used to examine
by examining averages for the entire differences in sleep variables for
sample, paired t-tests were used to sep- patients and parents who did and did Sample Demographics
arately examine differences in sleep in not experience the most common The final sample included 72 chil-
hospital and sleep at home for school- sleep disruptors. Finally, analysis of dren and adolescents (50% female,
aged children (8 to 12 years; n = 33) covariance (controlling for age) was 68% Caucasian) ages 8 to 21 years
and adolescents (13 to 21 years; n = used to examine differences in sleep (mean = 13.1 years, SD = 3.1) and 58
39). Descriptive statistics were used to for both reason for hospitalization and parents who roomed in with their
report the most common noises, wor- first night effect. child the previous night (89% female,

66 PEDIATRIC NURSING/March-April 2012/Vol. 38/No. 2

 Table 1. The most common worries/dis-
Means, Standard Deviations, and Paired t-Test Results for Sleep in the comfort that were rated as bothering
Hospital and at Home participants “somewhat” or “a lot”
were being homesick (36% children,
Hospital Home 19% adolescents) or worrying about
Mean (SD) Mean (SD) t p ES other family members (42% parents),
Children (8 to 12 years) worries about why the child is in the
hospital (24% children, 25% adoles-
Bedtime 22:38 (98) 21:05 (46) 4.82 <0.001 1.22 cents, 59% parents), worries about
Wake time 7:32 (73) 6:49 (36) 2.87 0.02 0.74 missing school/work (30% children,
22% adolescents, 20% parents), and
Sleep onset latency (minutes) 24.1 (37.6) 18.9 (18.5) 0.80 0.43 0.18 an uncomfortable bed (15% children,
Night waking frequency 2.7 (1.7) 0.82 (1.0) 6.12 <0.001 1.35 22% adolescents, and 58% parents).
Total sleep time (minutes) 501.9 (102.4) 558.0 (52.1) 2.70 0.01 0.70 Finally, participants were asked
about specific sleep disruptors (such as
Adolescents (13 to 21 years) pain, vital sign checks, noises in the
Bedtime 22:49 (92) 22:32 (76) 1.12 0.27 0.20 room) that may have bothered them
specifically while trying to fall asleep
Wake time 7:42 (83) 6:32 (64) 4.19 <0.001 0.94 at bedtime or during the night, or that
Sleep onset latency (minutes) 25.7 (33.0) 24.5 (21.4) 0.18 0.86 0.04 caused early sleep termination in the
Night waking frequency 2.7 (2.2) 1.2 (1.6) 3.48 0.001 0.78 morning. No specific time periods
were given for bedtime and wake
Total sleep time (minutes) 515.3 (95.2) 460.3 (93.9) 2.54 0.02 0.58 time, but rather, participants were
Parents asked about disruptors that bothered
them when trying to fall asleep and
Bedtime 23:03 (83) 22:46 (66) 1.49 0.14 0.22 upon waking in the morning. For chil-
Wake time 6:38 (77) 6:17 (73) 1.86 0.07 0.28 dren, vital sign checks and pain were
Sleep onset latency (minutes) 23.0 (20.6) 17.7 (8.9) 1.41 0.16 0.33 most frequently identified as bother-
some at bedtime (vitals 39%, pain
Night waking frequency 4.7 (3.6) 2.0 (1.5) 5.53 <0.001 0.98 36%), during the night (vitals 46%,
Total sleep time (minutes) 427.9 (104.1) 428.2 (88.9) 0.02 0.98 0.003 pain 28%), and in the morning (vitals
39%, pain 23%). For adolescents, vital
Note: Bedtime and wake time expressed by 24-hour clock; SD expressed in minutes. sign checks and pain were also the
Effect size is Cohen’s d. most frequently identified disruptors
at bedtime (vitals 57%, pain 51%) and
during the night (vitals 60%, pain
