The Open Nursing Journal




ISSN: 1874-4346 ― Volume 14, 2020
RESEARCH ARTICLE

Night-time Noise Levels and Patients’ Sleep Experiences in a Medical Assessment Unit in Northern England



Felicity Astin1, 2, *, John Stephenson1, Jonathan Wakefield1, Ben Evans1, Priyanka Rob1, Garside Joanna1, Emma Harris1
1 School of Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield, UK
2 Department of Research, Huddersfield Royal Infirmary, Acre Street, Huddersfield, UK

Abstract

Background:

Hospital in-patients need sleep so that restorative process and healing can take place. However, over one third of in-patients experience sleep disturbance, often caused by noise. This can compromise patients’ perceptions of care quality and cause physical and psychological ill health.

Aims:

To assess 1) in-patients sleep quality, quantity, reported sources of sleep disturbance and their suggestions for improvement 2) objectively measure decibel levels recorded at night.

Methods:

This descriptive study conducted in a Medical Assessment Unit used multi-methods; a semi-structured ‘sleep experience’ questionnaire administered to a purposive sample of in-patients; recording of night-time noise levels, on 52 consecutive nights, using two calibrated Casella sound level meters.

Results:

Patient ratings of ‘in-hospital’ sleep quantity (3.25; 2.72 SD) and quality (2.91; 2.56 SD) was poorer compared to ‘home’ sleep quantity (5.07; 2.81 SD) and quality (5.52; 2.79 SD). The difference in sleep quality (p<0.001) and quantity (p<0.001) ratings whilst in hospital, compared to at home, was statistically significant. Care processes, noise from other patients and the built environment were common sources of sleep disturbance. Participants’ suggestions for improvement were similar to interventions identified in current research. The constant noise level ranged from 38-57 decibels (equivalent to an office environment), whilst peak levels reached a maximum of 116 decibels, (equivalent to banging a car door one metre away).

Conclusion:

The self-rated patient sleep experience was significantly poorer in hospital, compared to home. Noise at night contributed to sleep disturbance. Decibel levels were equivalent to those reported in other international studies. Data informed the development of a ‘Sleep Smart’ toolkit designed to improve the in-patient sleep experience.

Keywords: Hospitals, Noise, Sleep hygiene, Nursing care, Patient-centered care, Patient satisfaction, Physical environment.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 80
Last Page: 91
Publisher Id: TONURSJ-14-80
DOI: 10.2174/1874434602014010080

Article History:

Received Date: 28/01/2020
Revision Received Date: 25/04/2020
Acceptance Date: 07/05/2020
Electronic publication date: 18/06/2020
Collection year: 2020

© 2020 Astin et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Correspondence: Address correspondence to this author at the School of Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield, UK;
Tel: 07850684065; E-mails: F.Astin@hud.ac.uk, Felicity.Astin@cht.nhs.uk






1. INTRODUCTION

The quality of the physical environment in which care takes place is important because it contributes to patient safety and well-being [1Devlin AS, Arneill AB. Health Care Environments and Patient Outcomes:A Review of the Literature. Environ Behav 2003; 35(5): 665-94.
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]. Florence Nightingale highlighted the importance of a healing environment for hospital patients in her Environment Theory [2Nightingale F. Notes on Nursing: What it is and What it is Not 1860.]. She drew attention to several important environmental factors that cause patient distress and delay recovery, including unwanted noise [2Nightingale F. Notes on Nursing: What it is and What it is Not 1860.]. Positive patient care experience is an important indicator of high-quality health care [3Department of Health. The Government’s mandate to NHS England for 2018-19 2018.]. However, the physical characteristics and milieu of the hospital setting make it a challenge to create a healing environment that promotes patient comfort and well-being [4Huisman ERCM, Morales E, van Hoof J, Kort HSM. Healing environment: A review of the impact of physical environmental factors on users. Build Environ 2012; 58: 70-80.
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].

Hospital in-patients are particularly in need of sleep for its restorative and healing properties, but 30-60% of in-patients experience sleep disturbance [5Dogan O, Ertekin S, Dogan S. Sleep quality in hospitalized patients. J Clin Nurs 2005; 14(1): 107-13.
[http://dx.doi.org/10.1111/j.1365-2702.2004.01011.x] [PMID: 15656855]
-8Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med 2012; 172(1): 68-70.
[http://dx.doi.org/10.1001/archinternmed.2011.603] [PMID: 22232151]
]. Studies show that in-patients experience dynamic changes in their sleeping patterns that can lead to sleep disruption and sleep deprivation [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
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[http://dx.doi.org/10.1097/00004650-200511000-00006] [PMID: 16269944]
]. Sleep has an important biological function and is essential for good health. However, the prevalence of sleep insufficiency has led to its recognition as a public health epidemic [12Chattu VK, Sakhamuri SM, Kumar R, Spence DW, BaHammam AS, Pandi-Perumal SR. Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease? Sleep Sci 2018; 11(2): 56-64.
[http://dx.doi.org/10.5935/1984-0063.20180013] [PMID: 30083291]
]. Poor sleep is known to have a negative effect on all physiological systems; leading to abnormal emotional processing, reduced immune function, delayed wound healing and an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke [13Alvarez GG, Ayas NT. The impact of daily sleep duration on health: a review of the literature. Prog Cardiovasc Nurs 2004; 19(2): 56-9.
[http://dx.doi.org/10.1111/j.0889-7204.2004.02422.x] [PMID: 15133379]
-17NHS Confederation. Key Statistics on the NHS nhsconfedorg 2016.]. Poor sleep is also associated with delirium [18Watson PL, Ceriana P, Fanfulla F. Delirium: is sleep important? Best Pract Res Clin Anaesthesiol 2012; 26(3): 355-66.
[http://dx.doi.org/10.1016/j.bpa.2012.08.005] [PMID: 23040286]
] and is an independent risk factor for falls [19Wu L, Sun D. Sleep duration and falls: A systemic review and meta-analysis of observational studies. J Sleep Res 2017; 26(3): 293-301.
[http://dx.doi.org/10.1111/jsr.12505] [PMID: 28220576]
]. Disruption to sleep patterns following hospitalisation can persist for up to a year after discharge to home [20Altman MT, Knauert MP, Pisani MA. Sleep Disturbance after Hospitalization and Critical Illness: A Systematic Review. Ann Am Thorac Soc 2017; 14(9): 1457-68.
[http://dx.doi.org/10.1513/AnnalsATS.201702-148SR] [PMID: 28644698]
]. At its most extreme, sleep deprivation is a form of torture [21Goldfeld AE, Mollica RF, Pesavento BH, Faraone SV. The physical and psychological sequelae of torture. Symptomatology and diagnosis. JAMA 1988; 259(18): 2725-9.
[http://dx.doi.org/10.1001/jama.1988.03720180051032] [PMID: 3282086]
]. Sleep quality is a rather neglected aspect of patient care and is typically underreported by health professionals, despite being an important factor contributing to optimal health and wellness [18Watson PL, Ceriana P, Fanfulla F. Delirium: is sleep important? Best Pract Res Clin Anaesthesiol 2012; 26(3): 355-66.
[http://dx.doi.org/10.1016/j.bpa.2012.08.005] [PMID: 23040286]
].

