Crit Care Nurs Clin N Am 15 (2003) 329 – 340

Use of complementary and alternative therapies to promote

sleep in critically ill patients
Kathy Richards, PhD, RNa,b,*, Corey Nagel, BSN, RNc, Megan Markie, BSb,
Jean Elwell, BSN, RNb, Claudia Barone, EdD, RNb
a
Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, 3J/NLRVA, North Little Rock, AR 72114, USA
b
University of Arkansas for Medical Sciences 4301 W. Markham, Slot 529 Little Rock, AR 72205, USA
c
Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA

Sleep disturbance is common among patients in
intensive care units (ICUs). The impact of acute
illness and its treatment, pain, stress, environmental
noise, disruption of light/dark cycle, and caregiver
interruptions can all contribute to critically ill
patients’ inability to get adequate, restful sleep.
Occurring at a time when sleep needs are greatest,
sleep disturbance is a significant stressor for persons
experiencing acute illness. Furthermore, sleep disrup-
tion has been implicated in the development of the
iatrogenic delirium syndrome known as ICU psycho-
sis [1,2]. The mainstay of treatment for sleep disturb-
ance has been sedative-hypnotics, although these
compounds may have adverse effects including
rebound insomnia, falls, tolerance and withdrawal,
and delirium [3]. While still largely unexamined in
the ICU, the use of complementary and alternative
therapies to promote sleep in this setting may offer a
promising alternative to the pharmacologic approach.
In fact, recent clinical practice guidelines from the
American College of Critical Care Medicine on the
use of sedatives and analgesics in critically ill adults
advocate the use of nonpharmacologic methods such
as massage and music therapy to promote sleep [4].
This article uses a review of literature to present
factors contributing to sleep disturbance in critically
ill patients and interventions to promote sleep. Illness,
* Corresponding author. Central Arkansas Veterans
Healthcare System, 2200 Fort Roots Drive, 3J/NLRVA,
North Little Rock, AR 72114, USA.
E-mail address: richardskathyc@uams.edu
(K. Richards).
medications, environment, and anxiety are discussed
as factors contributing to sleep disturbance in crit-
ically ill patients. The complementary and alternative
therapies presented as possible nursing interventions
to promote sleep in critically ill patients are massage,
music, relaxation techniques, aromatherapy, thera-
peutic touch, environmental interventions, and alter-
native sedatives.
Normal sleep patterns
The ‘‘gold standard’’ in the objective measure-
ment of sleep is polysomnography, which consists
of simultaneous recordings of a patient’s electro-
encephalogram, electrooculogram, and electromyo-
gram. The stages that make up normal sleep
patterns are defined on the basis of these physiologic
parameters [5]. Broadly speaking, sleep consists of
two separate states: nonrapid eye movement (NREM)
sleep and rapid eye movement (REM) sleep. NREM
sleep, which accounts for approximately 70% to 75%
of total sleep, is further divided into four stages
(stages, 1, 2, 3, and 4) of progressively deeper sleep.
REM sleep is characterized by muscle atonia, epi-
sodic bursts of rapid eye movement, and brain activa-
tion. Sleep initiation occurs with stage 1 NREM, then
progresses through each stage of NREM sleep, with a
brief period of REM sleep occurring approximately
70 to 90 minutes after sleep onset. This cycle repeats
itself throughout the sleep period at intervals of 90 to
120 minutes, with periods of REM sleep becoming
progressively longer throughout the night [6].

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330 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
Sleep in critically ill patients
A number of studies have found that severely
disturbed sleep is common in ICUs [7 – 11]. Patients
in the ICU experience reduced sleep efficiency,
altered sleep stage patterns, severe fragmentation of
sleep, and diminished total sleep time [12]. They also
have decreased stages 3 and 4 NREM and REM
sleep, with more light sleep (stage 1 NREM) [13]. A
number of studies have shown that patients perceive
that their sleep is disturbed while they are in the ICU
[14]. Patients report having trouble falling and stay-
ing asleep, not feeling rested, increased daytime
napping, and a reduction of sleep quality [11].
Although the causes of sleep disturbance among
intensive care patients are not fully understood, there
are a number of potential sleep disrupters, including
the effects of the patients’ illness, medications, envi-
ronmental factors specific to the ICU, and patients’
anxiety [13].
Factors contributing to sleep disturbance in
critically ill patients
Illness and medications
Health-related changes and the resulting pain,
anxiety, and stress may contribute to sleep distur-
bance among critically ill patients. Medical prob-
lems that contribute to sleep disturbance include
cardiovascular disease and chronic obstructive pul-
monary disease [15]. For example, hypertension is
associated with breathing disturbances during sleep,
and chest discomfort from angina pectoris is asso-
ciated with awakenings [16]. Patients with chronic
bronchitis or emphysema frequently experience
hypoxemia while sleeping and have been shown to
experience more awakenings and decreased stages 3
and 4 NREM and REM sleep than healthy persons
[17]. Pain is frequently reported by hospitalized
patients to be a major cause of poor sleep and
nighttime awakenings, a fact underscoring the
importance of appropriate pain control among the
critically ill [18].
Lastly, a number of medications used to treat acute
and chronic illness may contribute to disturbed sleep.
Beta-adrenergic blockers and bronchodilators are
examples of two such medications. For a more com-
plete review of medications and sleep, refer to Rob-
inson and Zwillich [19]. Beta-adrenergic blockers
such as metoprolol, propranolol, and pindolol are
commonly used to treat hypertension and angina
pectoris in critically ill patients. These three beta-
blockers increase awakenings and decrease REM
sleep [20]. In a study of 10 female subjects, pindolol
significantly increased awakenings [20]. Two of the
bronchodilators used to treat reversible airway
obstruction in patients with chronic obstructive pul-
monary disease, aminophylline and theophylline, dis-
turb sleep [21,22]. In one study, 10 male patients with
obstructive sleep apnea were administered aminophyl-
line. The patients’ sleep efficiency was significantly
reduced and sleep fragmentation significantly
increased compared to a placebo [21]. In another
study, a trial of oral theophylline was administered
to 12 patients and overnight polysomnography was
used to measure sleep [22]. Sleep quality was sig-
nificantly reduced when theophylline was taken com-
pared to placebo. This was evidenced by a significant
decrease in the time from onset of sleep to final
awakening and an increase in awakenings [22].
