Name:______MY DANG___________

Texas Womans University

N3612 Intro to Nursing Research
Evidence-base Nursing Practice: Evaluating a Systematic Review
INSTRUCTIONS: Answer the questions referencing the assigned article. Use only the assigned article.
Keep your answers in table format. You may expand the size of the box as needed but your entire paper
can be no longer than 5 pages. Use complete sentences where indicated. Use proper grammar and
punctuation. You may have to use your textbook and/or other resources to answer the questions.
Question

Answer

Cite the article in APA format.

Hellstrom, A., Fagerstrom, C., & Willman, A. (2011).

Promoting sleep by nursing interventions in health
care settings: a systematic review. Worldviews on
Evidence-Based Nursing, 8(3). 128-142.
https://dx.doi.org/10.1111/j.17416787.2010.00203.x
According to Hellstrom, Fagerstrom, and Willman
(2011), some human reactions to sleep deprivation and
insomnia are impaired glucose tolerance, reduced insulin
sensitivity; alter levels of GH and cortisol (lower GH and
higher cortisol); higher peptide gherline at night (increase
hunger and appetite); indirectly affects neurogenesis;
increase risk for diabetes, hypertension and obesity;
mimic some hallmarks of ageing
Causes of sleep disturbances in health care settings:
Uncomfortable environment (bed, temperature, noise,
other patients, pain); Present of catheters, tubes;
Increased daytime sleepiness; Undergone coronary artery
bypass graft; Routine of health care personnel; Health
problem ( stress, anxiety, accidents)
The aim of the systemic review is to describe and
evaluate the effectiveness of sleep-promoting nursing
interventions for patient in health care settings
Based on the article, heath care settings are defined as
facility where patients can stay overnight which includes
hospital wards, nursing homes, retreats, and hospices.
Nursing interventions, as defined by the theorist Myra
Levine, are human interactions that rely on
communication which focuses on organic dependency
of one human beings relationships with other human
beings to provide individualized cares (p. 128)
P: patients who develop sleep disturbances in health care
settings

According to the literature

review in the article, what are
some human reactions to sleep
deprivation and insomnia?

What are some causes of sleep

disturbances in health care
settings?

What was the aim of the

systematic review?
Based on the article, define
health care settings.
Based on the article, what is
the theoretical definition of
nursing interventions.
For this systematic review
article, identify the PICOT
components for the review

Possible
Points
3

2
2
2

article.

What were the inclusion

criteria for the review? How
many studies met the inclusion
criteria and were appraised?
What were the exclusion
criteria for the review?
According to Table 2, these
articles were excluded:
Koyama et al. (1999) and
Walder et al. (2000). Why?

I: sleep hygiene, music, natural sounds and vision,

stimulation of acupoints, relaxation, massage, and
aromatherapy
C: No comparisons assessed.
O: effective methods for reducing disturbance and
promoting sleep
T: There is no time specific for when these interventions
have taken place. During hospitalization at a health care
setting.
The inclusion criteria were studies on sleep promotion in
health care settings, written in English or Scandinavian,
inclusion of experimental design or being systematic
reviews or meta-analysis. 21 articles were appraised.
Exclusion criteria were studies with shift workers, health
care personnel, pharmacological treatment, children
under 19 years old, no involvement of patients in health
care settings.
The article of Koyama et al. (1999) was excluded
because no recognized outcome measured but the
observations of six individuals.

The article of Walder et al. (2000) was excluded because

of convenience sample, small sample n = 17, no report
concerning drop-outs. No direct measures of sleepjust
light and noise..
In Table 2, what does RCT
mean? What is the difference
between RCT and quasiexperimental?

How was the scientific quality

of each article evaluated?

RCT means randomized control trials.