78% Caucasian; mean age = 41.9, SD It is notable that children reported 40%). In the morning, adolescents
7.1; 48% high school/some college, sleeping almost one hour less in hos- were bothered by vital sign checks
50% college degree or higher). Forty- pital. Adolescents (13 to 21 years of (55%) and noise in the room (45%).
nine percent of youth were in the hos- age) reported a later wake time, more For parents, vital sign checks for the
pital due to a chronic illness that night wakings, and longer TST in the child and the child’s pain were again
required treatment (such as asthma, hospital compared to at home. As the most frequently endorsed as both-
cancer, cystic fibrosis, sickle cell dis- opposed to children, it is notable that ering sleep at bedtime (vitals 41%,
ease), and 21% were in the hospital for adolescents slept 55 minutes more in pain 41%) and during the night (vitals
surgery. Other reasons for hospitaliza- hospital. Parents reported a slightly 45%, pain 37%). In the morning, par-
tion included medical tests, infections, later wake time and significantly more ent sleep was most commonly both-
flu, stomach pain/virus, and blood night wakings during the previous ered by vital sign checks for the child
transfusion. This was the first hospital- night in hospital. (46%) and noises in the room (35%).
ization for 36% of the youth, with the Because sleep disruptions at these
median length of hospitalization of 3 Sleep Disruptions in Hospital specific time periods would likely be
days (range 1 to 150 days). Thirteen Three types of sleep disruptors were associated with sleep continuity vari-
children (18%) reported taking a med- examined: noises, worries/discomfort, ables, t-tests were used to compare
ication to help them sleep the previ- and hospital specific variables (pain, sleep onset latency at bedtime, night
ous night during hospitalization vital sign checks). “Alarms beeping on waking frequency during the night,
(including diphenhydramine, benzo- medical equipment” was rated as and morning wake time between par-
diazepines, zolpidem, and morphine) bothering 42% of children, 33% of ticipants who endorsed specific sleep
compared to 2 children (3%) who adolescents, and 66% of parents disruptions and participants who did
took a medication to help them sleep “somewhat” or “a lot.” This was fol- not endorse these sleep disruptions. As
at home. lowed by “doors opening, closing, outlined in Table 2, children who
slamming” (21% children, 22% ado- reported pain at bedtime had a signif-
Sleep at Home and in Hospital lescents, 29% parents), and “people icantly longer sleep onset latency.
Sleep variables at home and during talking outside your room” (18% chil- Moderate to large effect sizes were
the previous night in hospital can be dren, 19% adolescents, 23% parents). found for adolescents during the
found in Table 1. Compared to typical For patients with a roommate (43%), night, with more night wakings
weekday sleep at home, children (8 to “roommate making noise (snoring, reported by adolescents whose sleep
12 years of age) reported a later bed- moaning)” was disruptive for 20% of was bothered by pain, vital sign
time, later wake time, more night wak- children, 23% of adolescents, and checks, or noise in the room. In addi-
ings, and shorter TST in the hospital. 35% of parents. tion, adolescents whose sleep was