Environment
Several environmental factors have been iden-
tified as contributing to poor sleep in the ICU.
Multiple studies have illustrated that noise is a
leading factor in sleep disturbance among hospital-
ized patients [23,24]. Most hospitals today have noise
levels ranging from 50 to 70 dBA during the day and
an average of 67 dBA at night, greatly surpassing the
United States Environmental Protection Agency
recommendation of 45 dBA throughout the day and
35 dBA at night [25]. A study conducted in the ICU
found that 51% of noise was modifiable, with patients
reporting staff conversation and television as the most
irritating disturbances [24].
Frequent awakenings by care providers present a
significant barrier to sleep in the hospital. An obser-
vational study of nursing practices in the ICU found
that patients were interrupted an average of once
every hour by care providers [14]. Light exposure
can also serve as an obstacle in attaining adequate
sleep. The absence of diurnal light cycles in many
hospital environments can result in sleep disruption,
because these cycles act as a cue, or zeitgeber,
supporting adequate function of the circadian system,
which regulates sleep. When this system is disrupted,
increased sleep onset latencies and decreased sub-
jective sleep quality have been reported [26]. Con-
stant light exposure also has been correlated with
cognitive disturbance in critically ill patients [27].
Other factors observed to contribute to sleep distur-
bance in the ICU environment include patients’
inability to perform their usual bedtime routines,
room temperature, and sleeping on an uncomfortable
or unfamiliar surface [28].
 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
Anxiety
Patients experiencing anxiety have difficulty
going to sleep and staying asleep [28,29]. Being
admitted to an ICU with a serious illness can cause
patients to experience an increase in anxiety [30]. The
patient’s uncertainty about the illness, lack of famil-
iarity with the hospital environment, and change in
routine can all contribute to increased anxiety. Of 84
postcardiac surgery patients in an ICU, 55% remem-
bered anxiety as being ‘‘at least moderately disturb-
ing’’ to their sleep [14]. Recognizing that anxiety is
one factor contributing to sleep disturbance in crit-
ically ill patients, nurses can focus interventions to
reduce patients’ anxiety.
Interventions
We conducted a systematic literature review of
research examining the use of complementary and
alternative therapies in intensive care to promote
sleep. We searched CINAHL and MEDLINE using
the keywords sleep, intensive care, massage, relaxa-
tion, imagery, aromatherapy, therapeutic touch, herbs,
melatonin, environment, and music therapy for En-
glish language articles from 1982 to 2002. This
search resulted in 43 articles. We also searched the
bibliographies of these articles. We found only seven
studies that reported a test of the effect of comple-
mentary and alternative therapies on sleep in ICUs.
Each complementary and alternative therapy will be
discussed in light of the evidence supporting its
efficacy in intensive care and the implications of each
therapy for nursing care. Table 1 summarizes studies
of the effect of complementary and alternative ther-
apies on patients in ICUs.
Massage
Beck defined massage as ‘‘the systematic manual
or mechanical manipulations of the soft tissues of the
body by such movements as rubbing, kneading,
pressing, rolling, slapping, and tapping, for thera-
peutic purposes such as promoting circulation of the
blood and lymph, relaxation of muscles, relief from
pain, restoration of metabolic balance, and other
benefits both physical and mental.’’[31] The gliding
strokes used in the massage technique of effleurage
promote relaxation and sleep. These strokes are
performed in a slow, rhythmic fashion, using firm,
steady pressure. The palms of the hands are used to
perform gliding strokes over large body areas such as
the back. Contact is maintained with the skin when-
331
ever possible [32]. Relaxing massage lasting 5 to
10 minutes can promote sleep [33]. Massage has
traditionally been a component of the evening or
‘‘ PM ’’ care provided by nurses to hospitalized
patients, although this practice is virtually nonexistent
in today’s healthcare environment [34]. In a system-
atic literature review of the effects of massage,
Richards et al found that reduction in anxiety was
the most consistent effect of massage in acutely and
critically ill patients, with eight of ten original
research studies reporting decreases in subjective
perception of anxiety or tension. In seven of ten
studies, physiologic indicators of the relaxation
response were reported after administration of a
massage intervention; these include reductions in
heart rate, respiratory rate, muscle tension, and oxy-
gen consumption [32]. Thus, massage may be an
effective intervention to reduce anxiety or tension that
interferes with sleep.
A limited number of studies have examined the
effect of massage on sleep in hospitalized patients. In
a recent study of 175 elderly patients hospitalized on
a general medical unit, a nonpharmacologic sleep
protocol consisting of a warm drink, a 5-minute back
rub, and a relaxation audio tape was administered to
patients complaining of poor sleep or requesting a
sedative-hypnotic [3]. Patients were assessed 1 hour
after administration of the protocol, and a sedative-
hypnotic was provided if the patient still requested it.
A significant positive correlation was found between
administration of the massage intervention and
improvement in reported sleep quality. Interestingly,
a steadily rising correlation was demonstrated as the
number of components of the protocol received by
the subject increased, suggesting a dose-response
relationship. Overall, implementation of this protocol
resulted in a reduction in sedative-hypnotic adminis-
tration, from 54% at baseline to 31% during the
intervention period.