RCT is an experimental study conducted in a health care

setting includes a large number of subjects that randomly
assigned into control and intervention groups. Groups
must be comparable to key features at baseline;
interventions are performed to all subjects in the
experimental group. All groups are measured on the DV
using the same method of measurement at the same
points in time. (Schmidt & Brown, 2014, p 166- 167)
Quasi-experimental involves manipulation of the IV but
do not meet one of the other essential components of
experimental designs. They lack either control or
experimental group; their design is ranked lower as
sources of evidence than studies using the experimental
design (Schmidt &Brown, 2014, p.171)
Templates from the Critical Appraisal Skills Programme
(CASP) were used to evaluate scientific quality. It was

Describe the templates used for judged as high, medium or low based on the elusiveness
evaluation. How many articles and reliability of the methods and severity of the flaws in
were judged to be of quality?
design or in description. The full text documents were
independently assessed by two of the researchers. CASP
is used which contains of 10 to 11 questions about
design, ethical considerations, drop-outs, size of the
study, its effects and relevance, generalizability of the
findings. No scoring system. The scientific quality was
judged as high, medium, or low. There are 21 articles
were judged to be of quality.
What system was used for
compiling and assessing the
quality of the evidence in the
articles? Define this system.

Define the categories of sleeppromoting interventions. You

may have to look outside the
article for definitions.

The GRADE system includes four-grade scale that offers

a systematic approach to evaluate the quality of evidence
and the strength of recommendation is used for
compiling and assessing the quality of evidence. Four
key elements are of great importance to the reviewer,
namely the design, quality, consistency and directness of
the study.
Sleep Hygiene: refers to the general rules of behavioral
practices and environmental factors that are consistent
with good quality sleep. It includes guidelines for general
health practices (e.g., diet, exercise, substance use),
environmental factors (e.g., light, temperature, noise), as
well as sleep-related behavioral practices (e.g., regularity
of sleep schedule, pre-sleep activities, efforts to try to
sleep). (Chien & Shih, 2010)
Stimulation of Acupoints: Acupuncture is a method in
which specific body areas, the acupoints (also called
meridian points), are pierced with fine needles for
therapeutic goals. Acupoints are points on the body
surface that when stimulated are thought to cause
therapeutic effects. It is one of the major modalities of
treatment in Traditional Chinese Medicine. (Cheuk et al.,
2012)
Massage is the technique that produce relaxation by
tactile stimulation in body tissues causing complex
neurohumoral responses in the hypothalamicpituitary
axis (HPA) to circuit through the central nervous system
pathways (Harris & Richards, 2010)
Relaxation: usage of mental imagery, music, oral or
auto-taped instruction to relax
Music, natural sound and vision: vocal or instrumental
sounds to produce harmony and emotional expression. It
also includes sounds produced by natural sources,
unadorned production sounds (Film Sound Organization,
1997)

How was sleep measured in

the studies listed in Table 3?
Describe each measurement.
You may have to look outside
the article for definitions.

Aromatherapy: Aromatherapy is the controlled use of

essential oils to restore or enhance mental, emotional,
physical or spiritual health (Borromeo, 1998)
Sleep was measured by:

Actigraph devices generally placed on the wrist

(although they can also be placed on the ankle or trunk)
to record movement. Collected data are downloaded to a
computer for display and analysis of activity/inactivity
that in turn can be further analyzed to estimate
wake/sleep (Israel et al., 2003)
MQ (morning questionnaire)- asked subjects to report the
amount of time slept the preceding night, Subjects were
requested to complete this within 1 hour after getting out
of bed each morning (Byrom & Tiplady, 2010)
ISI (insomnia severity index)- impact of insomnia has on
the persons daily life (p.132)
AIS (Athens insomnia scale)- describes the symptoms of
the sleep difficulties (p.132)
RCSQ (Richard Campbell sleep questionnaire)- a simple,
validated survey instrument for measuring sleep quality
in intensive care patients. The RCSQ is a brief 5-item
questionnaire used to evaluate perceived sleep depth,
sleep latency (time to fall asleep), number of awakenings,
efficiency (percentage of time awake), and sleep quality.
It was recorded on a 100m-m visual-analogue scale
(higher scores representing better sleep). The total score
representing the overall perception of sleep (Kamdar et
al., 2012)
PSG (polysomnography)- is the current gold standard for
measuring sleep. This technique employs numerous
collections of surface electrodes, each measuring
physiologic parameters of sleep, including brain
dynamics of electroencephalography (EEG), eye
movements, muscle activity, heart physiology, and
respiratory function. (Marino et al., 2013)
VSH (Verran & Snyder- Helpern) such scale that has

been used to measure sleep quality in hospitalized

patients. It encompasses the different parameters of sleep
such as sleep disturbances, number of awakenings,
difficulty in falling asleep and time spent sleeping is a
valuable instrument. (Frighetto et al., 2004)
In Table 3, define the
following outcomes. You may
have to look outside the article
for definitions.

