eye masks and earplugs improve patient's perception of sleep

EVALUATION

doi: 10.1111/j.1478-5153.2012.00501.x

Eye masks and earplugs improvepatient’s perception of sleepCatherine Jones and Deborah Dawson

ABSTRACTBackground: Critical care patients experience deranged sleep for a number of reasons including noise, environment, severity of illness andcare activities. This service evaluation was prompted by the concern that patients were not getting enough sleep because of excessive noiselevels in our unit.Aim: To determine self-reported sleep experiences and perceived factors affecting sleep quality among intensive care patients before andafter the introduction of earplugs and eye masks.Design: A pre/post intervention service evaluation (n = 100) was completed to evaluate the efficacy of eye masks and earplugs in criticalcare patients.Methods: Participants (n = 100) were recruited from one large critical care unit. During August 2008 to January 2009, 50 patients wererecruited and received standard care. A further 50 were recruited between May and October 2009. This group was given eye masks andearplugs to aid their sleep on the critical care unit. A data collection tool was devised comprising three elements: (1) collection of demographicdata from hospital charts and medical notes, (2) rating quality and quantity of sleep using two likert scales and (3) a four-item data collectionsheet was used comprising of one closed and three open-ended questions.Results: Noise was identified as a significant factor preventing sleep in the pre-intervention (50%) and intervention (52%) group. Thepre-intervention group identified medication (26%) (i.e. night sedation or analgesia) and ‘simply nothing’ (24%) as factors promoting sleep.Conclusion: The intervention group identified earplugs (22%) and eye masks (28%) as factors promoting sleep. It appears that simpleinterventions such as eye masks and earplugs may be a valuable addition to patients attempting to sleep in a critical care unit.Relevance to clinical practice: Earplugs and eye masks are a useful adjunct to strategies promoting sleep in critical care areas.

Key words: Critical care • Ear-plugs • Eye-masks • Sleep • Sleep deprivation • Noise

BACKGROUNDNormal sleep is characterised by four to five 90-min sleep cycles. During each sleep cycle, there isan orderly progression through non-rapid eye move-ment (NREM) and rapid eye movement (REM) sleep.NREM sleep is divided into four stages. Stages 1 and2 of NREM sleep are associated with superficial orlighter sleep. Stages 3 and 4 (slow wave sleep) aredescribed as deeper restorative sleep and often lastfor longer periods. These last two stages are oftencombined and referred to as stage 3. Little is knownabout the function of REM sleep. It is thought to beassociated with dreaming and memory formation. Thissleep/wake cycle is regulated by the circadian rhythm,which operates over 24 h. (Friese, 2008; Kudchadker

Authors: C Jones, BA (Hons) Dip HE, RN, Senior Staff Nurse, GeneralIntensive Care Unit, St George’s Hospital, London, UK; D Dawson, MSc,BSc (Hons), RGN, Consultant Nurse, General Intensive Care Unit, StGeorge’s Hospital, London, UKAddress for correspondence: C Jones, General Intensive Care Unit,St George’s Hospital, London, UKE-mail: [email protected]

et al., 2009). Sleep disruption is commonly identified asa feature of admission to critical care units. The envi-ronment, level of intervention and patient morbidityare understood to influence patient’s poor experiencesof sleep in critical care. That these experiences shouldhave a deleterious effect on recovery and rehabilitationnot only appears plausible but is the subject of ongoingclinical research (Friese, 2008).

LITERATURE REVIEWA literature search was undertaken in 2009 usingthe databases Medline and CINAHL. The search waslimited to work published after 1999. The keywords‘sleep,’ ‘sleep deprivation,’ ‘critical care’ and ‘intensivecare’ were searched in the following combinations:sleep and critical care; sleep and intensive care; sleepdeprivation and critical care; sleep deprivation andintensive care to obtain primary sources. Secondarysources were then identified from the reference lists.

There is divergence within the literature regardingthe quantity of sleep attained by patients in criticalcare settings. Some authors assert that there is reduced

© 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses 1

Evaluation of eye masks and earplugs

total sleep time observed in these patients (Hilton,1976; Gabor et al., 2003; Kudchadker et al., 2009), whilstothers maintain that critical care patients are notquantitatively sleep deprived (Friese et al., 2007; Patelet al., 2008). There is some evidence that althoughpatients may be sleeping for the same amount of timeover a 24-h period, the distribution of that sleep may beabnormal as critical care patients are 50% more likelyto sleep during the day (Freedman et al., 2001; Gaboret al., 2003; Parthasarathy and Tobin, 2004).