Richards tested the effect of a back massage, a
relaxation audiotape, or usual care on the sleep of 69
older men with cardiovascular illness hospitalized in
intensive care [35]. Subjects were randomly assigned
to receive either a 6-minute effleurage back massage;
a 7.5-minute relaxation audiotape consisting of
music, guided imagery, and muscle relaxation; or
normal nursing care. The subjects’ sleep was objec-
tively evaluated using polysomnography. An increase
in the sleep efficiency index (the ratio of total sleep
time to nocturnal time spent in bed) was reported
among subjects in the massage group, who slept an
average of 1 hour longer than the control group. The
sleep efficiency index for the massage group was
14.7% higher than for the control group. REM sleep
 332
Table 1
Studies of the effect of alternative and complementary therapy on sleep in the ICU
Author/Year Setting/Sample Intervention Results Type of Study
Cox and Hayes . 2 Critical care units, ICU . A specially trained nurse . 29 patients fell asleep immediately . One group pretest-posttest
(1999) [58] and coronary care unit delivered therapeutic touch upon initiation of therapeutic touch experimental study

K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340

. 53 subjects, 37 men,
16 women, mean age
65 years
Richards . Veterans with diagnosis
(1998) [35] of cardiovascular illness in the ICU 6-minute effleurage back
. 69 men, mean age 65.8 years
Ryan et al . Hospitalized patients
(1992) [64] with coronary artery
disease (unclear if in ICU)
. Convenience sample of
33 subjects: 18 men, 15 women,
mean age 68 years
to all subjects
. Psychodynamic responses
were measured by patient
interviews immediately following
the therapeutic touch sessions
. Physiologic variables were
measured before and after
administration by changes in
heart rate, blood pressure,
respiration, and peripheral
oxygen saturation
. Group 1 (n = 24) received a
massage at bedtime
. Group 2 (n = 28) received a
teaching session on relaxation and
a 7.5-minute audiotape at bedtime
consisting of muscle relaxation,
mental imagery, and relaxing
background music
. Group 3 (controls, n = 17) received
usual nursing care with a 6-minute
rest period at bedtime
. Night 1: patients administered
nitroglycerin paste treatment according
to routine schedule (every 4 hours)
. Night 2: patients administered
nitroglycerin paste treatment
every 6 hours
or shortly after and stayed asleep until
later nursing care was performed
. There were no significant increases
or decreases in any of the physiologic
variables measured
. Patients who received a 6-minute . Randomized controlled trial
back massage slept 1 hour longer
than control group
. Nonsignificant trend toward increased
sleep efficiency; percent stage 2 nonrapid
eye movement (NREM) sleep; REM
sleep; percent wake after sleep onset;
and latency to sleep onset
. Sleep on night 2 (M = 6.48) was over . One group pretest-posttest
1 hour longer than night 1 (M = 5.24, P < .025) experimental study
. Sleep quality, measured by St. Mary’s
Hospital Sleep Questionnaire was
significantly ( P < .005) better on night 2
compared to control group
. None of the participants experienced
nocturnal angina on either night
Shilo et al . Pulmonary ICU
(2000) [69] . 8 patients hospitalized for
respiratory failure, 5 women,
3 men, mean age 62 years
. Control group: 6 patients
in general medical ward
Walder et al . Surgical ICU subdivided
(2000) [62] into 6 identical 3 bed-rooms
. 8 critically ill adults (gender
and mean age not stated)
Williamson . A step-down unit of a
(1992) [60] large public hospital
. 60 postoperative coronary
artery bypass graft patients:
45 men, 15 women, mean
age 58.6
Zimmerman et al . Convenience sample of 96
(1996) [37] postoperative patients having
coronary artery bypass surgery
. 68% men, 32% women,
mean age 67 years
. Day 1: baseline actigraphy scores
collected for all subjects
. Days 2 and 3: patients either received
3 mg of controlled-release melatonin
or placebo at 22:00
. Period 1 (n = 9) measurement of
baseline noise levels, using a sound
level meter; light levels, using a
luxmeter; and patients’ sleep, using
a multiple choice questionnaire
. Period 2 (n = 8) implementation of
guidelines to reduce nighttime light
and noise levels
. Group 1 (n = 30) Ocean sounds were
played throughout the night for three
consecutive nights
. Group 2 (controls, n = 30) No
modification of the environment except
for the elimination of white noise
. Group 1 (n = 32) music therapy:
30-minute sessions on second and
third postoperative days
. Group 2 (n = 32) music video therapy:
30-minute sessions of music and
visual images on second and third
postoperative days
. Group 3 (controls, n = 32) scheduled rest:
30-minute sessions of undisturbed
rest on second and third postoperative days
. Means for sleep variables were either . Pilot study—design unclear
not provided or were unclear and there
were no tests of significance
. In the patients who received melatonin,
only a few (1.4 F 3.7), short periods
(12 F 5.0 min) of awakenings were
observed in 5 participants, 3 experienced no
nighttime awakenings
. A significant decrease in noise ( P = 0.03), . One group pretest-posttest
and light ( P = 0.01) levels occurred in period 2 experimental study
K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
. A significant increase in light
variation ( P = 0.05)
. Patients estimated a higher number
of awakenings in period 2
. Patients in group 1 showed a significant . Randomized controlled trial
increase in sleep depth ( P = 0.001), quality
of sleep ( P = 0.003) and total sleep scores
( P = 0.002) compared to the control group
. Patients in group 1 reported being awake
less during the night ( P = 0.026) and
returning to sleep quicker ( P = 0.009) than
control group
. Music therapy group had significantly . Randomized controlled trial
( P < .05) lower scores on the evaluative
component of pain than control group on
postoperative day 2
. Video music therapy group had significantly
( P < .05) better sleep scores, measured by the
Richards-Campbell Sleep Questionnaire, than
the control group on morning of
postoperative Day
333
334 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
in the massage group was 35 minutes, whereas in the
control group REM sleep was 25 minutes (Table 1).
The results of these studies support the use of
relaxing massage as a nursing intervention to promote
sleep in ICU patients. Nurses are in a position to be
leaders in designing and implementing massage ther-
apy interventions. Richards et al have developed
protocols that nurses can use to guide development
of interventions specific to their setting [33]. By
reinstating massage as a nursing intervention, ICU
nurses can improve the quality of their patients’ sleep
and perhaps reduce the need for sedative-hypnotics.