PEDIATRIC NURSING/March-April 2012/Vol. 38/No. 2 67

Patient and Parent Sleep in a Children’s Hospital

Table 2. bothered by vital sign checks in the

Means, Standard Deviations, and Paired t-Test Results for Sleep morning had an earlier wake time
Disruptions and Sleep Variables (large effect size). Parents whose sleep
was bothered by noise in the room
Pain Mean (SD) reported a significantly longer sleep
onset latency and significantly more
Yes No t ES
night wakings (large effect sizes).
Sleep Onset Latency (Minutes)
Child 44.3 (56.5) 12.5 (11.0) 2.41a 0.91
Additional Factors Related
To Sleep in Hospital
Adolescent 22.4 (18.1) 30.7 (44.5) -0.70 0.25 One way ANCOVA (controlling for
Parent 23.3 (25.1) 23.4 (18.3) -0.01 0.00 age) was used to examine sleep differ-
Night Waking Frequency ences between groups for reason for
hospitalization and first night effects
Child 3.2 (2.1) 2.5 (1.6) 1.02 0.40 (see Table 3). Significant differences
Adolescent 3.5 (1.7) 2.4 (2.4) 1.58 0.53 for bedtime during hospitalization
were found, with youth who had sur-
Parent 4.6 (2.3) 4.8 (4.1) -0.20 0.06 gery reporting an earlier bedtime than
Wake Time the other two groups. Although not
Child 7:55 (1:51) 7:31 (1:03) 0.69 0.32 significant, youth who had surgery
also reported an earlier wake time (29
Adolescent 7:33 (1:41) 7:54 (1:19) -0.60 0.25 to 48 minutes). First-night patients
Parent 6:52 (1:25) 6:36 (1:18) 0.46 0.20 had a later bedtime (55 minutes), ear-
lier wake time (47 minutes), and sig-
Vital Sign Checks Mean (SD)
nificantly shorter total sleep time (85
Yes No t ES minutes).
Sleep Onset Latency (Minutes)
Child 19.1 (17.6) 27.1 (45.7) -0.55 0.21 Discussion and Clinical
Adolescent 22.8 (18.0) 31.3 (47.5) -0.71 0.25 Implications
Parent 25.1 (20.4) 20.7 (20.3) 0.75 0.22 This study is one of the first to pro-
vide information about multiple
Night Waking Frequency aspects of sleep for non-intensive care
Child 2.7 (1.2) 2.7 (2.1) 0.02 0.01 pediatric patients and rooming-in par-
Adolescent 3.6 (2.3) 1.8 (1.6) 2.54a 0.87 ents in a children’s hospital. In addi-
tion, the study contributes to the
Parent 4.8 (3.8) 4.7 (3.6) 0.11 0.03 existing literature by including sam-
Wake Time ples of both school-aged children and
adolescents, medical and surgical
Child 7:53 (1:33) 7:20 (0:56) 1.24 0.46
patients, and rooming-in parents.
Adolescent 7:23 (1:16) 8:22 (1:21) -2.26a 0.75 Furthermore, unlike previous studies
Parent 6:39 (1:21) 6:37 (1:18) 0.11 0.03 that have relied on a single question
or in-room observation to measure
Noise in Room Mean (SD) sleep or fatigue in the hospital, this
Yes No t ES study looked at sleep pattern variables
in the hospital and at home, multiple
Sleep Onset Latency (Minutes) causes of sleep disruptions, and the
Child 30.8 (30.8) 22.7 (38.0) 0.45 0.21 differences in sleep continuity vari-
Adolescent 30.3 (21.1) 24.2 (37.9) 0.49 0.18 ables based on reported sleep disrup-
tions during hospitalization.
c
Parent 35.9 (23.9) 15.5 (14.3) 3.73 1.09 Results showed that the surveyed
Night Waking Frequency night of sleep during hospitalization
differed from typical sleep at home,
Child 3.7 (2.7) 2.5 (1.4) 1.51 0.68
with school-aged children reporting
Adolescent 3.5 (1.4) 2.6 (2.4) 1.04 0.41 later bedtimes and shorter total sleep
Parent 6.3 (4.9) 3.5 (1.5) 2.97 b
0.82 time in the hospital, while adolescents
had a later wake time and longer total
Wake Time sleep time in the hospital. This devel-
Child 7:05 (0:12) 7:31 (1:10) -0.90 0.41 opmental difference is striking, with
school-aged children getting 56 min-
Adolescent 7:30 (1:32) 8:05 (1:12) -1.30 0.43
utes less sleep in the hospital and ado-
Parent 6:24 (1:14) 6:49 (1:20) -1.14 0.32 lescents 55 minutes more sleep in the
a
p < 0.05 hospital. Adolescents getting more
b
p < 0.01 sleep during hospitalization may be a
c
p < 0.001 result of chronic partial sleep depriva-
tion, with the teens averaging just 7.7
Note: Wake time expressed by 24-hour clock; SD expressed in minutes. Effect size (ES) hours per night at home. Parents also
is Cohen’s d.

68 PEDIATRIC NURSING/March-April 2012/Vol. 38/No. 2

 Table 3
Means, Standard Deviations, and Analysis of Covariance Results for Sleep and
Reason for Hospitalization and First Night Effect (Controlling for Age)

Chronic Illness Surgery Other Partial ETA

Reason for Hospitalization (n = 35) Mean (SD) (n = 14) Mean (SD) (n = 22) Mean (SD) F p Squared
Bedtime 23:09 (1:47) 21:52 (1:11) 22:40 (1:06) 3.91 0.03 0.11
Wake time 7:55 (1:27) 7:07 (1:09) 7:38 (1:07) 2.16 0.12 0.06
Sleep onset latency (minutes) 23.7 (32.4) 26.4 (32.8) 26.4 (41.4) 0.04 0.96 0.001
Night waking frequency 2.7 (2.3) 3.4 (2.0) 2.5 (1.3) 0.82 0.45 0.02
Total sleep time (minutes) 507.8 (103.3) 533.1 (85.0) 497.7 (95.1) 0.51 0.60 0.02
First Night (n = 13) Not First Night (n = 55) Partial ETA
Night of Hospitalization Mean (SD) Mean (SD) F p Squared
Bedtime 23:30 (1:27) 22:35 (1:32) 3.73 0.06 0.05
Wake time 7:00 (1:02) 7:47 (1:19) 3.64 0.05 0.05
Sleep onset latency (minutes) 21.3 (21.1) 25.8 (37.1) 0.15 0.70 0.003
Night waking frequency 3.0 (2.9) 2.7 (1.7) 0.19 0.67 0.003
Total sleep time (minutes) 438.7 (80.3) 523.6 (94.1) 7.85 0.007 0.11

