Effects of strengthening prospective nursing practice on sleep quality, anxiety, and depression of awake patients in intensive care unit

Abstract

BACKGROUND

The intensive care unit (ICU) is a specialized hospital department. Awake patients in the ICU frequently encounter adverse psychological states, such as anxiety and fear, often accompanied by poor sleep quality. This situation has garnered significant attention within the medical community.

AIM

To investigate the impact of prospective nursing intervention strategies on the sleep quality and negative emotional state of conscious ICU patients.

METHODS

One hundred and twenty ICU awake patients admitted to our hospital were selected and randomly divided into control (n = 60) and observation (n = 60) groups. Patients in the control group were cared for using the conventional nursing model, while patients in the observation group were cared for using the prospective nursing model. Sleep improvement was assessed using the International Standardized Sleep Efficiency Formula and Pittsburgh Sleep Quality Index (PSQI). The PSQI, Generalized Anxiety Disorder 7-item (GAD-7) scale, Self-Depression Scale (SDS), and satisfaction before and after treatment were used to assess the negative emotional states of patients under the two care models.

RESULTS

Patient satisfaction in the observation group was significantly higher than in the control group. The GAD-7 and SDS scores in the observation group were significantly lower than those in the control group, and the total effective rate of sleep improvement in the observation group was significantly higher than in the control group. After treatment, the PSQI scores of the two groups significantly decreased (P < 0.05). The decrease in the observation group was more significant than that in the control group, and the difference between the two groups was statistically significant.

CONCLUSION

Prospective nursing interventions can improve sleep quality and psychological levels and significantly affect conscious patients in the ICU, which is worthy of clinical application.

Key Words: Prospective nursing; Intensive care unit; Sobriety; Mental health sleep quality; Anxiety and depression

Core Tip: This study establishes a theoretical foundation for the practical application of prospective nursing methods in clinical care and the rehabilitation prognosis of conscious patients within the intensive care unit (ICU). In the future, more attention should be focused on the sleep quality and mental well-being of awake patients in the ICU.

INTRODUCTION

Recent medical advances have increased the number of critically ill survivors in intensive care units (ICUs)[1]. Several studies have evaluated the prognosis of ICU-conscious patients[2]. Awake patients in the ICU often face complex rehabilitation processes, including long-term physical and cognitive impairments and poor quality of life[3,4]. The ICU constitutes a specialized department within the hospital. Conscious patients frequently experience negative psychological emotions, such as anxiety and fear, while those in ICUs often report poor sleep quality[5]. Their sleep patterns are highly dispersed and lack deep restorative rapid eye movement sleep. In the ICU environment, various factors are thought to lead to sleep deprivation, such as underlying disease status, pain, stress, anxiety, exposure to noise and irregular light, laboratory sampling, and mechanical ventilation[6,7]. Simultaneously, patients within the ICU often have varying degrees of depression, anxiety, and other adverse symptoms, which will destroy the physiological balance of patients and aggravate the symptoms. The mental symptoms of ICU-conscious patients were mainly related to the decline in their quality of life[4,8,9]. Recently, people have become increasingly interested in the mental health outcomes of ICU patients[10]. Recent systematic reviews focus on different aspects of mental health in this population, such as post-traumatic stress disorder and depression[5,9]. However, to the best of our knowledge, there are no published systematic reviews on nonspecific anxiety symptoms and sleep quality in awake patients in the ICU. Therefore, we decided to use a prospective nursing model to increase information exchange, psychological care, and sleep care, specifically for awake patients in the ICU, and to evaluate the effect of this nursing model using the Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder 7-item (GAD-7) scale, and Self-Depression Scale (SDS). Our goals were to: (1) Examine the prevalence of anxiety symptoms in awake ICU patients; (2) Evaluate sleep quality symptoms in awake ICU patients; (3) Determine patients’ risk factors during ICU admission; and (4) Evaluate intervention measures to prevent or treat anxiety symptoms after ICU admission. Prospective nursing, considering factors that could contribute to patients’ negative moods and sleep disturbances, aims to mitigate these issues and improve mood and sleep quality for patients.