Music
The use of music to promote health and well being
is referred to as music therapy [36]. Music therapy to
reduce anxiety has been well documented, with a
number of studies examining its effect on patients in
the ICU [37 – 42]. White reported that acute myo-
cardial infarction patients (N = 15) who received a
20-minute music therapy intervention had significant
reductions in heart rate, respiratory rate, and myocar-
dial oxygen demand when compared to matched
controls (N = 15) [30]. Other investigators have
reported similar reductions in subjective reports of
anxiety among patients with acute cardiovascular
illness and patients receiving ventilatory assistance
[39,43]. A recent meta-analysis of the effect of music
in acute inpatient settings concluded that music
therapy is effective in reducing anxiety during normal
care delivery, although it was not found to reduce the
anxiety of patients undergoing invasive or unpleasant
procedures [44].
Although a significant body of research exists
examining the effect of music therapy on anxiety,
few studies have explored sleep as an outcome mea-
sure. The effect of music therapy on the sleep of 96
postoperative cardiac surgical patients was the focus of
a study by Zimmerman et al [37]. Participants received
a music intervention, a music video intervention, or
scheduled rest period (control group), on the second
and third postoperative days. One way analysis of
variance was calculated on participants’ subjective
sleep scores taken on the third postoperative morning,
revealing significant differences between groups.
Posthoc analysis revealed that recipients of the music
video intervention had significantly higher sleep
scores indicating better sleep than did the control
group. The sleep scores of the music intervention
group also indicated an improvement in sleep when
compared with the control group, with the difference
between these two groups approaching statistical sig-
nificance (Table 1).
ICU nurses can easily integrate music therapy into
a patient’s plan of care [36]. A library of taped
musical selections is first needed as a radio’s selec-
tions and interruptions can be disruptive to the
patient. The characteristics of music best suited for
sleep and relaxation promotion are a tempo of
approximately 60 beats per minute, are composed
primarily of low tones, and are played predominately
by stringed instruments [30]. Headphones are neces-
sary to control volume and music quality. Tape play-
ers are convenient ways to play the music and do not
interfere with the other equipment necessary for the
patient’s care. Infection control issues must be
addressed, especially if tape players and headphones
are shared among patients. Before implementing
music therapy, the nurse needs to determine that the
patient enjoys listening to music.
Aromatherapy
Aromatherapy is the use of essential oils, such as
thyme, rosemary, lavender, and jasmine, extracted
from plants to facilitate healing or improve mood
[45,46]. These oils may be inhaled or applied to the
patient’s skin using baths, compresses, and massage. A
number of studies have examined the efficacy of
aromatherapy oils in improving mood, inducing
relaxation, and reducing anxiety, but only a few were
found that examined its’ efficacy in promoting sleep
[45,47].
Sleep was a variable in a study of the effects of
aromatherapy and massage on the well being of nine
patients with rheumatoid arthritis [47]. Participants
were randomized to received a 10-minute massage
with lavender oil, massage alone, or usual nursing
care on two consecutive nights. The patients receiv-
ing massage with lavender oil reported improved
sleep; however, quantitative measures yielded no
significant findings. In another study, sleep of 10
hospitalized older people was assessed by patient
report before and after aromatherapy [45]. Aroma-
therapy consisted of atmospheric vaporization of a
blend of basil, juniper, lavender, and sweet mar-
joram oils or vaporization of the oils combined with
a 5-minute hand massage. Night sedation was avail-
able as needed and was given on 34 patient nights
versus on 85 patient nights before use of aroma-
therapy. Before aromatherapy, patients reported a
good nights sleep on 73% of patient nights, whereas
after aromatherapy they reported a good nights sleep
on 97%.
The effect of aromatherapy on patients’ levels of
anxiety has been studied more frequently. The effects
of aromatherapy massage were evaluated in an
 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
experimental study of 122 ICU patients by assessing
physiologic stress indicators and patient reports of
anxiety levels, mood, and coping abilities [48]. The
study resulted in an improvement in levels of anxiety
and mood but no statistically significant differences
in the physiologic stress indicators [48]. Holmes et al
recently demonstrated in a placebo controlled study
of 15 severely demented patients that exposure to an
aerosolized lavender oil compound from 4 PM to 6 PM
resulted in modest improvement of agitated behavior
for most (66%) of the test subjects [49]. In a study by
Kite et al, 58 patients undergoing radical oncologic
treatment received a series of six weekly aromather-
apy massage treatments. Comparison between base-
line and postintervention revealed a significant
decrease in anxiety and depression following the
aromatherapy[50]; however, one drawback to this
and similar studies combining aromatherapy and
massage is the difficulty in determining the specific
source of the effects observed by the investigators.
Randomized controlled trials to study the efficacy
and safety of aromatherapy for promoting sleep in
ICU patients are needed. Aromatherapy may be
contraindicated for persons with reactive airway dis-
ease, although this has not been studied.
Relaxation techniques
Progressive relaxation and guided imagery are
two techniques that have been effective in reducing
anxiety and promoting rest. Relaxation procedures
are aimed at activating the parasympathetic nervous
system, which decreases arousal levels and induces a
calm state. Progressive relaxation involves the con-
traction and relaxation of each major muscle group
while identifying areas of tension and consciously
releasing it. In guided imagery, the patient imagines
being in a peaceful setting, using all senses to
experience the situation. Cues, provided by the nurse,
are used to lead the patient through the process.
Scenes commonly used include lying on a beach,
watching a sunset, and floating down a stream.
Nurses can teach guided imagery and progressive
muscle relaxation to the patient so they can continue
to use them independently.
These techniques have been proven efficacious in
promoting sleep, reducing pain, and relieving anxiety
among hospitalized patients [51,52]. In a study of 30
patients in the coronary care unit, the treatment group
was given two cassette tapes guiding progressive
muscle relaxation sessions and told to listen to them
at least once a day. Patients who used the tapes had
significantly lower scores on the state component of
the Spielberger State-Trait Anxiety Inventory when
335
compared to baseline, indicating a decrease in anxi-
ety. The treatment group also reported a significantly
lower incidence of pain than the control group at
discharge [53]. Griffin et al found that when 100
acutely ill hospitalized patients used progressive
muscle relaxation, they scored significantly lower
than baseline on the Top Disturbance Due to Hospital
Noise Scale [54]. Johnson examined the effect of
progressive relaxation on sleep in 176 men and
women living in their homes. During the intervention
phase, participants received instruction in progressive
relaxation and were provided a tape for home use at
bedtime. Sleep variables were measured by the Sleep
Pattern Questionnaire. After using progressive relaxa-
tion for 5 days, participants reported a significant
increase in bedtime state of mind, lower sleep onset
latency, improved soundness of sleep, a decrease in
nighttime arousal, and a greater satisfaction with
sleep [55]. Guided imagery has been shown to
decrease pain and anxiety in perioperative patients.