Several factors cause sleep disturbances and sleep disruption for hospital in-patients, but noise, defined as ‘unwanted sound’ [22Stansfeld SA. Noise, noise sensitivity and psychiatric disorder: epidemiological and psychophysiological studies. Psychol Med Monogr Suppl 1992; 22: 1-44.
[http://dx.doi.org/10.1017/S0264180100001119] [PMID: 1343357]
], is one of the most common causes [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
, 23Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in hospitalized medical patients, part 2: behavioral and pharmacological management of sleep disturbances. J Hosp Med 2009; 4(1): 50-9.
[http://dx.doi.org/10.1002/jhm.397] [PMID: 19140196]
, 24DuBose JR, Hadi K. Improving inpatient environments to support patient sleep. International journal for quality in health care : journal of the International Society for Quality in Health Care 2016; 28(5): 540-3.
[http://dx.doi.org/10.1093/intqhc/mzw079]
]. The problem of unwanted night-time noise in hospitals is both widespread and significant, as over 17 million people are admitted to hospital each year in England alone [25Baker C. NHS Key Statistics: England 2019. Available from: https://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7281]. Results from a UK patient experience survey, with a sample of over 70,000 respondents, indicate that 39% of patients reported being disturbed by noise from other patients and 20% by noise from the hospital staff [26Care Quality Commission. 2019.Adult Inpatient Survey: Statistical release Newcastle Upon Tyne: Care Quality Commission; Available from: https://www.cqc.org.uk/publications/surveys/adult-inpatient-survey-2018]. Similar survey data collected from patients across America show that over 40% of the respondents reported noise around their bed space at night [27Quick M, Chantarat T, Norris A, Moscovice I. Patients’ Experiences in CAHs: HCAHPS Results, 2017 2019.http://www.flexmonitoring.org/wp-content/uploads/2018/12/HCAHPS-National-Summary-Report-CY-2017-Data.pdf]. Unwanted noise in the workplace also has a negative impact on staff and can lead to lapses in concentration and at worst, burnout [28Horsten S, Reinke L, Absalom AR, Tulleken JE. Systematic review of the effects of intensive-care-unit noise on sleep of healthy subjectsA and the critically ill. Br J Anaesth 2018; 120(3): 443-52.
[http://dx.doi.org/10.1016/j.bja.2017.09.006] [PMID: 29452801]
].

To understand how we can improve in-patient sleep, it is important to understand the patients’ perspective about their sleep experience, identify sources of disturbance, and accurately measure noise levels in the ward environment. Several studies have measured noise levels in critical care and operating theatre settings, but less is known about the soundscape of general wards [29Delaney LJ. Behavioral modification of healthcare professionals in an adult critical care unit to reduce nocturnal noise: An evidence based implementation project. JBI Database Syst Rev Implement Reports 2014; 12(7): 505-20.
[http://dx.doi.org/10.11124/jbisrir-2014-1647]
]. Of the few published studies conducted on wards, common sources of noise at night reported by patients were staff conversations, other patients, alarms and ward equipment [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
, 8Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med 2012; 172(1): 68-70.
[http://dx.doi.org/10.1001/archinternmed.2011.603] [PMID: 22232151]
, 30Shield B, Shiers N, Glanville R. The acoustic environment of inpatient hospital wards in the United Kingdom. J Acoust Soc Am 2016; 140(3): 2213-24.
[http://dx.doi.org/10.1121/1.4962276] [PMID: 27914398]
]. The World Health Organisation (WHO) has published guidelines for acceptable levels of environmental noise in hospital wards; a maximum sound level (LAmax) of 40 A-weighted decibels (dBA) and an equivalent continuous sound level (LAeq) of 30 dBA, overnight [31World Health Organisation. Guidelines for Community Noise 1999. Available from: https://apps.who.int/iris/handle/10665/66217]. International studies have reported that noise levels in hospitals have increased over the past 50 years and frequently exceed WHO recommendations by approximately 20-40 dBA [32Basner M, McGuire S. WHO Environmental Noise Guidelines for the European Region: A Systematic Review on Environmental Noise and Effects on Sleep. Int J Environ Res Public Health 2018; 15(3)E519
[http://dx.doi.org/10.3390/ijerph15030519] [PMID: 29538344]
, 33Busch-Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am 2005; 118(6): 3629-45.
[http://dx.doi.org/10.1121/1.2118327] [PMID: 16419808]
]. It is readily apparent that the problem of unwanted noise at night is not new [34Hurst TW. Is noise important in hospitals? Int J Nurs Stud 1966; 3(3): 125-35.
[http://dx.doi.org/10.1016/0020-7489(66)90023-X]
] despite it being a ubiquitous problem that impacts negatively on care quality and patients’ health and well-being. Additional research is required to understand in-patients’ experiences of sleep and the factors that cause sleep disturbance, including environmental noise. Little research has been conducted in ward settings, but existing evidence reports that noise reduction interventions are feasible and have the potential to improve patients’ sleep experiences [35Garside J, Stephenson J, Curtis H, Morrell M, Dearnley C, Astin F. Are noise reduction interventions effective in adult ward settings? A systematic review and meta analysis. Appl Nurs Res 2018; 44: 6-17.
[http://dx.doi.org/10.1016/j.apnr.2018.08.004] [PMID: 30389061]
]. Successful interventions may have the potential to mediate improved patient outcomes, shorten hospitalisations and improve the working environment for staff.

The aim of this multi-methods study, conducted on a Medical Assessment Unit, was to evaluate patient self-report questionnaire data (self-reported sleep quality/quantity at home and in-hospital, sources of in-hospital sleep-disturbance) and measure night-time noise levels.

2. MATERIAL AND METHODS

2.1. Study Design

A multi-methods study design was chosen to address the research aims. This was an appropriate design as we aimed to objectively measure noise levels in a Medical Assessment Unit and explore patients’ subjective sleep experiences and ideas for improvement using a brief researcher generated questionnaire.