MATERIALS AND METHODS

Research designers and participants

This was a controlled study; the participants were conscious patients admitted to our hospital’s ICU. Nursing interventions and questionnaire surveys were administered to the two research groups through randomized grouping. The inclusion criteria of the subjects were as follows: (1) The age of the subjects was more than 18 years old; (2) The patients were conscious; (3) All patients were admitted to ICU in our hospital; (4) All patients signed informed consent before participating in the study; and (5) Good compliance and ability to complete all questionnaires. Patients with severe heart, lung, liver, and renal diseases; cognitive impairment; and inability to complete the nursing research were excluded from the study (Ethical Approval Number: 231005).

Investigation methods

The control group included nursing and drug interventions. The patient’s vital signs were closely monitored, and routine nursing care in the ICU was provided. Observation group: The prospective nursing model was implemented to provide care for the patients in the observation group. The instruments used in this study had a certain degree of accuracy and stability and the consistency of multiple measurements was good under the same conditions.

The primary measures included: (1) Information transmission: Upon confirming the patient’s conscious state, the basic environment, attending doctor, and competent nurse were introduced to the patient to instill a sense of security. Detailed explanations of the treatment and nursing measures were provided, emphasizing their necessity; and (2) Communication strategies: For patients who faced difficulties in verbal expression, active communication was established using hand gestures or communication via pen and paper. This approach aimed to ensure patients correctly understood their condition upon awakening. Additionally, dedicated caregivers were assigned to provide bedside care for patients experiencing movement disorders in their hands, feet, or heads. These caregivers conveyed thoughts and intentions by interpreting eye-opening or closing movements, shaping lips, and other non-verbal cues. Psychological nursing: Nurses should care about patients as much as possible, communicate with them effectively, strengthen ward inspections, and pay attention to nonverbal communication to convey encouragement and comfort to patients. The degree of pain was evaluated based on the patient’s facial expressions. Patients who express themselves in words should listen patiently to their complaints, and their reasonable requirements should be satisfied as much as possible. Sleep care: Fully understand the sleep status of each patient and try to create a clean and quiet environment. Music can be played when individuals sleep; night equipment alarms should be set in an appropriate range; treatment and nursing-related operations should be concentrated during the day as far as possible; and movement, walking, talking, and closing the door should be performed gently to avoid waking the patient. Paying attention to the cleanliness and quietness of the environment: Patients can play their favorite music, but the volume must be adjusted between 25-30 dB. At night, lights must be turned off; floor lights must be turned on for easy inspection. Nursing operations can be arranged when the patient is awake, with gentle movements to prevent them from being interrupted during sleep and the inability to fall asleep. Early exercise guidance for patients: After thoroughly analyzing the recovery of the disease for walkable patients, assist in walking exercises at a designated time, with a distance of 500-1000 m and a time limit of 20 min. Attention should be paid to monitoring the various signs during exercise to determine tolerance. Once symptoms, such as palpitations and shortness of breath, occur, they stop immediately.

General information questionnaire

General information about the participants was collected, including name, age, sex, place of residence, marital status, income, and previous prevalence of chronic diseases.

PSQI

The PSQI was used to evaluate the participants’ sleep quality in the past month. It comprises 19 self-assessment items and five other self-assessment items, of which the 19^th self-assessment project and five other self-assessment items do not participate in the score; here, only 18 self-assessment items are involved[11]. A total of 18 items comprised seven components; each component was scored according to a grade of 0-3, the cumulative score for each element was the total score of the PSQI, and the total score ranged from 0-21. Higher scores indicate worse sleep quality. Score 0-5: Normal sleep quality; 6-10: Mild sleep disorder; 11-15: Moderate sleep disorder; 16-20: Severe sleep disorder; 21: Very severe sleep disorder.

Generalized Anxiety Scale

The GAD-7 had seven entries. Each entry is divided into four levels: 3 = almost every day, 2 = more than a week, 1 = several days, 0 = not at all. The total score is the sum of the scores of the seven entries, and the total score ranges from 0-21 points. Furthermore, 0-4 points were no clinically significant anxiety, 5-9 points, mild anxiety: 10-14 points, moderate anxiety: 2-15 points, or severe anxiety[12].

SDS

The SDS was developed by Zung in 1965. The scale comprises 20 items that reflect subjective feelings of depression, each of which is divided into four grades according to the frequency of symptoms, of which 10 are positive and 10 are negative. Individual scores for the 20 items were added to obtain an approximate score. The coarse score is multiplied by 1.25 and rounded to the nearest integer to obtain the standard score. The upper limit of the normal reference score was 53. Additionally, 53-62 years are considered to have mild depression, 63-72 years are believed to have moderate depression, and those aged 72 years or older are considered to have severe depression[13].