When participants used guided imagery tapes 3 days
before surgery and 6 days after surgery, they required
almost 50% less postoperative narcotic medications
(median 185 mg) than the control group (median
326 mg) [56].
Relaxation techniques have been shown to be
effective in improving patient comfort by reducing
anxiety and tension. Instruction in progressive
relaxation and guided imagery should be part of
routine nursing care. No adverse effects have been
reported in association with using these methods of
treatment. Imagery should be immediately discon-
tinued if the patient becomes notably agitated or
upset. After initial instruction and outcome evalu-
ation, guide tapes can be provided to encourage
independent use.
Therapeutic touch
Therapeutic touch, formally introduced into the
nursing profession in 1979 by Dolores Krieger [57],
is a technique in which a trained practitioner uses
mental and physical methods to restore a balanced
energy field to the compromised individual. It is used
under the assumption that all humans possess an
energy field that lies within and immediately outside
of the body. With illness and pain, this field becomes
disturbed; therefore, ailments can be alleviated by the
reorganization of energy by the practitioner through
mental intent. Tactile stimulation is often added to
facilitate the healing effect, but therapeutic touch also
can be performed without physical contact when
appropriate. Although this therapy is fairly new and
controversial in the United States, similar methods of
336 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
healing extend internationally to areas including
Egypt, Japan, China, Thailand, and India where they
have been used for centuries.
Therapeutic touch was recently identified as
increasing relaxation and sleep in the ICU envi-
ronment. Cox and Hayes presented two case studies
of patients in the ICU who received a 5-minute
therapeutic touch treatment session by a trained
practitioner for 5-10 days. Both participants reported
falling asleep during or soon after the treatment. One
of the patients stated, ‘‘I always go to sleep when you
do this. I can’t sleep very well at night because of all
the noise and lights and things that go on here. . .
would you come back tonight and do this to help me
go to sleep?’’[57] In separate study of 53 critically ill
patients who received therapeutic touch, Cox and
Hayes found that many of the subjects reported
falling asleep during the intervention and slept
soundly for several hours after the conclusion of the
intervention (see Table 1) [58].
Therapeutic touch also has been shown to reduce
anxiety, which may adversely affect sleep. In a study
of 31 psychiatric patients, those who were adminis-
tered therapeutic touch showed a significant decrease
in anxiety as measured by the State-Trait Anxiety
Inventory [59].
While the limited research indicates a positive
effect, randomized controlled trials are required to
determine if therapeutic touch would be an effective
intervention to promote sleep in the ICU. There have
been no adverse effects reported from this noninva-
sive therapy. Perhaps a future study could teach basic
techniques for administering therapeutic touch to
intensive care nursing staff and evaluate the effective-
ness of the program. Outcomes of interest would
include sleep, costs, and utilization. Advanced thera-
peutic touch practitioners, who have completed
90 hours of formal instruction and 2 or more years
of apprenticeship under an established professional,
could provide the education in therapeutic touch for
the ICU nurses.
Environmental interventions
Interventions to create an environment more con-
ducive to sleep can be extremely beneficial and easily
implemented. Modifiable sources of noise, such as
staff conversations, have been successfully reduced
after implementation of behavior modification tech-
niques directed toward hospital staff [24]. Following
the implementation of an environmental modification
program in the ICU, which consisted of staff edu-
cation on noise reduction techniques and posted
reminders to minimize disruptions, both total noise
levels and the number of sound peaks greater than or
equal to 80 dBA were significantly reduced [24].
The masking of noise has been demonstrated to
improve self-reported sleep quality and to reduce the
number of nighttime awakenings [11,60]. Williamson
tested the effect of ocean sounds on the sleep of
postoperative coronary artery bypass graft patients.
On 3 consecutive nights in a step-down unit, 30
subjects received an intervention consisting of ocean
sounds played over a speaker in their room from
evening to morning. A comparison group received
usual care. An analysis of covariance of subjective
sleep scores revealed significant difference in total
sleep score between groups, with the intervention
group reporting better quality sleep, fewer awaken-
ings, quicker return to sleep following awakenings,
and deeper sleep than did the comparison group
(Table 1) [60].
The use of earplugs also has been shown to
increase REM sleep onset and duration in adults
exposed to ICU noise conditions. Wallace et al
conducted a study of six healthy men in a sleep
laboratory for 5 nights. Polysomnography was per-
formed by experienced technologists to measure
sleep parameters. On nights 4 and 5, participants
were randomly divided and half were instructed to
use earplugs while both groups were exposed to
recordings of ICU noise throughout the night. Data
revealed that the group using earplugs experienced a
significant decrease in REM latency and an increased
percentage of REM sleep [61].
Unit lights should be dimmed during normal sleep
hours to maintain the circadian light cycles necessary
to healthy sleep. Although most hospital units already
decrease light levels at night, the increase in light
during nighttime interventions continues to be a dis-
turbance. Walder et al was successful in significantly
lowering light levels at night after implementing
guidelines to promote sleep but found that patients’
sleep, estimated by the nurse using a multiple choice
questionnaire, was more disturbed (Table 1). This may
be because of the greater variation occurring when
lights were turned up periodically throughout the night
to perform care activities [62]. Perhaps the use of eye
masks would be helpful in alleviating this problem.
Whenever possible, patient care activities should
be clustered to provide sufficient time for uninter-
rupted sleep [63]. For example, when patients with
coronary artery disease were administered nitropaste
every 6 hours instead of every 4 hours to increase
periods of undisturbed rest, increased sleep time
and significantly improved sleep quality were
reported without the occurrence of nocturnal angina
(Table 1) [64].