2.2. Setting and Participants

We recruited a purposive sample of patients consecutively admitted to the Medical Assessment Unit (24 beds) of a district general hospital in Northern England. All eligible adult patients (≥18 years) admitted to the Medical Assessment Unit, for a minimum of one night, were invited to participate providing they were clinically stable, gave consent, and were able to communicate in English. Those participants who were completely deaf, or diagnosed with a sleep disorder were excluded. We aimed to recruit a sample of 150 participants, which is comparable to other similar studies [5Dogan O, Ertekin S, Dogan S. Sleep quality in hospitalized patients. J Clin Nurs 2005; 14(1): 107-13.
[http://dx.doi.org/10.1111/j.1365-2702.2004.01011.x] [PMID: 15656855]
, 8Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med 2012; 172(1): 68-70.
[http://dx.doi.org/10.1001/archinternmed.2011.603] [PMID: 22232151]
, 36Park MJ, Yoo JH, Cho BW, Kim KT, Jeong WC, Ha M. Noise in hospital rooms and sleep disturbance in hospitalized medical patients. Environmental health and toxicology [Internet] 2014; 29: e2014006.
[http://dx.doi.org/10.5620/eht.2014.29.e2014006]
].

2.3. Data Collection

The collection of the patient survey data and measurement of environmental noise levels took place in two concurrent phases, between September and November 2016, following ethical approval.

2.3.1. Phase 1. Development and administration of a brief ‘Sleep Experience Questionnaire’ (SEQ)

Several aspects of sleep can be evaluated. International recommendations tend to focus upon sleep quantity and recommend that adults aim for 7-8 hours of sleep to support healthy ageing [37Watson NF, Badr MS, Belenky G, et al. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep (Basel) 2015; 38(6): 843-4.
[http://dx.doi.org/10.5665/sleep.4716] [PMID: 26039963]
]. For the purpose of this study, we chose to ask in-patients about sleep quantity and quality as both are important. We defined ‘sleep quantity’ as the total sleep time in hours, and ‘sleep quality’ as the subjective assessment of how refreshed and rested an individual felt after sleep [38Hoey LM, Fulbrook P, Douglas JA. Sleep assessment of hospitalised patients: a literature review. Int J Nurs Stud 2014; 51(9): 1281-8.
[http://dx.doi.org/10.1016/j.ijnurstu.2014.02.001] [PMID: 24636444]
]. A scoping review of available measures to assess patient sleep patterns identified the Richards-Campbell Sleep Questionnaire (RCSQ) as a potential measure [39Richards KC, O’Sullivan PS, Phillips RL. Measurement of sleep in critically ill patients. J Nurs Meas 2000; 8(2): 131-44.
[http://dx.doi.org/10.1891/1061-3749.8.2.131] [PMID: 11227580]
]. However, the RCSQ had some limitations as it was validated for use in critical care settings [38Hoey LM, Fulbrook P, Douglas JA. Sleep assessment of hospitalised patients: a literature review. Int J Nurs Stud 2014; 51(9): 1281-8.
[http://dx.doi.org/10.1016/j.ijnurstu.2014.02.001] [PMID: 24636444]
]. Also, it does not fully assess the quality and quantity of sleep in the hospital, compared to that at home, from the patients’ perspective. We wanted to evaluate the considerable variation in individuals’ sleep-wake cycles [40Waterhouse J, Fukuda Y, Morita T. Daily rhythms of the sleep-wake cycle. J Physiol Anthropol 2012; 31(1): 5.
[http://dx.doi.org/10.1186/1880-6805-31-5] [PMID: 22738268]
] and began to understand how sleep quality, and quantity, altered at home compared to that in thehospital. As there were no suitable measures, we designed the brief ‘Sleep Experience Questionnaire’ (SEQ) in consultation with service users and a sleep scientist (available from authors on request). The measure included clinical and demographic items (e.g. age, gender, use of medication to promote sleep, use of a hearing aid, Modified Early Warning Score and self-reported pain rating) and questions designed to assess sleep quality and quantity, both at home, and in-hospital, self-rated by participants using 10 cm Visual Analogue Scales (VAS). Open-ended questions were also included to determine the aetiology of sleep disturbances in the Medical Assessment Unit and suggestions for ways to promote sleep for hospital in-patients from their own unique perspective. The questionnaire was circulated to a working group (2 service users, 4 health professionals, 5 academics including a sleep scientist) to support the face and content validity of the measure. In response to user feedback, the wordings used in question 5 and 6 was modified and a lay explanation of sleep quality and sleep quantity added.

During the data collection period, a senior nurse identified potential participants admitted before 22.00 hrs, on the previous night, who were clinically stable. A research nurse then screened participants against set exclusion criteria (inability to communicate in English, diagnosis with a sleep disorder, complete deafness). Study information was given to eligible participants and the opportunity to ask questions. Following informed consent, willing participants completed the paper-based SEQ.

2.3.2. Phase 2. Objective measurement of environmental night-time noise levels

Most studies recording environmental noise levels in hospitals have done so for a period of days, rather than months, and predominantly in critical care settings. We recorded night-time noise levels for a sustained period for three reasons; first, so that we could add a new perspective to what is known on this topic. Second, we could minimise the observer effect, which potentially undermines the integrity of research findings. Third, data from participant’s subjective assessment of sleep quality and quantity in the Medical Assessment Unit, and night-time noise level could be collected simultaneously. Data triangulation is a useful approach to validate research findings [41Bryman A. Quantity and Quality in Social Research 1988.] and results using both data collection methods contributed to a comprehensive explanation of this phenomenon.

Noise levels were continuously recorded in one-minute intervals over each 24-hour period, using two sound level meters (Casella, model CEL-632C, Class 1) calibrated, as per manufacturer’s recommendations. The meter settings (fast i.e. a time constant of integration of 125ms and A-weighted) were chosen as recommended in the WHO guidelines [31World Health Organisation. Guidelines for Community Noise 1999. Available from: https://apps.who.int/iris/handle/10665/66217].

The sound meters were located in two 4-bedded patient bays; one located at the end of the corridor, and the other room situated close to the nurses’ station in the centre of the unit. These bays represented a typically quieter (End Room) and a busier (Middle Room) clinical environment according to feedback from clinical staff. The microphone (Casella, CEL-251) for each sound level meter was secured to the ceiling in each bay. Sound level meters were calibrated regularly using an acoustic calibrator (Casella, CEL-120).

2.4. Data Analysis

2.4.1. Patient Questionnaire Data

Quantitative data were extracted from the questionnaires and data entered into SPSS (version 24). Data were analysed using descriptive and inferential statistics. VAS data for ‘sleep quality’ and ‘sleep quantity’ in hospital, and at home, were compared using paired samples t-tests with significance level set to 0.05.