Evaluation of patient satisfaction

Satisfaction evaluation method: On the day the patient was discharged from the hospital, nursing service satisfaction during the treatment was scored anonymously, with 100 points as the full score, more than 80 points as satisfaction, less than 60 points as dissatisfaction, and the rest as basic satisfaction.

Statistical analysis

The SPSS Windows software version 26.0 was used to analyze the data. Continuous data were normally distributed and expressed as means and percentages. The median (quartile) was used to describe continuous variables with skewed distributions, and classified variables were expressed as numbers and percentages (%). A t-test was used to analyze the differences between the two groups of quantitative data. The χ² test was used to analyze multiple groups of data. Logical regression was used to analyze risk factors. All the analyses were conducted at the test level of α = 0.05, and the difference was considered statistically significant when P < 0.05.

RESULTS

General information about the study population

Between January 2022 and August 2023, 120 conscious patients at our hospital were randomly divided into control (n = 60) and observation (n = 60) groups. In the control group, there were 37 male and 23 female patients. The patients were admitted to the ICU for 1-6 d. The average treatment time was 2.7 ± 0.6 d, the patients were 20-73 years old, and the average age was 42.3 ± 6.4 years old. Additionally, 33 male and 27 female patients were in the observation group. The hospitalization time of the patients was 1-6 d. The average treatment time was 2.4 ± 0.5 d, the patients were 19-75 years old, and the average age was 43.9 ± 5.2 years old. There were no significant differences in the abovementioned indices between the observation and control groups (P > 0.05; Table 1).

Table 1 General survey of the case and control groups.

Variable		Observation group (n = 60)	Control group (n = 60)	P value
Year		43.9 ± 5.2	42.3 ± 6.4	0.091
Sex	Male	33	37	0.459
	Female	27	23
Current address	Urban	16	7	0.037
	Townships	44	53
Education	Junior high school and below	34	42	0.314
	High school	11	8
	College and above	15	10
Economic	≤ 2000	6	7	0.176
	2001–2999	23	32
	≥ 3000	31	21
Smoke	Yes	36	29	0.200
	No	24	31
Drink	Yes	45	50	0.261
	No	15	10
Inheritance	Yes	22	6	< 0.001
	No	38	54
Married	Yes	51	47	0.345
	No	9	13

Analysis of sleep and psychological state of the two groups of participants

Analysis of the difference in sleep quality between the two groups: The sleep analysis among the two groups revealed that six patients in the observation group had poor sleep quality, thus accounting for 10.0%. In comparison, the control group was 25, accounting for 41.7%. These differences were statistically significant (P < 0.05; Table 2).

Table 2 Analysis of the difference in sleep quality between the two groups, n (%).

Groups	Good quality of sleep	Poor sleep quality	Total
Observation group	54 (90.0)	6 (10.0)	60
Control group	35 (58.3)	25 (41.7)	60
χ2			15.7
P value			< 0.001

Analysis of GAD-7 scale differences between the two groups: To evaluate the anxiety state of the two groups, the anxiety state of the control group was significantly higher than that of the observation group (P < 0.001). The patients’ average scores were 3.9 in the observation group and 10.2 in the control group (Table 3).

Table 3 Analysis of the anxiety status of the two groups of patients.

Groups	Anxiety level score	Total
Observation group	3.9 ± 1.2	60
Control group	10.2 ± 3.2	60
t		8.21
P value		< 0.001

Analysis of the difference in depressive status between the two groups: The depression state in the case group was significantly higher than that in the control group (P < 0.05). Depression rates were 66.5% and 86.0% in the case and control groups, respectively (Table 4).

Table 4 Analysis of depression in the two groups of patients.

Groups	Standard score	Total
Observation group	38 ± 7.4	60
Control group	61 ± 9.2	60
t		19.2
P value		< 0.001

Effects of disease knowledge and satisfaction compared between the two groups

In the observation group, there were 58 satisfied patients, resulting in a satisfaction rate of 96.67% and an awareness rate of 91.67%. Conversely, the control group had 45 satisfied patients, equating to a satisfaction rate of 75.00% and an awareness rate of 70.00%. The observation group exhibited significantly higher rates than the control group, with a statistically significant difference (P < 0.05). The results are presented in Tables 5 and 6.