The quality of sleep experienced in critical careenvironments has been shown to be poor, withabnormal sleep architecture. Polysomography hasshown that patients spend greater periods than normalin stages 1 and 2 of NREM sleep and significantlylower amounts of time in stages 3 and 4 and REMsleep (Hilton, 1976; Freedman et al., 2001; Gabor et al.,2003; Parthasarathy and Tobin, 2003; Friese et al., 2007;Kudchadker et al., 2009), where sleep is achieved it isfragmented and subject to frequent arousals (Gaboret al., 2003; Parthasarathy and Tobin, 2003; Friese et al.,2007; Cabello et al., 2008; Nicolas et al., 2008). Theevidence from polysomography studies is supportedby other subjective studies. When asked to comparetheir sleep in critical care with that at home, patientshave reported that their sleep quality is significantlypoorer (Freedman et al., 1999; Nicolas et al., 2008).

The critical care environment itself has often beenidentified as a major sleep-disrupting factor. Abnormallighting practices that obfuscate normal circadianrhythm cues may influence the patient’s sleep, withlow light intensity of less than 500 lux being sufficientto suppress nocturnal melatonin secretion (Boivinet al., 1996; Drouot et al., 2007; Patel et al., 2008).The extraordinary noise levels that are prevalent incritical care units are well documented and have oftenbeen identified as a key cause of sleep disruption(Christensen, 2002, 2007). That this should be thecase appears to be intuitively correct, however theliterature is ambivalent about the precise role noiseplays in sleep disruption as experienced by criticalcare patients. Healthy subjects (n = 60) exposed toaudio-taped critical care noise reported less sleep, moreawakenings and poorer quality of sleep comparedto home (Topf et al., 1996). Freedman et al. (1999)found that the intensive care unit (ICU) environmentwas not solely responsible for sleep disruption,postulating the possibility that sleep disruption ismultifactorial and that there could be an element ofpatient adaptation to the hostile environment. Gaboret al. (2003) found in their small scale study (sevenmechanically ventilated participants and six healthyparticipants) that a significant number of arousals(68·1 ± 9·7%) and awakenings remain unexplained,

with sound and patient care activities accounting foronly 30% of these arousals. An earlier investigationutilising polysomography, direct observation andpatient interview identified that most sleep disturbancewas caused by noise (Hilton, 1976).

A number of studies have demonstrated that patientsoften experience frequent and repeated interventionfrom nursing and medical staff leaving little timefor patients to achieve the deeper levels of sleep(Hilton, 1976; Meyer et al., 1994; Freedman et al., 1999;Celik et al., 2005). Patients are subjected to continuousmonitoring; are shackled to invasive lines and variouswires that lead to discomfort. Pain can also disturbsleep. It is also likely that the patients will feel anxiousand isolated contributing to stress that can also disturbsleep. Many of the medications commonly found in thecritical care unit (such as beta-blockers, GABA agonists,ACE inhibitors, calcium channel blockers, opiods,barbiturates and catecholamine’s) have been identifiedas disrupting normal sleep architecture (Honkus, 2003;Pandharipande and Ely, 2006; Weinhouse, 2008; Temboand Parker, 2009; Weinhouse and Watson, 2009).

There have been various studies aimed at improvingpatient’s experiences of sleep. These include protocolsaimed at nursing staff to reduce noise and inap-propriate nursing interventions (Walder et al., 2000;Monsen and Edell-Gustafsson, 2004), ‘intrinsic’ noisereduction strategies in terms of sound masking andmuffling (Richardson et al., 2007; Xie et al., 2009) andmanipulation of patients’ hormone levels using mela-tonin to promote sleepfulness (Patel et al., 2008). Friese(2008) argues convincingly for an integrated strat-egy directed at promoting sleep within critical care,this should include elements of noise control, diur-nal lighting practice, suitable medicinal intervention,uninterrupted periods ring-fenced for sleeping, painrelief, relaxation and individual patient rooms.

A study by Richardson et al. (2007) evaluating theuse of eye masks and earplugs in 64 patients ina critical care unit demonstrated equivocal results.The authors suggest this was due to environmentalissues in the unit at the time of the study. However,a recent crossover study using a simulated ICUenvironment identified that when volunteers woreeye masks and earplugs they had increased REMsleep compared to those times when these were notsupplied (Hu et al., 2010). Two studies of earplug usealone have demonstrated an improvement in sleepquality and quantity (Wallace et al., 1999; Scotto et al.,2009). Given the limited and inconclusive evidenceregarding eye masks and earplugs, a service evaluationwas undertaken to identify whether offering patientseye masks and earplugs would improve patients self-reported sleep experiences in our critical care unit.