 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
While in the ICU, patients are at the mercy of
hospital schedules. The loss of power experienced by
patients as a result of restrictions enforced in the ICU
may increase anxiety and adversely affect sleep.
Ziemann and Dracup examined the effects of
patient – nurse contracts in 41 patients regarding their
visitation, activity, patient teaching, and daily hygiene
schedules. They found that when patients were able
to maintain some control over their environment,
significant decreases in anxiety, depression, and hos-
tility occurred [65]. Although we found no studies
examining the specific relationship between this
intervention and sleep, an intervention that decreases
anxiety likely will improve sleep.
Nurses have direct control over the environment
and are responsible for creating and maintaining
optimum conditions to promote healing. Interven-
tions as simple as lowering voices and lights can
make the ICU more conducive to sleep. Equipment
such as earplugs and eye masks are easily used and
inexpensive and should be offered routinely. Nurses
need to be aware of the feelings of powerlessness that
patients experience and the resulting emotional dam-
age that can occur. Patients could take part in deter-
mining their own visitation and activity schedules to
provide them with a sense of control. Unnecessary
interruptions can be easily eliminated by improved
coordination of activities and postponement of non-
essential procedures while the patient is sleeping.
Most importantly, the hospital staff must have an
awareness of the important role sleep plays in pre-
serving physical and mental health. This realization
will compel nurses to take an active role in creating a
more sleep friendly environment.
Alternative sedatives
Recently, the use of nontraditional medications
as sleep aids has grown in popularity among the
public sector. Two of the most common are valerian
and melatonin.
Valerian (Valeriana officinalis) is a perennial herb
found in North America, Europe, and Asia. Valerian is
made up of volatile oils, valepotriates, and additional,
currently unidentified, constituents. These substances
act as a central nervous system depressant, presum-
ably by inhibiting the breakdown of gamma-amino-
butyric acid, an amino acid found in the brain, heart,
lungs, and kidneys that acts as a neurotransmitter.
In a study consisting of 128 volunteers who were
administered 400 mg of valerian 1 hour before
bedtime, sleep latency was significantly reduced,
sleep quality was increased significantly when com-
pared to placebo, and there were no reported hang-
337
over effects [66]. Donath et al found that when
multiple doses of valerian were administered to
patients with mild psychophysiologic insomnia,
stages 3 and 4 NREM sleep latency was significantly
reduced and the percentage increased [67]. Although
the only reported side effect is residual sedation with
higher doses and there have been no reported drug
interactions, further study is needed to validate the
safety and efficacy of this substance.
Melatonin, a hormone secreted by the pineal gland
in accordance with circadian rhythm, is secreted at
the highest level during the night in normal, healthy
individuals. A deficit in production and secretion of
melatonin may alter sleep function; therefore, the
administration of this hormone is thought to promote
sleep when imbalances occur.
Garfinkel et al conducted a randomized, double
blind cross-over study using 12 elderly subjects. For
3 weeks, participants were administered 2 mg of
controlled-release melatonin. Sleep efficiency, mea-
sured by actigraphy, was significantly greater and
wake time after sleep onset decreased [68]. The only
study found pertaining to the use of melatonin
therapy in the ICU was a 3-day double-blind study
of eight patients in the pulmonary ICU. In this study,
Shilo et al found that the administration of 3 mg of
controlled-release melatonin induced sleep in all
subjects and produced no side effects; however,
means for sleep variables were either not provided
or were unclear and there were no tests of signifi-
cance (Table 1) [69].
Due to the limited knowledge concerning the side
effects and drug interactions of nontraditional medi-
cations as well as the compromised physical con-
dition of patients in the ICU, the present use of these
substances in this setting is not recommended. The
literature pertaining to the effects of melatonin and
valerian on specific sleep parameters is limited.
Further, more explicit evidence is needed to deter-
mine the safety and benefits of these modes of
therapy in the intensive care patient.
Summary
The efficacy of complementary and alternative
therapies for sleep promotion in critically ill patients
is largely unexamined. We found only seven studies
(three on environmental interventions and one each
on massage, music therapy, therapeutic touch, and
melatonin) that examined the effect of complemen-
tary and alternative therapies. A number of studies,
however, have shown that massage, music therapy,
and therapeutic touch promote relaxation and comfort
338 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
in critically ill patients, which likely leads to
improved sleep. Massage, music therapy, and thera-
peutic touch are safe for critically ill patients and
should be routinely applied by ICU nurses who have
received training on how to administer these speci-
alized interventions. Environmental interventions,
such as reducing noise, playing white noise such as
ocean sounds, and decreasing interruptions to sleep
for care, also are safe and logical interventions that
ICU nurses should use to help patients sleep. Pro-
gressive muscle relaxation has been extensively
studied and shown to be efficacious for improving
sleep in persons with insomnia; however, progressive
muscle relaxation requires that patients consciously
attend to relaxing specific muscle groups and practice
these techniques, which may be difficult for critically
ill patients. We do not currently recommend aroma-
therapy and alternative sedatives, such as valerian and
melatonin, for sleep promotion in critically ill patients
because the safety of these substances is unclear.
In summary, we recommend that ICU nurses
implement music therapy, environmental interven-
tions, therapeutic touch, and relaxing massage to
promote sleep in critically ill patients. These inter-
ventions are safe and may improve patient sleep,
although randomized controlled trials are needed to
test their efficacy. Aromatherapy and alternative sed-
atives require further investigation to determine their
safety and efficacy.
References
[1] Wilson VS. Identification of stressors related to pa-
tients’ psychologic responses to the surgical intensive
care unit. Heart Lung 1987;16:267 – 73.
[2] Helton MC, Gordon SH, Nunnery SL. The correlation
between sleep deprivation and the intensive care unit
syndrome. Heart Lung 1980;9:464 – 8.
[3] McDowell JA, Mion LC, Lydon TJ, Inouye SK. A
nonpharmacologic sleep protocol for hospitalized older
patients. J Am Geriatr Soc 1998;46:700 – 5.
[4] Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D,
Wittbrodt ET, et al. Clinical practice guidelines for the
sustained use of sedatives and analgesics in the critically
ill adult. Crit Care Med 2002;30:119 – 41.