Qualitative data from open-ended questions were analysed using thematic analysis to identify patterns or themes in the data [42Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77-101.
[http://dx.doi.org/10.1191/1478088706qp063oa]
]. This method matched the multi-method study design because it is not aligned with a specific epistemological perspective or qualitative methodology. Data were read, and re-read, as part of a familiarisation process. We coded the data using a theoretical approach as we had a specific research question. The aim was to explore patient-reported sources of sleep-disturbance to develop an aetiology specific to the Medical Assessment Unit setting using an inductive approach. We also wanted to understand participants’ views about suggestions for sleep-promoting strategies. To support the management and retrieval of qualitative data, we used Microsoft Excel, an approach used by others to provide an audit trail [43Meyer DZ, Avery LM. Excel as a Qualitative Data Analysis Tool. Field Methods 2009; 21(1): 91-112.
[http://dx.doi.org/10.1177/1525822X08323985]
]. Using an open coding approach, one researcher developed a preliminary coding frame. A second researcher repeated the process independently to support the trustworthiness of the analytical process. Preliminary codes were compared, refined and grouped together to form themes, which were reviewed against the data set. There are two levels of themes in the thematic analysis [42Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77-101.
[http://dx.doi.org/10.1191/1478088706qp063oa]
]; in this analysis, we focused on each participant resulting in semantic themes that stayed close to the explicit meaning of the data set. The final stage of the six-stage analysis [42Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77-101.
[http://dx.doi.org/10.1191/1478088706qp063oa]
] was the refinement of the themes.

2.4.2. Environmental Night-time Noise Level Data

Environmental night-time noise levels were recorded for 52 consecutive days. Three parameters were studied; 1) maximum sound pressure level (LAmax dBA), 2) mean sound pressure level (LAeq dBA), 3) the number of night-time 15-minute intervals in which maximum sound pressure levels ≥ 80dBA. A technician downloaded sound level meter data daily using Casella Insight software. For completeness, details of the analytical approaches that were used are available on request from the authors.

3. RESULTS

3.1. Participant Characteristics

Two hundred and four patients were screened and eligible to participate. Of these, 147 (72%) agreed to participate. Two participants consented but did not complete items on self-reported sleep quality and quantity. The final sample comprised 145 participants. Participant characteristics and self-reported outcomes are summarised in Table 1.

Fig. (1)
Patient self-reported sleep quality and quantity at home and on the Medical Assessment Unit.


Table 1
Summary of participants’ characteristics and self-reported outcomes.


3.2. Self-Reported Sleep Quality and Quantity

Fig. (1) shows data from a 10-point VAS of (n=145) participants’ self-reported sleep quality, and quantity.

Participants’ average home sleep quality was rated by participants as 5.07 (SD 2.81 points) and sleep quantity as 5.52 (SD 2.79 points). The average sleep quality and quantity on the Medical Assessment Unit was 3.25 points (SD 2.72 points) and 2.91 points (SD 2.56 points), respectively. Paired samples t-tests showed a statistically significant difference between self-reported sleep quality, and sleep quantity at home compared to that in the hospital. Participants reported poorer sleep quality and quantity whilst in hospital compared to that at home; a statistically significant decrease was evident in both parameters (t146=6.01, p<0.001) sleep quality; (t146=10.3, p<0.001) sleep quantity).

3.3. Qualitative Data

3.3.1. Aetiology of Sleep Disturbance in a Medical Assessment Unit

Five themes characterised the qualitative data from open-ended questions about sources of sleep disturbance shown in Fig. (2). Table 2 provides supporting details, including participants’ quotes and suggestions for improving in-patient sleep. Many participants did not think it was possible to reduce the level of noise in the ward.

Fig. (2)
Aetiology of night-time sleep disturbances in a medical assessment unit.


Table 2
Patient self-reported causes of sleep disturbance on a Medical Assessment Unit and their suggestions for improvement.


3.3.1.1. Care Processes

In this theme, participants described a range of care processes that led to frequent night-time sleep disturbances. The broader health and social care team provided the care, which included nurses, health care assistants, doctors and allied health professionals. Participants were disturbed by a variety of care processes received by themselves or patients nearby, such as the monitoring of vital signs, the implementation of various diagnostic tests such as chest X-ray and blood tests, and the delivery of medication through nebulisers. Participants recognised that many of these clinical procedures were a necessary part of their health care, but commented on the lack of care co-ordination. Sleep promoting suggestions related to reducing or changing the organisation of patient admissions at night.

3.3.1.2. Other Patients

In this theme, participants described factors that caused sleep disturbance caused by other patients in the clinical area. The noise generated by patients was either ‘general’ or ‘specific’. Participants described ‘general noise’ from patients that did not have a single identifiable cause. Specific noises that caused their sleep disturbance reported by participants were often linked to physical noises such as patient snoring, coughing or audible breathing. Participants also mentioned the noise caused by patients needing to get up in the night to use the toilet or commode. However, the most commonly reported source of sleep disturbance was the noise from patients described as being distressed or disruptive who were talking, or shouting out. Participants suggested offering earplugs or headphones to in-patients to muffle environmental noise. An increase in staff numbers was suggested to provide additional care for distressed patients.

3.3.1.3. Built Environment

In this theme, participants described non-human factors in their environment that caused sleep disturbance. Most factors caused sleep disturbance by generating unwanted environmental noise. For example, participants identified a wide range of noise-generating fixtures and fittings. Participants reported sleep disturbance being caused by noise from doors and cupboards banging, trolleys, squeaky wheels on beds, televisions and a printer. Participants also described noise from medical devices and equipment used in the ward setting as sources of disturbance during the night. They described ‘beeping’, ‘bleeping’, and the noise from alarms, buzzers, call bells and intravenous fluid delivery pumps as sources of sleep disturbance. Ambient temperature and light were also identified by participants as sources of sleep disturbance; being either too hot or too cold and lights being switched on, or on and off. Providing individual patient rooms was the most common sleep-promoting suggestion offered by participants across all themes. Other suggestions included reducing the volume on alarms and buzzers and repairing or replacing noisy equipment such as bins and trolley wheels.

3.3.1.4. Physical and Emotional Factors

In this theme, participants described intrinsic physical symptoms or sensations that disturbed their sleep. Some participants complained of being in pain, coughing or feeling generally unwell, which made it difficult for them to sleep. Others mentioned that they needed to get up to go to the toilet frequently because of the effects of the medication they had been given. A few participants mentioned that they were feeling physically uncomfortable due to the mattress or pillow. Others mentioned that their sleep was disturbed because they were feeling tired, were unable to sleep or felt anxious.

3.3.1.5. Staff Noise

A small proportion of participants mentioned noise from staff as a source of sleep disturbance. This could be general noise from staff moving about the ward, or from staff talking to one another. Participants mentioned hearing singing, shouting, loud conversations and music that caused their sleep disturbance. One participant mentioned that the noise caused by staff opening and closing plastic folders had caused sleep disturbance. Participants suggested that staff talking could be reduced and staff awareness about the volume of noise caused by talking should be increased.

