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Esther Bernhofer, RN-BC, PhD September 14, 2012

Esther Bernhofer, RN-BC, PhD September 14, 2012 2012 National State of the Science Congress on Nursing Research Washington, DC. Describing Light Exposure, Sleep, Mood, and Pain in Medical Inpatients. Background/Significance.

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Esther Bernhofer, RN-BC, PhD September 14, 2012

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  1. Esther Bernhofer, RN-BC, PhD September 14, 2012 2012 National State of the Science Congress on Nursing Research Washington, DC Describing Light Exposure, Sleep, Mood, and Pain in Medical Inpatients l l 1

  2. Background/Significance • Hospital lighting may interfere with circadian rhythmicity and sleep-wake patterns • Lighting may affect mood • Mood and lighting may be related to pain which remains an issue for medical inpatients l l 2

  3. Purpose • To examine the relationships among the four variables of light exposure, sleep-wake patterns, mood and pain in hospitalized adult medical patients l l 3

  4. Theoretical Framework • Nightingale’s Environmental Theory • 1859, Florence Nightingale: sunlight is critical to the healing of body and mind; light exposure could be manipulated by the nurse • The Heitkemper and Shaver Human Response Model (HRM) • Describes the relationships among the concepts of person (patient), environment (light exposure), and individual adaptation (sleep-wake patterns, mood, and pain). l l 4

  5. Study Model Sleep-Wake Patterns Light Exposure Pain Mood l l 5

  6. Design and Method • Predictive correlational design • 72-hour data collection: • Light exposure and sleep-wake patterns continuously measured via actigraph/light meter • Mood measured daily with POMS™ Brief Form • Demographics, pain scores, and opioid use abstracted from participants’ medical records. l l 6

  7. Sample (N = 40) • 246 eligible patients identified • 168 unavailable • 78 approached • 19 declined (24%) • 59 enrolled • 19 dropped from analysis due to incomplete data: actigraph failure (n = 9) or medical condition (n = 10) l l 7

  8. l l 8

  9. Light Exposure Patterns Among Study Participants l l 9

  10. Light exposure patterns based on geographical orientation Statistically significant difference between light exposure in the north-east facing beds and the south-west facing beds, t(37) = -2.16, p < .05 during Day time. l l 10

  11. Sleep-wake patterns • Nighttime sleep, in minutes (M = 236.35, SD = 72.27, range 62.00 to 391.00) • Daytime sleep, in minutes (M = 161.02, SD = 81.40, range 5.33 to 391.33) • Further analysis • 35% - slept >3 hours (>183 minutes) day • 50% - slept <4 hours (<233 minutes) night l l 11

  12. Sleep-wake patterns: Fragmentation l l 12 • FRAG score (M = 9.37/8 hours, SD = 5.55, range 2.0 to 27.0) • 20% scored greater than 12.0 on the FRAG • Wake after sleep onset (WASO) • WASO minutes (M = 112.51, SD = 48.67, range 28.00 to 228.33) • 25% were awake 145 minutes (2.5 hours) first sleep episode on the first night of the study

  13. Sleep-wake patterns: Fragmentation l l 13 • Intra-daily variability (IV) • Possible range = 0 to 2.0+ • IV values of 2.0+ were frequently seen, but decreased from Day 1(M = 1.56) to Day 2 (M = 1.22) to Day 3 (M = 1.26) • Inter-daily stability (IS) • Possible range = 0.0 to 1.0 • IS values indicated low synchronization (M = 0.37, SD = 0.13, range 0.04 to 0.76)

  14. l l 14

  15. Mood POMS™ Brief questionnaire results l l 15

  16. Mean Pain Scores over the 72 hours of the Study (N = 40) l l 16

  17. Age and Gender • No statistically significant differences were found between gender and pain intensity levels • No statistically significant differences in pain intensity reports were found among age groups • Contrast with other studies…Pain perception may change with the process of aging (Kelly, 2009; Martin et al., 2007). There may be gender-based differences in pain perception, pain expression, and mood (Trame & Rawe, 2009). l l 17

  18. Opioid Use • Over 72 hours: mean grams of oral morphine equivalent used daily = 219.97 (SD = 370.71) • Large SD: high variation of individual opioid use • Positive, moderately strong correlation between mean pain scores and opioids used (n = 38, r = .46, p < .01). • Opioid use did not significantly decrease over 3 days like pain scores did l l 18

  19. Significant Correlations • Total mood disturbance (TMD) and subscales • TMD and daytime light exposure (r = -.32, p < .05) • Daytime light exp. and fatigue (r = -.34, p < .05) • Daytime light exp. and confusion (r = -.32, p < .05) • Pain and fatigue (r = .34, p < .05) • Pain and opioid use (r = .47, p < .05) • TMD and opioid use (r = .42, p < .05) • Anger and opioid use (r = .53, p < .05) l l 19

  20. Significant Predictors • Only one variable, fatigue, significantly predicted pain, R2 = .11, R2 adj= .09, F(1, 38) = 4.84, p < .01 • Light exposure significantly predicted mean fatigue scores, R2 = .11, R2 adj= .09, F(1, 38) = 4.86, p < .05. l l 20

  21. Interpretation • Brightest patient-bed rooms • very low light during the day/night in all seasons, eliminates vital photic stimuli • still statistically significant negative correlations between daytime light exposure and TMD, fatigue, and confusion l l 21

  22. Interpretation • Sleep was fragmented with little circadian synchronization with hospital lighting • Pain remained moderate to high • Fatigue significantly predicted pain • Light exposure significantly predicted fatigue l l 22

  23. Sleep-Wake Patterns Light Exposure Pain Mood Checking the Study Model… X X X O O l l 23 • YES, light exposure and mood • YES, aspects of mood and pain • NO, light exposure and sleep-wake patterns • NO, sleep-wake patterns and pain • NO, mood and sleep-wake patterns

  24. Sleep-Wake Patterns Light Exposure Pain Mood But perhaps… O O X O O l l 24 • If fatigue were categorized as a sleep-wake pattern (disturbance), then the model may look more like this… • And mood needs further study in this population

  25. Limitations • Wrist-worn device could be covered with clothing or bedding – although preliminary studies showed high reliability • High attrition rate resulted in the lower than expected sample size of 40 • Biological markers: serum melatonin and salivary cortisol would have added to the findings on circadian entrainment and mood • POMS™ mood instrument may not be valid in this population l l 25

  26. Summary Participants suffered significant pain and little, fragmented sleep. 24-hour light exposure was inadequate to support circadian entrainment (sleep-wake rhythmicity). Although significant relationships among all of the four variables were not found, certain significant associations were found, among them light/fatigue and fatigue/pain. Study provides a basis for future nursing research and education in the utilization of light exposure in the hospital and community l l 26

  27. Long-term Goals Bring to light the problem of inadequately managed pain in adult medical inpatients Develop intervention studies involving manipulation of hospital lighting to treat sleep-wake disturbances, mood, and pain. l l 27

  28. CWRU-FPB • Patricia Higgins, RN, PhD • Thomas Hornick, MD • Barbara Daly, RN, PhD • Christopher Burant, PhD • Cleveland Clinic • Patient participants • ASPMN Research Grant Acknowledgement and Thanks! l l 28

  29. Questions? l l 29

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