[5] Carskadon MA, Rechtschaffen A. Monitoring and
staging human sleep. In: Kryger MH, Roth T, Dement
WC, editors. Principles and practice of sleep medi-
cine. 3rd edition. Philadelphia: W.B. Saunders; 1994.
p. 1197 – 215.
[6] Carskadon MA, Dement WC. Normal human sleep: an
overview. In: Kryger MH, Roth T, Dement WC, edi-
tors. Principles and practice of sleep medicine. 3rd
edition. Philadelphia: WB Saunders; 2000. p. 15 – 25.
[7] Aaron JN, Carlisle CC, Carskadon MA, Meyer TJ, Hill
NS, Millman RP. Environmental noise as a cause of
sleep disruption in an intermediate respiratory care
unit. Sleep 1996;19:707 – 10.
[8] Cooper AB, Thornley KS, Young GB, Slutsky AS,
Stewart TE, Hanly PJ. Sleep in critically ill patients
requiring mechanical ventilation. Chest 2000;117:
809 – 18.
[9] Edell-Gustafsson UM, Hetta JE, Aren CB. Sleep and
quality of life assessment in patients undergoing coro-
nary artery bypass grafting. J Adv Nurs 1999;29:
1213 – 20.
[10] Richards KC, Bairnsfather L. A description of night
sleep patterns in the critical care unit. Heart Lung
1988;17:35 – 42.
[11] Redeker NS. Sleep in acute care settings: an integrative
review. J Nurs Scholarsh 2000;32:31 – 8.
[12] Richards KC. Sleep promotion in the critical care unit.
AACN Clin Issues Crit Care Nurs 1994;5:152 – 8.
[13] Cooper AB, Gabor JY, Hanly PJ. Sleep in the critically
ill patient. Seminars in Respiratory and Critical Care
Medicine 2001;22:153 – 63.
[14] Simpson T, Lee ER, Cameron C. Patients’ perceptions
of environmental factors that disturb sleep after cardiac
surgery. Am J Crit Care 1996;5:173 – 81.
[15] Beck-Little R, Weinrich SP. Assessment and manage-
ment of sleep disorders in the elderly. J Gerontol Nurs
1998;24:21 – 9.
[16] Redeker NS, Tamburri L, Howland CL. Prehospital
correlates of sleep in patients hospitalized with cardiac
disease. Res Nurs Health 1998;21:27 – 37.
[17] Calverley PM, Brezinova V, Douglas NJ, Catterall JR,
Flenley DC. The effect of oxygenation on sleep quality
in chronic bronchitis and emphysema. Am Rev Respir
Dis 1982;126:206 – 10.
[18] Ersser S, Wiles A, Taylor H, Wade S, Walsh R, Bentley
T. The sleep of older people in hospital and nursing
homes. J Clin Nurs 1999;8:360 – 8.
[19] Robinson RW, Zwillich CW. Medications, sleep, and
breathing. In: Kryger MH, Roth T, Dement WC, edi-
tors. Principle and practice of sleep medicine. 3rd edi-
tion. Philadelphia: W.B. Saunders; 2000. p. 797 – 812.
[20] Betts TA, Alford C. Beta-blockers and sleep: a con-
trolled trial. Eur J Clin Pharmacol 1985;28(Suppl):
65 – 8.
[21] Espinoza H, Antic R, Thornton AT, McEvoy RD. The
effects of aminophylline on sleep and sleep-disordered
breathing in patients with obstructive sleep apnea syn-
drome. Am Rev Respir Dis 1987;136:80 – 4.
[22] Mulloy E, McNicholas WT. Theophylline in obstruc-
tive sleep apnea: a double-blind evaluation. Chest
1992;101:753 – 7.
[23] Foy A, O’Connell D, Henry D, Kelly J, Cocking S,
Halliday J. Benzodiazepine use as a cause of cognitive
impairment in elderly hospital inpatients. J Gerontol A
Biol Sci Med Sci Series A, Biological Sciences &
Medical Sciences 1995;50:M99 – 106.
[24] Kahn DM, Cook TE, Carlisle CC, Nelson DL, Kramer
NR, Millman RP. Identification and modification of
 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
environmental noise in an ICU setting. Chest 1998;
114:535 – 40.
[25] Tullmann DF, Dracup K. Creating a healing environ-
ment for elders. AACN Clin Issues 2000;11:34 – 50.
[26] Monk TH, Buysse DJ, Billy BD, Kennedy KS, Kupfer
DJ. The effects on human sleep and circadian rhythms
of 17 days of continuous bed rest in the absence of
daylight. Sleep 1997;20:858 – 64.
[27] Fontaine DK, Briggs LP, Pope-Smith B. Designing
humanistic critical care environments. Crit Care Nurs
Q 2001;24:21 – 34.
[28] Webster RA, Thompson DR. Sleep in hospital. J Adv
Nurs 1986;11:447 – 57.
[29] Floyd JA. Sleep promotion in adults. Annu Rev Nurs
Res 1999;17:27 – 56.
[30] White JM. Effects of relaxing music on cardiac auto-
nomic balance and anxiety after acute myocardial in-
farction. Am J Crit Care 1999;8:220 – 30.
[31] Beck MF. Milady’s theory and practice of therapeutic
massage. Albany: Milady Publishing; 1999.
[32] Richards KC, Gibson R, Overton-McCoy AL. Effects
of massage in acute and critical care. AACN Clin Is-
sues 2000;11:77 – 96.
[33] Richards KC, Benham B, Shannon L, DeClerk L. Pro-
moting sleep in acute and critical care. Alisa Viejo, CA:
American Association of Critical Care Nurses; 1998.
[34] Richards K, Brunk Q. Whatever happened to PM care?
Little Rock, AR: 1999. (unpublished presentation).
[35] Richards KC. Effect of a back massage and relaxation
intervention on sleep in critically ill patients. Am J Crit
Care 1998;7:288 – 99.
[36] Chlan L, Tracy MF. Music therapy in critical care:
indications and guidelines for intervention. Crit Care
Nurse 1999;19:35 – 41.