Table 3 describes the studies.

List the PICO components for
the following studies.

MSA (mid sleep awakening)- waking up in the middle of

the night occurred during period of stress (Morgenthaler,
2014)
According to National Sleep Foundations sleeptionary
(n. d), the definitions of common sleep terms:
SD (sleep depth)- common term for combined NREM
stage 3 and 4 sleep. In some literature, deep sleep is
applied to REM sleep.
SE (sleep efficiency) the proportion of sleep in the
episode potentially filled by sleep
SL (sleep latency) the duration of time from lights
out, or bedtime, to the onset of sleep.
SQ (sleep quality) ones satisfaction of the sleep
experience
TST (total sleep time) the amount of actually sleep
time in a sleep episode.
Alessi et al. (2005)
P- patients who ages not reported, develop sleep
deprivation in nursing homes (n =118, drop-out: 10)
I Sleep hygienic protocol; keep patient out of bed
during day time, sunlight exposure, bedtime routines and
reduction of light and noise levels.
C- compared with others who are cared as usual (n = 56)
O- reduced daytime sleep less than before, unchanged
total sleep time and mid sleep awakening

12

LaReau et al. (2008)

P- adult with mean age of 79.6 years on medical and
cardiology unit (n = 70, drop out 11)
I sleep hygiene protocol with personal hygiene, room
temperature adjustment, noise and light control,
relaxation, and other nursing interventions
C- compared to other patients who have usual night- time
care (n = 30)
O increase sleep quality, higher than before mid sleep
awakening, and the reduction of sleep medication.
Zimmerman et al. (1999)
P 96 older CABG patients with mean age of 67 in a
post-intensive care in hospital

In Table 4, what intervention

had the greatest effect on the
following outcomes?
You are a nurse working on a
hospital medical-surgical floor.
Based on this review, what
nursing interventions might
you consider using to promote
sleep in patients? Give
rationale for your answer.

You are on a research team at

the hospital that wants to test a
sleep hygiene protocol. Based
on this review, what should be
included in the protocol?

One of your relatives asks you

if using lavender oil for
aromatherapy is helpful to
promote sleep. Based on this
review, what would your reply
be?

I soothing music, instrumental music video divided into

2 groups getting two different interventions
C compared with controlled groups of patients who
offered rests before going to bed (n = 32)
O- In both groups, the use of music videos and music
therapy increases sleep quality higher than before.
Total sleep time: Stimulation of acupoints____
Sleep efficiency:_Massage_________________
Sleep latency:_Stimulation of acupoitnts______
According to Hellstrom, Fagerstrom, and Willman
(2011), massage, acupuncture, music therapy, natural
sounds and vision are effective to advance sleep in health
care settings. I would recommend the use of music
therapy because it is non-pharmacologic, convenient and
easily accessible and free from side effects. Even though
it is shown not as effective to increase total sleep time, I
would encourage sleep in patients by organizing my
routine assessment to minimize disturbance to them.
Also, reducing noise, adjusting comfortable room
temperature and light can add to effective sleep
promoting. And if it is indicated, I would recommend
massage therapy scheduled to relieve muscle tension
before bedtime.
Based on this review, sleep hygiene intervention is to
reduce and minimize environmental and personal factors
that can interrupt sleep. The protocol should include
regulation of room temperature, control of light and noise
level during the night, physical activities, avoid caffeine
and fluids at late hours, avoid daytime naps, and reduce
unnecessarily routine disturbance to patients.
I would not recommend the use of lavender oil for
aromatherapy to promote sleep. The evidence strength is
found in the article appeared to be low. Based on this
review, aromatherapy was investigated in only one study
and the efficacy of the study wasnt significant compared
to the group received no treatment.

3
5

References
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sleep quality in coronary care unit patients (Unpublished doctoral dissertation). Texas Womans
University, Denton, TX.
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%20ques
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Schmidt, N.A., & Brown, J.M. (2015). Evidence-based practice for nurses: Appraisal and application
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