3.4. Night-time Noise Levels

Table 3 shows the data on noise levels recorded for 52 nights in total. During the entire data collection period, in both the ‘Middle Room’ and ‘End Room’, there were no 15-minute periods where sound pressure levels were within the WHO guidelines (i.e. LAmax ≤40 dBA and LAeq ≤30 dBA). No significant differences were observed between maximum or equivalent continuous noise levels at weekdays or weekends.

Table 3
Summary of night-time sound levels on the Medical Assessment Unit.


4. DISCUSSION

This multi-methods study addressed two interrelated study objectives with findings that add new insights concerning patients’ sleep experiences and levels of night-time noise in a Medical Admissions Unit.

First, we evaluated participants’ reports of their sleep quantity and quality at home, and in a hospital. Second, we asked them about the causes of sleep disturbances during their hospital stay so we could develop an aetiology of sleep disturbances in the Medical Assessment Unit. We also asked participants to offer suggestions for ways to promote sleep for hospital in-patients at night.

Participants’ self-reported sleep quality and quantity were significantly poorer in the hospital compared to at home. This finding was not unexpected as several international studies have reported that between 40-60% of patients in hospitals report poor sleep quality [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
, 44Adib-Hajbaghery M, Izadi-Avanji F, Akbari H. Quality of sleep and its related risk factors in hospitalized older patients in Kashan’s Hospitals, Iran 2009. Iran J Nurs Midwifery Res 2012; 17(6): 414-20.
[PMID: 23922581]
, 45Lei Z, Qiongjing Y, Qiuli W, Sabrina K, Xiaojing L, Changli W. Sleep quality and sleep disturbing factors of inpatients in a Chinese general hospital. J Clin Nurs 2009; 18(17): 2521-9.
[http://dx.doi.org/10.1111/j.1365-2702.2009.02846.x] [PMID: 19694879]
]; with an average decrease in night-time sleep duration of 1.8 hours between home and in a hospital [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
]. Our findings show a self-reported decrease in sleep of over 2 hours in a hospital compared to home. This suggests that patients in the Medical Assessment Unit are likely to experience fragmented sleep, which if sustained, could lead to sleep deprivation. In the short-term, sleep deprivation can have an immediate effect on the neuroendocrine and hormone systems (e.g. increased cortisol secretion), cardiovascular system (increased heart rate and blood pressure) and on behaviour and cognition (daytime sleepiness, reduced alertness, negative emotions) [46Zaharna M, Guilleminault C. Sleep, noise and health: review. Noise Health 2010; 12(47): 64-9. [Review].
[http://dx.doi.org/10.4103/1463-1741.63205] [PMID: 20472951]
]. Sleep disturbance also has a long-term effect; studies have reported that in-patients’ sleep patterns are often disrupted for up to a year following a period of hospitalisation which has a negative impact on health and well-being [20Altman MT, Knauert MP, Pisani MA. Sleep Disturbance after Hospitalization and Critical Illness: A Systematic Review. Ann Am Thorac Soc 2017; 14(9): 1457-68.
[http://dx.doi.org/10.1513/AnnalsATS.201702-148SR] [PMID: 28644698]
]. International recommendations state that adults should aim for 7-8 hours of sleep to support healthy ageing [37Watson NF, Badr MS, Belenky G, et al. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep (Basel) 2015; 38(6): 843-4.
[http://dx.doi.org/10.5665/sleep.4716] [PMID: 26039963]
]. Participants in this study reported an average sleep duration at home of 6 hours per night, which was unexpectedly low. Poor health and associated symptoms ahead of hospital admission may explain this finding. Alternatively, the older age of participants (mean age 67 years) may be a contributory factor as the ability to maintain sleep tends to decrease with age. A recent study from Australia provides some useful comparative data. The authors published data on the self-reported sleep duration, at home, of a sample of 144 participants with a mean age of 64.2 years as 7.1 hours [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
]. The minimum (1 hour) and maximum (15 hours) sleep duration was surprisingly diverse [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
]. From these data, we can assume that many in-patients may have accumulated a sleep deficit prior to hospital admission that could negatively influence their health and response to treatment. These data highlight the importance of a holistic patient assessment. Sleep and rest patterns are important aspects of biological function that should be assessed as part of person-centred care. Self-report data on sleep quality and quantity has some limitations and may be subject to recall bias. That said, studies comparing self-report data and polysomnography data have reported that the former tends to overestimate sleep quantity compared to the latter [47Jackson CL, Patel SR, Jackson WB II, Lutsey PL, Redline S. Agreement between self-reported and objectively measured sleep duration among white, black, Hispanic, and Chinese adults in the United States: Multi-Ethnic Study of Atherosclerosis. Sleep (Basel) 2018; 41(6)
[http://dx.doi.org/10.1093/sleep/zsy057] [PMID: 29701831]
]. So the ‘at home’ sleep quality and quantity reported by our study participants may be potentially better than data recorded using objective techniques.

Findings from the qualitative data enabled us to develop a novel aetiology of sleep disturbance in a Medical Assessment Unit. The most frequently reported causes of sleep disturbance were care processes, noise from other patients, built environment and physical and emotional factors. There are surprisingly few recent studies available for comparison. A literature review on noise at night in general wards, published five years ago, reported that staff, other patients and visitors were the most common causes of environmental noise [48Fillary J, Chaplin H, Jones G, Thompson A, Holme A, Wilson P. Noise at night in hospital general wards: a mapping of the literature. Br J Nurs 2015; 24(10): 536-40.
[http://dx.doi.org/10.12968/bjon.2015.24.10.536] [PMID: 26018021]
]. A more recent Australian study reported that clinical care provision, and noise from staff, as the most common causes of in-patient sleep disturbance [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
]. A UK study that focused upon the acoustic environment of wards, rather than sources of sleep disturbance, reported ward equipment as the most common source of noise [30Shield B, Shiers N, Glanville R. The acoustic environment of inpatient hospital wards in the United Kingdom. J Acoust Soc Am 2016; 140(3): 2213-24.
[http://dx.doi.org/10.1121/1.4962276] [PMID: 27914398]
]. Medical Admissions Unit in-patients reported similar sources of noise.