Table 5 Condition awareness table.

Groups	Number of examples	Knowledge of illness
		Totally aware	Aware	Not sure
Observation group	60	55	3	2
Control group	60	42	8	10
χ2				19.2
P value				< 0.001

Table 6 Nursing job satisfaction table.

Groups	Number of examples	Satisfaction with nursing work
		Totally satisfied	Basically satisfied	Not satisfied
Observation group	60	58	2	0
Control group	60	45	11	4
χ2				8.31
P value				< 0.001

DISCUSSION

Patients typically face severe conditions, leading to psychological distress marked by frequent fluctuations, and experience fear, depression, and other negative emotions. These factors contribute to poor sleep quality and can significantly impact the prognosis[10]. Therefore, it is necessary to provide humanized nursing intervention measures to improve the quality of sleep and life and reduce the psychological burden on patients. Addressing the importance of sleep and comfort during hospitalization in critically ill patients has been highlighted as a priority in intensive care. This study adopted prospective nursing care, including health education, teaching relevant health knowledge to sober patients in the ICU, eliminating fear, actively cooperating with treatment, explaining disease mechanisms, and improving treatment enthusiasm. Psychological nursing is characterized by individualization, integration, and effectiveness. This can maintain patients psychological and physiological balance and enhance their compliance with treatment to further improve the curative effect, reduce complications, and improve prognosis actively understanding patients negative mood, dredging psychological problems, informing patients about the impact of positive treatment, enhancing treatment confidence, listening to patients worries, providing answers, and eliminating destructive emotions furthermore, completing treatment with optimistic, positive, and healthy attitudes. Maintaining comfort in the treatment environment, creating a warm environment, reducing noise as much as possible improving sleep quality, ensuring adequate sleep caring for patients, communicating with patients, encouraging patients to express their emotions, eliminating strangeness, and enhancing their self-esteem. In the nursing process, patients can effectively reduce their panic about entering an unfamiliar environment by taking the initiative to introduce the environment. Inform the patient of the positive aspects of the results and the positive aspects of the recovery. The results indicated that after treatment, the PSQI score of the observation group decreased compared to the control group. Moreover, patient satisfaction in the observation group significantly surpassed that in the control group. Additionally, the GAD-7 and SDS scores among patients receiving prospective nursing intervention in the observation group were notably lower than those in the control group. Furthermore, the overall effective rate of sleep improvement was higher in the observation group than in the control group. Simultaneously, early exercise intervention can help some patients recover their physical function as soon as possible and promote blood circulation positively affecting the recovery from diseases. All the processes of nursing staff in the entire nursing process take into account the actual condition of patients and realize patient-centered nursing. This has a positive effect on nursing satisfaction. Both the physical and psychological aspects of awake patients are affected to a certain extent, and it is relatively complex to perform nursing interventions. To improve the quality of care for awake patients, nurses should possess proficient nursing skills, extensive clinical experience in the ICU, and the capability to address various challenges encountered during actual caregiving. In prospective nursing interventions, the psychological level of patients is always emphasized. By reinforcing health education and providing psychological counseling to ICU patients, we can strive to fulfill their physical and mental needs to the fullest extent possible. This approach can enhance their emotional well-being, promote treatment compliance, shorten the gap between nurses and patients, and foster a positive nurse patient relationship. The prospective nursing service model is a type of preventive nursing. By setting the research objects and methods in advance, we can further standardize nursing service behaviors, raise related questions predictably, and improve service homogeneity. Thus, we can provide scientific and effective forward-looking nursing service measures for patients, reduce nursing errors, and avoid the risks posed by nursing services to the greatest extent possible. Owing to the limited sample size of this study, larger multicenter randomized controlled studies are needed to expand our findings.

CONCLUSION

This study established that compared to the control group, the observation group with the prospective nursing intervention was less likely to have decreased sleep quality, anxiety, and depression. Additionally, they experienced significantly improved conditions, awareness, and discharge satisfaction. The study establishes a theoretical foundation for clinical nursing and rehabilitation prognosis of conscious patients within the ICU. In summary, the use of prospective nursing interventions in treating this disease has achieved a good clinical effect and is worthy of clinical application.