Note: Bedtime and wake time expressed by 24-hour clock; SD expressed in minutes.

reported more night wakings and examined the role of cognitions in sleep evening to diminish homesickness)
poorer sleep quality while rooming-in disruptions during hospitalization, but and support/education for parents to
with their child than at home. the findings from this study suggest reduce stress and improve sleep would
Specific noises, including alarms on that thoughts and worries may be asso- be valuable.
medical equipment and doors opening ciated with disrupted sleep. Approxi- Vital sign checks and pain were
and closing, were identified as bother- mately 20% to 30% of the hospitalized commonly identified as sleep disrup-
some for a number of patients and par- youth reported being homesick, worry- tors and were found to be associated
ents in the hospital. These findings are ing about missing school, and worrying with sleep continuity variables.
similar to studies of medical and surgi- about being sick/hospitalized as disrup- Although vital sign checks and pain
cal hospitalized adults, as well as pedi- tive to their sleep. Nurses should are an unfortunate consequence of
atric ICU and oncology patients encourage visits and phone calls from pediatric hospitalization, when med-
(Cureton-Lane & Fontaine, 1997; family, friends, and teachers to help ically appropriate, it would be benefi-
Hinds et al., 2007; Topf, 1985; Topf & lessen homesickness and worries about cial for health care teams to work with
Thompson, 2001; Tranmer et al., school. For parents, sleep disruptions families to manage these concerns. For
2003). Laboratory-based studies have due to cognitive worries were consistent example, nurses should advocate for
demonstrated that simulated noises with a previous study that found stress less frequent vital sign checks for med-
during sleep are related to negative related to the child’s health was as dis- ically stable patients (every six to eight
self-reported sleep quality and daytime ruptive to sleep as nighttime caregiving hours instead of every four hours).
performance (Marks & Griefahn, 2007; in mothers of children with chronic ill- This would reduce night waking fre-
Schapkin, Falkenstein, Marks, & nesses (Meltzer & Mindell, 2006). quency and prolong sleep opportunity
Griefahn, 2006). Being the largest con- Therefore, nurses should identify par- in the morning, resulting in increased
tingent of care providers, it is impor- ents whose coping may be negatively sleep duration for patients and par-
tant for nurses to work toward noise impacted by disrupted or insufficient ents. Similar recommendations have
reduction on inpatient pediatric floors. sleep, referring them to an appropriate been made by Hinds and colleagues
For example, unit noise could be psychosocial care provider for brief (2007) in their study of youth with
reduced with policies that include interventions to address thoughts and cancer. In addition, a study of flexible
“quiet zones” outside patient rooms worries that may interfere with sleep medication times suggested that shift-
and at the typically boisterous nurses’ onset or sleep maintenance. Further, as ing administration times to follow the
station, encouraging bedside report, part of family-centered care, health care normal medication regimen of
and using slow release mechanisms on team members can work to facilitate patients allows for longer sleep, espe-
doors. Equipment alarms can be antic- timely and appropriate communication cially in the morning (Jarman, Jacobs,
ipated and intercepted while alarm with parents regarding their hospital- Walter, Witney, & Zielinski, 2002).
volumes can be adjusted lower (or to ized child’s current health status and Further, pain and sleep have a bidirec-
silent, if appropriate) during rest times test results. Such access to patient infor- tional relationship, with pain disrupt-
and at nighttime. Noisy pagers can be mation has the potential to lessen some ing sleep, and sleep loss exacerbating a
set to vibrate. Along with reducing of the worries parents experience patient’s pain (Lewin & Dahl, 1999;
noise, clustering care to reduce inter- (Hopia et al., 2005). Research investigat- Raymond, Nielsen, Lavigne, Manzini,
ruptions and dimmed lights at night ing the effectiveness of these potential & Choiniere, 2001). Nurses should
may have a synergistic effect in creat- interventions on sleep, including advocate for increased pain manage-
ing a calm, restful environment. behavioral strategies (such as the use of ment when needed to achieve ade-
Previous studies in youth have not child life activities for distraction in the quate sleep. Careful attention to both