Noise from other patients, rather than staff, was the second most frequently reported cause of sleep disturbance in this study, which contrasts with findings from other studies [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
, 30Shield B, Shiers N, Glanville R. The acoustic environment of inpatient hospital wards in the United Kingdom. J Acoust Soc Am 2016; 140(3): 2213-24.
[http://dx.doi.org/10.1121/1.4962276] [PMID: 27914398]
, 48Fillary J, Chaplin H, Jones G, Thompson A, Holme A, Wilson P. Noise at night in hospital general wards: a mapping of the literature. Br J Nurs 2015; 24(10): 536-40.
[http://dx.doi.org/10.12968/bjon.2015.24.10.536] [PMID: 26018021]
]. Our study participants described different types of noise generated by other patients. They identified physical factors, such as snoring and coughing, as causing sleep disturbance. Study participants also referred to ‘distressed’ or ‘disruptive’ patients as disturbing the sleep of other in-patients. Similar patient-related noise sources have been reported in other studies [36Park MJ, Yoo JH, Cho BW, Kim KT, Jeong WC, Ha M. Noise in hospital rooms and sleep disturbance in hospitalized medical patients. Environmental health and toxicology [Internet] 2014; 29: e2014006.
[http://dx.doi.org/10.5620/eht.2014.29.e2014006]
, 49Dias B. Noise in the Modern Hospital. Nurs Times 1992; 88: 37-8., 50Whitfield S. Noise on the ward at night. Nurs Times 1975; 71(11): 408-12.
[PMID: 1114055]
]. Noise from distressed or disruptive patients is stressful for both staff, patients and those close to them. As the average age of patients in general hospitals is 70 years of age, many in-patients are likely to have dementia and/or delirium. Furthermore, staff often lack specialist training to enable them to assess patients with dementia and develop appropriate interventions [51Goldberg SE, Whittamore KH, Harwood RH, Bradshaw LE, Gladman JRF, Jones RG. The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age Ageing 2012; 41(1): 80-6.
[http://dx.doi.org/10.1093/ageing/afr106] [PMID: 21890483]
]. A new 24-hour service staffed by specialist support workers, trained to provide one-to-one care for distressed patients, was piloted at the participating organisation following this research. The use of single-patient rooms may offer an additional solution, but this approach may not always be practicable or desirable. A recent review identified both positive and negative aspects of caring for patients in single rooms [52Kelly R, Brown D, McCance T, Boomer C. The experience of person-centred practice in a 100% single-room environment in acute care settings-A narrative literature review. J Clin Nurs 2019; 28(13-14): 2369-85.
[PMID: 30552821]
]. The use of earplugs is a feasible alternative to reduce general background noise to reduce sleep disturbance, but is a less effective approach for masking peak noise levels [35Garside J, Stephenson J, Curtis H, Morrell M, Dearnley C, Astin F. Are noise reduction interventions effective in adult ward settings? A systematic review and meta analysis. Appl Nurs Res 2018; 44: 6-17.
[http://dx.doi.org/10.1016/j.apnr.2018.08.004] [PMID: 30389061]
].

Noise from the Built Environment, which we conceptualised as the building, medical equipment, fixtures and fittings, was the third most frequently reported cause of sleep disturbance by our study participants. Other studies have reported noise from alarms, doors, trolleys and cupboards as a common source of sleep disturbance [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
, 48Fillary J, Chaplin H, Jones G, Thompson A, Holme A, Wilson P. Noise at night in hospital general wards: a mapping of the literature. Br J Nurs 2015; 24(10): 536-40.
[http://dx.doi.org/10.12968/bjon.2015.24.10.536] [PMID: 26018021]
]. Findings from our study add to research on this important topic by confirming that whilst there are likely to be similarities in specific ‘noise generators’ across clinical settings, each has its own specific soundscape.

Participants’ physical and emotional status was reported as a potential source of sleep disturbances. For example, physical sensations such as pain and discomfort were reported as factors that caused sleep disturbances. Other studies have reported similar findings [6Lane T, East LA. Sleep disruption experienced by surgical patients in an acute hospital. Br J Nurs 2008; 17(12): 766-71.
[http://dx.doi.org/10.12968/bjon.2008.17.12.30306] [PMID: 18825852]
,7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
,10Lee CY, Low LP, Twinn S. Older men’s experiences of sleep in the hospital. J Clin Nurs 2007; 16(2): 336-43.
[http://dx.doi.org/10.1111/j.1365-2702.2005.01491.x] [PMID: 17239069]
,53Gellerstedt L, Medin J, Karlsson MR. Patients’ experiences of sleep in hospital: a qualitative interview study. J Res Nurs 2014; 19(3): 176-88.
[http://dx.doi.org/10.1177/1744987113490415]
]. A closer look at the implementation of pain assessment protocols at night may address sleep disturbance caused by pain. It is accepted that interventions designed to educate nurses about acute pain management often lack theoretical foundation [54Drake G. de C Williams AC. Nursing education interventions for managing acute pain in hospital settings: A systematic review of clinical outcomes and teaching methods. Pain management nursing : official journal of the American Society of Pain Management Nurses 2017; 18(1): 3-15.] and current practice could be improved [55Duncan F, Day R, Haigh C, et al. First steps toward understanding the variability in acute pain service provision and the quality of pain relief in everyday practice across the United Kingdom. Pain Med 2014; 15(1): 142-53.
[http://dx.doi.org/10.1111/pme.12284] [PMID: 24206362]
]. Emotions and feelings linked to being in a strange environment with other people also caused sleep disturbances. Studies conducted in China and Iran have reported worries and concerns about health and illness as emotions that contributed to poor sleep quality for patients; this was also evident in our findings [44Adib-Hajbaghery M, Izadi-Avanji F, Akbari H. Quality of sleep and its related risk factors in hospitalized older patients in Kashan’s Hospitals, Iran 2009. Iran J Nurs Midwifery Res 2012; 17(6): 414-20.
[PMID: 23922581]
, 45Lei Z, Qiongjing Y, Qiuli W, Sabrina K, Xiaojing L, Changli W. Sleep quality and sleep disturbing factors of inpatients in a Chinese general hospital. J Clin Nurs 2009; 18(17): 2521-9.
[http://dx.doi.org/10.1111/j.1365-2702.2009.02846.x] [PMID: 19694879]
].

In the final part of the qualitative study, we asked participants to make suggestions for improvements that could promote sleep and reduce sleep disturbance for in-patients. This is a unique and innovative aspect of this study as all too often, patients are not included in quality improvement initiatives. Interestingly participants’ suggestions broadly reflect several of the noise reduction interventions reported in a systematic review [35Garside J, Stephenson J, Curtis H, Morrell M, Dearnley C, Astin F. Are noise reduction interventions effective in adult ward settings? A systematic review and meta analysis. Appl Nurs Res 2018; 44: 6-17.
[http://dx.doi.org/10.1016/j.apnr.2018.08.004] [PMID: 30389061]
]. This demonstrates the value of seeking patients’ feedback in the development of health services.