[37] Zimmerman L, Nieveen J, Barnason S, Schmaderer M.
The effects of music interventions on postoperative
pain and sleep in coronary artery bypass graft (CABG)
patients. Sch Inq Nurs Pract 1996;10:153 – 70.
[38] Guzzetta CE. Effects of relaxation and music therapy
on patients in a coronary care unit with presumptive
acute myocardial infarction. Heart Lung 1989;18:
609 – 16.
[39] Bolwerk CA. Effects of relaxing music on state anxiety
in myocardial infarction patients. Crit Care Nurs Q
1990;13:63 – 72.
[40] Davis-Rollans C, Cunningham SG. Physiologic re-
sponses of coronary care patients to selected music.
Heart Lung 1987;16:370 – 8.
[41] Barnason S, Zimmerman L, Nieveen J. The effects of
music interventions on anxiety in the patient after cor-
onary artery bypass grafting. Heart Lung 1995;24:
124 – 32.
[42] Updike P. Music therapy results for ICU patients. Di-
mens Crit Care Nurs 1990;9:39 – 45.
[43] Valencia-Flores M, Campos RM, Mendez J, Haro R,
Schenkel E, Bliwise D, et al. Multiple sleep latency test
(MSLT) and sleep apnea in aged women. Sleep 1993;
16:114 – 7.
[44] Evans D. The effectiveness of music as an intervention
339
for hospital patients: a systematic review. J Adv Nurs
2002;37:8 – 18.
[45] Cannard G. Complementary therapies. On the scent of
a good night’s sleep. Nurs Stand 1995;9:21 – 3.
[46] Waldman CS, Tseng P, Meulman P, Whittet HB. Aro-
matherapy in the intensive care unit. Care of the Crit-
ically Ill 1993;9:170 – 4.
[47] Brownfield A. Aromatherapy in arthritis: a study. Nurs
Stand 1998;13:34 – 5.
[48] Dunn C, Sleep J, Collett D. Sensing an improvement:
an experimental study to evaluate the use of aroma-
therapy, massage and periods of rest in an intensive
care unit. J Adv Nurs 1995;21:34 – 40.
[49] Holmes C, Hopkins V, Hensford C, MacLaughlin V,
Wilkinson D, Rosenvinge H. Lavender oil as a treat-
ment for agitated behaviour in severe dementia: a pla-
cebo controlled study. Int J Geriatr Psychiatry 2002;17:
305 – 8.
[50] Kite SM, Maher EJ, Anderson K, Young T, Young J,
Wood J, et al. Development of an aromatherapy service
at a Cancer Centre. Palliat Med 1998;12:171 – 80.
[51] Turner RM. Behavioral self-control procedures for dis-
orders of initiating and maintaining sleep (DIMS). Clin
Psychol Rev 1986;6:27 – 38.
[52] Tiernan PJ. Independent nursing interventions: relaxa-
tion and guided imagery in critical care. Crit Care
Nurse 1994;14:47 – 51.
[53] Hase S, Douglas A. Effects of relaxation training on
recovery from myocardial infarction. Austral J Adv
Nurs 1987;5:18 – 27.
[54] Griffin JP, Myers S, Kopelke C, Walker D. The effects
of progressive muscular relaxation on subjectively re-
ported disturbance due to hospital noise. Behav Med
1988;14:37 – 42.
[55] Johnson JE. Progressive relaxation and the sleep of
older men and women. J Community Health Nurs
1993;10:31 – 8.
[56] Tusek D, Church JM, Fazio VW. Guided imagery as a
coping strategy for perioperative patients. AORN J
1997;66:644 – 9.
[57] Cox C, Hayes J. Experiences of administering and
receiving therapeutic touch in intensive care. Intensive
Crit Care Nurs 1999;15:283 – 7.
[58] Cox C, Hayes J. Physiologic and psychodynamic
responses to the administration of therapeutic touch
in critical care. Intensive Crit Care Nurs 1999;15:
363 – 8.
[59] Gagne D, Toye RC. The effects of therapeutic touch
and relaxation therapy in reducing anxiety. Arch Psy-
chiatr Nurs 1994;8:184 – 9.
[60] Williamson JW. The effects of ocean sounds on sleep
after coronary artery bypass graft surgery. Am J Crit
Care 1992;1:91 – 7.
[61] Wallace CJ, Robins J, Alvord LS, Walker JM. The
effect of earplugs on sleep measures during exposure
to simulated intensive care unit noise. Am J Crit Care
1999;8:210 – 9.
[62] Walder B, Francioli D, Meyer JJ, Lancon M, Romand
JA. Effects of guidelines implementation in a surgical
340 K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340
intensive care unit to control nighttime light and noise
levels. Crit Care Med 2000;28:2242 – 7.
[63] Hilton BA. Quantity and quality of patients’ sleep and
sleep-disturbing factors in a respiratory intensive care
unit. J Adv Nurs 1976;1:453 – 68.
[64] Ryan M, Gallagher S, Wandel JC. Effect of nitropaste
administration times on sleep and nocturnal angina.
Appl Nurs Res 1992;5:84 – 6.
[65] Ziemann KM, Dracup K. Patient-nurse contracts in
critical care: a controlled trial. Prog Cardiovasc Nurs
1990;5:98 – 103.
[66] Leathwood PD, Chauffard F, Heck E, Munoz-Box R.
Aqueous extract of valerian root (Valeriana officinalis
L.) improves sleep quality in man. Pharmacol Biochem
Behav 1982;17:65 – 71.
[67] Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I,
Roots I. Critical evaluation of the effect of valerian
extract on sleep structure and sleep quality. Pharma-
copsychiatry 2000;33:47 – 53.
[68] Garfinkel D, Laudon M, Nof D, Zisapel N. Improve-
ment of sleep quality in elderly people by controlled-
release melatonin. Lancet 1995;346:541 – 4.
[69] Shilo L, Dagan Y, Smorjik Y, Weinberg U, Dolev S,
Komptel B, et al. Effect of melatonin on sleep quality
of COPD intensive care patients: a pilot study. Chrono-
biol Int 2000;17:71 – 6.