2 © 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses


AIMS AND OBJECTIVESThe aim was to explore patients’ experiences of sleepin a critical care environment. The objectives were to

• evaluate the quantity and quality of sleep thatpatients perceived they experienced in the criticalcare setting

• identify factors preventing sleep• identify factors promoting sleep• evaluate the usefulness of eye masks and earplugs

as an intervention to improve sleep in the criticalcare environment.

METHODOLOGYSetting and audit populationWe conducted a prospective pre/post service eval-uation over 2008/2009 based on Richardson et al.’s(2007) investigation into the efficacy of eye masks andearplugs.

This service evaluation took place in a 17-bedteaching hospital’s general ICU. The unit is dividedinto an 11-bed horseshoe-shaped area with an adjacent6-bed nightingale style ward. The unit provides care foremergency medical and surgical patients and electivesurgical patients from a range of specialities.

A convenience sample of 100 patients was identifiedto participate in the evaluation. Participants wereidentified by team members at the start of eachshift using the inclusion and exclusion criteria.Potential participants were approached and givenstandardised information about the project. If thepotential participant agreed to take part then a timewas arranged for the investigator to interview. Thefirst 50 patients (August 2008–January 2009) werenot offered eye masks and earplugs. These patientswere included in the ‘pre-intervention’ group. Thefollowing 50 patients (May–October 2009) comprisedthose patients who had accepted the offer of eyemasks and earplugs. These patients were includedin the ‘intervention’ group. Here the patient selectiondiffered from Richardson et al. (2007) in that the pre-intervention group were not given the opportunity toself-select into the intervention group.

The inclusion criteria and exclusion criteria areoutlined below in Table 1.

Demographic data are presented in Table 2.

Ethical considerationsIn line with the Trust policy, formal ethics approvalwas not required for a service evaluation. However,general ethical principles were considered and valuedwhen designing the evaluation. Confidentiality wasmaintained throughout the process. Informed verbal

Table 1 Inclusion and exclusion criteria

Inclusion Exclusion

More than 24 h post intravenoussedation

24 h or less post intravenoussedation

More than 24 h since generalanaesthetic

24 h or less since generalanaesthetic

Length of stay greater than 24 h Length of stay 24 h or lessLevel 2 high dependency care (DH 2000) Level 3 (ICU) care (DH 2000)The patient is sufficiently lucid and

capacious to understand questionsand provide verbal consent

The patient is not sufficiently lucidand capacious to understandquestions and provide verbalconsent

The patient has sufficient ability tocommunicate in English

The patient has insufficient ability tocommunicate in English

Eye or ear contra-indications (e.g.ear-related surgery/trauma, deaf,eye-related surgery/trauma, blind)

ICU, intensive care unit.

Table 2 Demographic data

Pre-intervention Post-intervention

AgeMean (SD) 58·07 (18·44) years 56·34 (18·41) yearsMedian 63 57Range 22–90 years 21–87 years

GenderMale 27 30Female 23 20

LocationSide room 7 2ICU area 18 21HDU area 23 27Data missing 2 0

SpecialityMedical 22 13Surgical 23 30Trauma 5 4Obs/Gynae 0 1Data missing 0 2

Length of stayMean (SD) 6·68 (6·78) 4·14 (3·36)Median 4 3·5Range 2–35 2–24

ICU, intensive care unit; SD, standard deviation.

consent was obtained from each participant prior totheir interview by discussing the study with each ofthem and giving standardised information about theaims of the project and reassurance that their responseswould not affect their care. Potential participants werealso informed that participation was purely voluntaryand that they could withdraw consent at any time. Datawas collected in hard copy using the patients hospital



number as an identifier, this data was transferredto a password protected database and paper copiesdestroyed.

Data collectionThe service evaluation was undertaken as a teamproject as part of the units’ drive for staff develop-ment and evidence-based care. Data collection wasundertaken by members of one nursing team con-sisting of 20 nurses. Each member of the team wastrained individually by the project lead in the useof the data collection tool. The advantage of using agreater number of investigators was that it allowedour data collection to be responsive to the presence ofthe sample. A smaller number of investigators may nothave had the same success capturing the sample givenclinical demands of the unit and internal shift rotation.This was particularly important in the interventionstage of data collection as the patient was consentedwhen offered the earplugs and eye masks. Because of alimited supply of the product there had to be certaintythat there was a team member present the followingday to interview the participant. Clearly, there are alsoa number of disadvantages associated with using sucha large number of inexperienced investigators, theseare discussed fully in the limitations section.

