Most people know that being in hospital is not synonymous with a good night’s sleep – yet while the primary reason might be that patients are unwell, and that pain or medication effects often reduce sleep quality and quantity, one of the most common problems is linked to noise.
Psychological stress resulting from anxiety about health problems, the unfamiliar hospital environment, disruption of routine, or reduced personal autonomy, can also all significantly contribute to sleep degradation, reports Medscape.
But if these factors are at least partially unavoidable, the hospital environment itself does not seem to consider sleep quality adequately, with complaints about noise levels being universal.
“The call bells in the nursing station, the continuous manoeuvres of ambulances, which had their alarms on when they reversed right under the window, nurses talking to each other…” are common complaints.
The word “hospital” comes from the Latin hospitale, a place where strangers were hosted. But the hospital setting is not that hospitable generally.
In a place dedicated to care and rest, the fundamental need (sleep) is neglected, and almost everyone who has spent a night in a hospital, whether admitted or assisting a loved one, knows that resting is difficult.
Studying hospital sleep
A meta-analysis from 2022 that examined 203 studies showed that the average total sleep time for patients varies significantly between age groups.
Children and adolescents sleep an average of about 7.8 hours per night, while adults and older adults manage only 5.6 and 5.8 hours, respectively. Most of the studies – 76% – reported sleep duration below the average that is considered healthy. Almost half indicated that adults slept less than six hours per night: a threshold commonly associated with adverse health outcomes.
Furthermore, patients frequently experience numerous nocturnal awakenings (up to 42 times per night) and prolonged awakenings after sleep onset of more than 105 minutes.
Paediatric patients, however, are a separate case. According to the meta-analysis, sleep efficiency in children overall remains comparable to that in healthy populations. But their sleep quality is deficient, and hospitalisation affects various ages differently.
Finally, sleep quality can be altered by the development of conditions, such as insomnia, restless leg syndrome, or sleep-related breathing disorders, that are rarely taken into consideration.
Noise, the main problem
Several studies have shown a correlation between the number of sound peaks in a hospital setting and the number of patient awakenings. One attributed 20% of sleep awakenings to noise level peaks, while another indicated that environmental noise caused 11.5% of interruptions and 17% of awakenings.
The average noise level in hospitals could also play a crucial role.
At least one study has noted a significant dose-response relationship between self-reported sleep disturbances and average noise levels, suggesting that constant background noise may have a greater effect than louder intermittent noises.
Sharing a room with other patients, and thus with their noises, is one of the most common sources of discomfort, although some studies show the use of single wards does not necessarily improve the situation.
Light and sleep
Light is an equally important problem. Many patients report difficulty sleeping because light constantly shines into the rooms from passages. Several studies have identified light intensity as a factor that disturbs sleep in intensive care units, as well as in regular admissions.
According to one study, lighting conditions had an even more pronounced effect than noise on sleep quality.
Proper lighting conditions are also as important as reduced night-time lighting to maintain a proper sleep-wake cycle. Several studies have reported that bright light during the day improves the quality of night-time sleep, and patients near windows, and thus exposed to a natural light rhythm, tend to sleep better.
Night shifts
Night nursing activities are another important. Many patients relate experiences where night staff interventions thwarted hopes of good rest.
“The night goes on, but every two hours, a nurse comes in and turns on the light to check your BP and so on, ask if you feel nauseous, and give you meds,” said one.
On this point, things are changing in some regions.
“In the past, measurements could be taken or the room entered at any time of day or night. Now there is a tendency to absolutely avoid entering at night, or it is done only to check that the patient is not unwell. The patient is not awakened unless something urgent happens,” said Francesca Casoni, MD, a neuro-physiopathologist at the Sleep Medicine Centre of the IRCCS San Raffaele Turro Hospital in Milan, Italy.
Sleeping poorly and insufficiently is a risk factor for many conditions, like cardiovascular events, cancer, metabolic disorders, and all-cause mortality, as well as for cognitive function deterioration.
It also leads to a weakened immune system and a higher risk for falls. Poor sleep can hinder recovery processes, increase the length of hospital stay, and negatively affect patients’ subjective well-being.
Reduced quantity and quality of sleep during hospitalisation have been correlated, for example, with hyperglycaemia.
“Not sleeping disturbs recovery mechanisms from illness. The circadian rhythms of production of numerous hormones are altered, including insulin; night-time blood pressure often increases with increased cardiac workload, oxidative stress increases, and a general inflammatory state is observed.
“So the patient struggles to recover, and moreover, in a vicious cycle, stress, anxiety, and concern increase. Consequently, this leads to worsening of insomnia,” said Casoni.
Data suggest that hospitalisation may be a risk factor for the development of long-term insomnia, which can persist for months or even years after discharge.
Research carried out in 2022 also suggests that hospital sleep disturbances, such as decreased total sleep time, poor quality, and increased nocturnal awakenings, may, in some cases, persist for up to 12 months after discharge.
Sleep deprived
Sleep deprivation can be even more critical in worsening the conditions of older adult patients. “Sleep disturbance is one of the major risk factors for delirium,” said Casoni.
While hospitals cannot always be places of perfect quiet, sometimes, such as in the ICU, the presence of equipment and various needs can make suboptimal light and noise levels unavoidable.
There is room for improvement, however. A 2016 review showed that reducing noise and light during hospitalisation is associated with sleep improvements. Providing simple and inexpensive tools like earplugs and eye masks can also improve patients’ experiences.
Implementing “quiet periods” during which noise is minimised and lights are dimmed has proved promising.
Approaches to medications and therapies can also be modified.
“Pain is one of the most frequent causes of insomnia onset during hospitalisation and therefore, if possible, should be treated,” said Casoni.
“But it’s important to remember that some drugs that might be better to avoid in the evening… the right drug is not always chosen.”
The main and most immediate intervention, however, is to listen to the patient.
“The doctor should ask questions and talk to the patient, understand, for example, if they already suffered from a sleep disorder before entering the ward. The most human aspect, dialogue with the patient and understanding of sleep quality, is fundamental. Talking and reassuring the patient helps a lot.”
PubMed article. – Improving inpatient environments to support patient sleep (Open access)
Sleep quality among inpatients of Spanish public hospitals
Medscape article – The Hospital Is an Enemy of Sleep (Open access)
See more from MedicalBrief archives:
Noise in hospitals is hitting deafening levels
Even minor changes in nightly sleep impact on next-day pain burden
Noisy incubators could stunt infant hearing – Austrian study