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

l l 2 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 Background/Significance

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

l l 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 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 8 M (SD); range Age (in years)50.5(14.7); n (%) Gender Female Male 23 (57.5) 17 (42.5) Race African American Caucasian 11 (27.5) 29 (72.5) Admitting Diagnosis Category Digestive Disease Wound/Vascular Respiratory Disease Infectious Processes Spine Related Head/Brain Disease Urinary Disease Endocrine Disease 15 (37.5) 8 (20.0) 5 (12.5) 3 ( 7.5) 2 ( 5.0) 1 ( 2.5)

l l 9 Light Exposure Patterns Among Study Participants

l l 10 nMSD South-West Day Night North-East Day Night 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 11 Sleep-wake patterns Nighttime sleep, in minutes (M = , SD = 72.27, range to ) Daytime sleep, in minutes (M = , SD = 81.40, range 5.33 to ) Further analysis – 35% - slept >3 hours (>183 minutes) day – 50% - slept <4 hours (<233 minutes) night

l l 12 Sleep-wake patterns: Fragmentation 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 = , SD = 48.67, range to ) – 25% were awake 145 minutes (2.5 hours) first sleep episode on the first night of the study

l l 13 Sleep-wake patterns: Fragmentation 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)

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l l 15 POMS™ Brief questionnaire results M SD RangeNormative Values MinimumMaximum M SD TMD Tension Depression Anger Vigor Fatigue Confusion Mood

l l 16 MSDMinimumMaximum Morning (6am-noon) Afternoon (noon–5pm) Evening (5pm-10pm) Night (10pm-6am) Total (24 hours) Mean Pain Scores over the 72 hours of the Study (N = 40)

l l 17 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 Age and Gender 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 18 Opioid Use Over 72 hours: mean grams of oral morphine equivalent used daily = (SD = ) 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 19 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) Significant Correlations

l l 20 Only one variable, fatigue, significantly predicted pain, R 2 =.11, R 2 adj =.09, F(1, 38) = 4.84, p <.01 Light exposure significantly predicted mean fatigue scores, R 2 =.11, R 2 adj =.09, F(1, 38) = 4.86, p <.05. Significant Predictors

l l 21 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 Interpretation

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

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 X X X OO Checking the Study Model… Light Exposure Sleep-Wake Patterns Mood Pain

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 X OO But perhaps… Light Exposure Sleep-Wake Patterns Mood Pain OO

l l 25 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 Limitations

l l 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 27 Long-term Goals 1. Bring to light the problem of inadequately managed pain in adult medical inpatients 2. Develop intervention studies involving manipulation of hospital lighting to treat sleep-wake disturbances, mood, and pain.

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

l l 29 Questions?