In the second part of this study, we objectively measured night-time environmental noise levels over a 52-day period in a Medical Assessment Unit. The prolonged recording period of night-time noise levels in this study is a particular strength. Few studies have objectively and accurately recorded night-time noise levels in a ward setting for such a prolonged period. For this reason, our study makes an important and significant contribution to the current literature on this topic. The average night-time equivalent continuous sound pressure levels were between 38-57 dBA. This is categorised as a ‘soft’ to ‘moderate’ noise level, that at the higher level, is equivalent to office conversation. The decibel levels in this study were similar to those reported in an overview of studies published between 1964 and 2005; equivalent sound pressure levels were reported as between 35-82 dBA [33Busch-Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am 2005; 118(6): 3629-45.
[http://dx.doi.org/10.1121/1.2118327] [PMID: 16419808]
]. More recent studies conducted in medical, general surgical and orthopaedic wards report average equivalent sound levels of between 42-64.6 dBA [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
, 8Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med 2012; 172(1): 68-70.
[http://dx.doi.org/10.1001/archinternmed.2011.603] [PMID: 22232151]
, 36Park MJ, Yoo JH, Cho BW, Kim KT, Jeong WC, Ha M. Noise in hospital rooms and sleep disturbance in hospitalized medical patients. Environmental health and toxicology [Internet] 2014; 29: e2014006.
[http://dx.doi.org/10.5620/eht.2014.29.e2014006]
, 56Pope D. Decibel levels and noise generators on four medical/surgical nursing units. J Clin Nurs 2010; 19(17-18): 2463-70.
[http://dx.doi.org/10.1111/j.1365-2702.2010.03263.x] [PMID: 20920074]
-59Richardson A, Thompson A, Coghill E, Chambers I, Turnock C. Development and implementation of a noise reduction intervention programme: a pre- and postaudit of three hospital wards. J Clin Nurs 2009; 18(23): 3316-24.
[http://dx.doi.org/10.1111/j.1365-2702.2009.02897.x] [PMID: 19732242]
], whilst in critical care settings, levels can be 80dBA [8Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med 2012; 172(1): 68-70.
[http://dx.doi.org/10.1001/archinternmed.2011.603] [PMID: 22232151]
]. The highest and lowest maximum sound pressure across all nights, across both rooms, on the Medical Assessment Unit was between 94-116 dBA. This instantaneous noise level is very loud and equivalent to hearing a banging car door at one metre distance. A peak noise level of this magnitude is common in hospital settings; others have reported similar maximum sound level pressures of 100 dBA [7Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. They can rest at home: An observational study of patients’ quality of sleep in an Australian hospital. BMC Health Serv Res 2018; 18(1): 524.
[http://dx.doi.org/10.1186/s12913-018-3201-z] [PMID: 29976191]
, 60Darbyshire JL, Young JD. An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care 2013; 17(5): R187.
[http://dx.doi.org/10.1186/cc12870] [PMID: 24005004]
].

There was no significant difference between average night-time equivalent continuous sound pressure levels and maximum sound pressure levels recorded on weekdays, compared to weekends. This was surprising, but the consistent patient flow rate through the Medical Assessment Unit provides a logical explanation for this finding. Over the last forty years, the (logarithmic) average night-time noise levels in a hospital setting have steadily increased [33Busch-Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am 2005; 118(6): 3629-45.
[http://dx.doi.org/10.1121/1.2118327] [PMID: 16419808]
]. It is clear from our study, and others, that hospitals are noisy places and are becoming increasingly so, largely due to the technological innovations that are now part of daily clinical practice. The level of noise required to cause sleep disturbance leading to poor health consequences is ≥ 55 dBA [61Passchier-Vermeer W, Passchier WF. Noise exposure and public health. Environ Health Perspect 2000; 108(1): 123-31., 62World Health Organisation. Night noise guidelines for Europe 2009. Available from: http://www.euro.who.int/__data/assets/pdf_file/0017/43316/E92845.pdf]. Maximum sound pressure levels in the Medical Assessment Unit were consistently above this level.

Noise levels in the Medical Assessment Unit, and those reported in most international studies, exceed current WHO recommendations [31World Health Organisation. Guidelines for Community Noise 1999. Available from: https://apps.who.int/iris/handle/10665/66217]. Unfortunately, WHO recommendations appear to be meaningless in today’s hospital environments as they set an unachievable target. In one study, noise levels recorded in an unoccupied room, set up with the equipment required for respiratory support alone, exceeded WHO recommendations [60Darbyshire JL, Young JD. An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care 2013; 17(5): R187.
[http://dx.doi.org/10.1186/cc12870] [PMID: 24005004]
].

Environmental noise levels recorded across different clinical settings vary considerably and multiple factors contribute to noise production and propagation. These include the architecture of the clinical setting, fixtures, fittings, equipment, the acuity of patients and the number of staff, to name a few [63MacLeod M, Dunn J, Busch-Vishniac IJ, West JE, Reedy A. Quieting Weinberg 5C: a case study in hospital noise control. J Acoust Soc Am 2007; 121(6): 3501-8.
[http://dx.doi.org/10.1121/1.2723655] [PMID: 17552702]
]. A welcome addition to the WHO guidance would be directives on effective approaches to reduce noise to reduce sleep disturbance. Suggestions for interventions that can either eliminate noise at source, or reduce the propagation of noise, could be a valuable first step in supporting health and social care professionals to promote sleep for hospital in-patients.

Another important consideration is the quality and familiarity of specific sounds and their impact on patients. Sounds from alarms are more likely to cause disturbance than other sounds such as human voices [64Buxton OM, Ellenbogen JM, Wang W, et al. Sleep disruption due to hospital noises: a prospective evaluation. Ann Intern Med 2012; 157(3): 170-9.
[http://dx.doi.org/10.7326/0003-4819-156-12-201208070-00472] [PMID: 22868834]
]. It may be worth considering whether interventions should target a reduction in maximum/peak noise levels in clinical settings rather than average noise levels. For example, the cabin of a commercial flight has an average equivalent sound pressure in the region of 80-85 dBA [65Ozcan HK, Nemlioglu S. In-cabin noise levels during commercial aircraft flights. Can Acoust 2006; 34(4)], yet many people are able to sleep in this environment. Further research could establish whether sudden loud noises in a clinical environment are more likely to cause sleep disturbance than continuous background noise.

This study has some limitations. The setting was a single ward in one hospital, which may reduce the generalisability of the results to other settings. Conversely, the focus upon a single clinical setting enabled us to develop a very comprehensive understanding of the soundscape in the Medical Assessment Unit. It is widely accepted that patient self-report data may be prone to recall bias. However, the use of polysomnography, the gold standard to assess sleep, was not feasible due to the invasive nature of the data collection process and expense of the equipment. The prolonged recording period of night-time noise levels is a strength of this study because it is longer than that reported in the majority of comparable studies.