PEDIATRIC NURSING/March-April 2012/Vol. 38/No. 2 69

Patient and Parent Sleep in a Children’s Hospital

pharmacological and behavioral pain studies of sleep in hospitalized youth, Closs, S.J. (1988). Assessment of sleep in
management by nurses and the psy- this was a cross-sectional study that hospital patients: A review of methods.
chosocial team (regarding relaxation only captured one night of hospital Journal of Advanced Nursing, 13, 501-
strategies, cognitive distraction) may sleep. Future studies should not only 510.
Cureton-Lane, R.A., & Fontaine, D.K. (1997).
also contribute to improved sleep. examine sleep patterns over several Sleep in the pediatric ICU: An empirical
Finally, more than half of the consecutive nights, but also sleep pat- investigation. American Journal of
study’s sample of parents reported terns post-discharge. A longitudinal Critical Care, 6, 56-63.
that an uncomfortable bed disrupted design would allow for a more in- Diette, G.B., Markson, L., Skinner, E.A.,
their sleep, similar to previous reports depth examination of illness factors Nguyen, T.T., Algatt-Bergstrom, P., &
(Dudley & Carr, 2004; McCann, 2008). related to child and parent sleep qual- Wu, A.W. (2000). Nocturnal asthma in
Thus, it is important to provide room- ity. Second, all data were self-report children affects school attendance,
ing-in parents a comfortable bed for with no objective measures of sleep school performance, and parents’ work
sleeping. Nurses can also assure that patterns or sleep disruptions. Future attendance. Archives of Pediatrics and
Adolescent Medicine, 154, 923-928.
small comforts, such as adequate pil- studies should use multi-method, Dinges, D.F., Pack, F., Williams, K., Gillen,
lows, blankets, and sheets, are avail- multi-reporter measurement (includ- K.A., Powell, J.W., Ott, G.E., …. Pack, A.
able to parents. Whenever possible, in ing actigraphy as an objective measure (1997). Cumulative sleepiness, mood
2-parent families, parents should be of sleep patterns); door-checklists to disturbance, and psychomotor vigilance
encouraged to alternate nights of track the frequency and timing of peo- performance decrements during a week
rooming-in so one parent can be at ple who enter the patient’s room dur- of sleep restricted to 4-5 hours per night.
home in a familiar sleeping environ- ing the night; and light and sound Sleep, 20, 267.
ment. For prolonged hospitalizations, meters that identify potential sleep Dudley, S.K., & Carr, J.M. (2004). Vigilance:
parents should be encouraged to have disruptions (Closs, 1988; Hinds et al., The experience of parents staying at the
bedside of hospitalized children. Journal
at least one night per week in a quieter 2007; Topf & Thompson, 2001). of Pediatric Nursing, 19, 267-275.
and often more comfortable sleep Third, this study was conducted in a Franck, L.S., Kools, S., Kennedy, C., Kong,
environment (for example, the Ronald large tertiary academic children’s hos- S.K., Chen, J.L., & Wong, T.K. (2004).
McDonald House). pital, limiting the generalizability of The symptom experience of hospitalised
Several areas not considered in this findings to smaller children’s hospitals Chinese children and adolescents and
study were related to rooming-in par- or pediatric units housed within an relationship to pre-hospital factors and
ents. First, parents often provide adult hospital. behaviour problems. International
nighttime care and assistance to their Journal of Nursing Studies, 41, 661-669.
child. Several studies have shown that Freedman, N.S., Kotzer, N., & Schwab, R.J.
most rooming-in parents are not only
Conclusion (1999). Patient perception of sleep qual-
ity and etiology of sleep disruption in the
vigilant, but want to be involved in Nurses are well positioned to influ- intensive care unit. American Journal of
their child’s medical care during the ence many of the sleep disruptors Respiratory and Critical Care Medicine,
night (Balling & McCubbin, 2001; identified in this study through small 159, 1155-1162.
Dudley & Carr, 2004; McCann, 2008). changes in practice and advocacy for Haack, M., & Mullington, J.M. (2005).
Hospital staff may also expect that the patient and family. In addition, Sustained sleep restriction reduces
parents will provide care throughout identifying families who are experi- emotional and physical well-being. Pain,
the night (Stremler et al., 2008). Such encing sleep disruptions due to wor- 119, 56-64.
nighttime care has the potential to Hagemann, V. (1981a). Night sleep of children
ries and working with the psychoso- in a hospital. Part I: Sleep duration.
further disrupt parents’ sleep; there- cial team may result in significant Maternal-Child Nursing Journal, 10, 1-
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to create a plan that takes into consid- tors at little to no cost in time or Hagemann, V. (1981b). Night sleep of children
eration the parent’s need for sleep and money. Overall, this study demon- in a hospital. Part II: Sleep disruption.
the child’s need for support and care strates the need for additional research Maternal-Child Nursing Journal, 10,
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insufficient sleep, but they are also References natural killer cell activity in humans.
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70 PEDIATRIC NURSING/March-April 2012/Vol. 38/No. 2

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