This study shows that the self-rated patient sleep experience was significantly poorer in the hospital, compared to home. Noise at night was a contributor to sleep disturbances in this study, with similar noise levels reported in other international studies. Future research should identify effective interventions to improve the quality and quantity of sleep for hospital in-patients. This is an important aspect of care because it influences the patient experience and health outcomes. Sleep deprivation is associated with poor physical and mental health. Moreover, sleep disturbance is associated with adverse events such as falls that lead to avoidable patient harm and prolonged hospital stay. This study provides a new aetiology of sleep disturbance, which shows that five key factors influence the patient sleep experience; additional research is needed to understand how such factors vary across different clinical settings. Several countries distribute patient experience surveys, but questionnaire items about the in-patient sleep experience are not consistently included and the specific sources of sleep disturbance poorly understood. Future research about sources of sleep disturbance caused by the ‘Built Environment’ are needed as this aspect of noise generation is often overlooked. Health architects play an important role in ‘designing out noise’ to create a healing environment in new hospital builds.

Research data informed the development of a research derived actionable ‘Sleep Smart’ toolkit designed for use by health professionals to guide the improvement of the in-patient sleep experience. Appendix 1 shows the sleep promotion framework and an overview of the ‘Sleep Smart’ toolkit (copyright © 2019 Sleep Smart Working Group) with additional resources available from the corresponding author.

CONCLUSION

This study confirms that sleep quality and quantity in a Medical Assessment Unit is significantly worse than at home. Most importantly, many patients admitted to the hospital due to ill health may already have a sleep deficit. The first aetiology of noise in the Medical Assessment Unit, from a patient perspective, shows that care processes, other patients and the built environment are key sources of sleep disturbance. Most importantly, our study shows that although sources of sleep disturbance may be broadly similar across clinical settings, each clinical setting is different. Noise levels at night in a Medical Assessment Unit, studied over a 52-day period, are above those recommended by the WHO [31World Health Organisation. Guidelines for Community Noise 1999. Available from: https://apps.who.int/iris/handle/10665/66217], but similar to those reported in multiple international studies. The problem of noise at night in hospitals is not new, but does not seem to be a priority amongst those with the most significant influence. Several simple strategies can reduce noise at night and promote sleep. Unfortunately, no one factor can be singled out against another as having a greater or lesser impact on noise reduction or sleep promotion [35Garside J, Stephenson J, Curtis H, Morrell M, Dearnley C, Astin F. Are noise reduction interventions effective in adult ward settings? A systematic review and meta analysis. Appl Nurs Res 2018; 44: 6-17.
[http://dx.doi.org/10.1016/j.apnr.2018.08.004] [PMID: 30389061]
]. Noise from other patients may be reduced by considering ward layout and using noise ‘blocking’ interventions, such as ear plugs. Other approaches include reminders for staff to ensure that they close doors, avoid conversations in hallways or next to the bedside, turn televisions off or provide headphones for patients wanting the television on, provide earplugs, have pagers/phones on vibrate and implement ‘quiet hours’ [59Richardson A, Thompson A, Coghill E, Chambers I, Turnock C. Development and implementation of a noise reduction intervention programme: a pre- and postaudit of three hospital wards. J Clin Nurs 2009; 18(23): 3316-24.
[http://dx.doi.org/10.1111/j.1365-2702.2009.02897.x] [PMID: 19732242]
, 66Lareau R, Benson L, Watcharotone K, Manguba G. Examining the feasibility of implementing specific nursing interventions to promote sleep in hospitalized elderly patients. Geriatr Nurs 2008; 29(3): 197-206.
[http://dx.doi.org/10.1016/j.gerinurse.2007.10.020] [PMID: 18555161]
-70World Health Organisation. Environmental Noise Guidelines for the European Region 2018. Available from: http://www.euro.who.int /__data/assets/pdf_file/0008/383921/noise-guidelines-eng.pdf?ua=1].

At a policy level, the current WHO guidance [31World Health Organisation. Guidelines for Community Noise 1999. Available from: https://apps.who.int/iris/handle/10665/66217] requires urgent updates and the addition of an action plan for change. The most recent version of the guidance avoided making recommendations for acceptable noise levels in hospital settings, which is unfortunate [61Passchier-Vermeer W, Passchier WF. Noise exposure and public health. Environ Health Perspect 2000; 108(1): 123-31.]. An important first step should be to raise awareness at a governmental level to ensure that this important aspect of patient care is on the agenda for change. At a national level, hospital staff, patients, and those close to them, need to be at the forefront of ‘designing out noise’ in new hospitals. Specific attention to the redesign of patient flow between Accident and Emergency/Emergency Departments and other clinical areas is warranted to minimise night-time disturbance. National patient experience surveys could revise items to reflect the key themes in our aetiology when asking participants about what caused noise at night. Care processes and built environment are two important factors that are not currently included. Patient feedback is a powerful driver of improvement, but only if it is meaningful to health and social care staff. We recommend that hospitals develop and implement methods of providing patient feedback to staff on sources of sleep disturbance. The first step in cultural change is to raise awareness about the need for change. The impact of poor sleep on physiological and mental health requires more emphasis in health professional education. Using a “patient story” is a useful way to raise awareness at a local level particularly as feedback is more likely to be actionable if it is locally applicable and context-specific. At a local level, health and social care teams can evaluate the frequency of clinical observations and patterns of care provision at night to identify opportunities to reduce disturbances where possible. To achieve sustainable cultural change, the approach needs to be participatory, and the teams need to include all hospital staff, including those working in estates, portering and domestic services. Workforce managers could also consider implementing a night-time response outreach team of staff trained to sensitively, and safely, support distressed patients to reduce night-time disturbance. Change needs to occur at several levels if we are to address this challenge effectively.

AUTHORS' CONTRIBUTION

FA, JS, JW, BE, JG contributed to the successful funding application for the research. FA, JS, JW, BE, EH, PR contributed to data collection and/or data analysis. All authors contributed to drafting the manuscript.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The Health Research Authority (16/NE/0269) and the Research Ethics Committee of the School of Human and Health Sciences at the University of Huddersfield, UK gave ethical approval for the research to be conducted.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures were followed in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

All study participants gave informed consent to participate in the research which included the agreement that results would be published.

AVAILABILITY OF DATA AND MATERIALS

The authors confirm that the data supporting the findings of this study are available within the article.

FUNDING

This research was funded by a grant from the General Nursing Council of England and Wales.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest in this research and article writing.

ACKNOWLEDGEMENTS

We would like to thank all patient participants for their contribution. We would like to acknowledge Ms Beverley Holliday and Ms Kathryn Hanson (research nurses) for collecting the patient questionnaire data and the Working and Steering groups for their helpful input.

APPENDIX



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