The data collection tool comprising of three elementswas adapted from Richardson et al.’s (2007) study. Thefirst element used hospital charts and medical notes togather data relating to age, gender, bed location, spe-ciality, length of stay, level of care/dependency. Thesecond element asked participants to rate the quan-tity (Figure 1) and quality (Figure 2) of sleep usingfive-point likert scales taken from Richardson et al.(2007). The scales were laminated so that they couldbe cleaned between patients as an infection controlmeasure.

The third element of the data collection tool wasa four-item data collection sheet comprising of oneclosed and three open-ended questions, adaptedfrom Richardson et al. (2007) (Table 3) designed to

Table 3 Four item data collection sheet

1 What factors helped you to sleep?2 What factors stopped you from sleeping?3 Were you in any pain or discomfort last night?4 Can we do anything to improve your sleep?

investigate the factors helping them to sleep andpreventing them from sleeping.

Participants in the intervention group were alsoasked to evaluate the comfort of eye masks andearplugs separately using a five-point likert scale againtaken from Richardson et al. (2007). The scales askedparticipants to evaluate the appliances on a spectrumranging from very uncomfortable through to verycomfortable.

The interviews took 10–30 min to complete. Theywere conducted at the bedside at a time that theparticipant had agreed was convenient to them.Those participants in the ‘intervention’ group wereinterviewed the day following their use of eye masksand earplugs at night.

Data analysisQuantitative data was analysed using Excel 2007(Microsoft Corporation, Redmond, Washington, DC,USA). Qualitative data was transcribed verbatim; thetranscripts were analysed using content analysis. Thesmall quantity of data for each patient was read andre-read to identify common themes, all of which weredescriptive. This was completed independently, byfour team members until the final themes were agreedby all.

RESULTSPatients identified the number of hours they slept inthe preceding night and compared this to the length oftime they would normally sleep.

Figure 3 demonstrates that in terms of quantityof sleep more patients reported that they had slept

0-2 HOURS 2-4 HOURS 4-6 HOURS 6-8 HOURS

MORE THAN 8

HOURS

Figure 1 The number of hours slept.

MUCH LESS

THAN

AVERAGE

THAN

AVERAGE

LESS

AVERAGE MORE THAN

AVERAGE

MUCH MORE

THAN

AVERAGE

Figure 2 Comparison with their normal/average sleep.



Figure 3 Number of hours slept.

longer using the eye masks and earplugs. In thepre-intervention group, 32% reported 0–2 h of sleepcompared with 20% of the intervention group.

Figure 4 shows that analysis of quality of sleepusing the comparative rating scale did not provideany evidence that the eye masks and earplugs hadenhanced participants’ perception of the quality oftheir sleep. Forty percent of participants reported thatthey had slept ‘less than average’ compared with 34%in the pre-intervention group.

Figure 5 identifies noise as a significant factor pre-venting sleep in both the pre-intervention (50%) andintervention (52%) group. Both groups also identifiedobservation/intervention, light, discomfort and envi-ronment as sleep-disturbing factors. Sixteen percent ofthe pre-intervention group identified anxiety as a sleep-preventing factor against only 2% of the intervention

Figure 4 Comparison with normal sleep.

Figure 5 Factors preventing sleep.

group. The pre-intervention group also seem morelikely to identify environment (28%) as a sleep-disturbing factor than the intervention group (14%).

It is interesting to note that whilst more participantsin the intervention group identified pain as a sleep-preventing factor there seemed to be broad consistencyacross both groups when asked directly whether theywere in pain/discomfort as shown in Figure 6.

Figure 7 shows that the pre-intervention group iden-tified medication (26%) (i.e. night sedation or analgesia)and simply ‘nothing’ (24%) as factors promoting sleep,whilst the intervention group identified both thesefactors less frequently (medication, 10%; nothing, 6%).

The intervention group identified earplugs (22%)and eye masks (28%) as factors promoting sleep.

There is broad consistency between the pre-intervention and intervention groups in identifyingother sleep promoting factors as shown in Figure 7.There is a slight difference in relation to lighting as afactor promoting sleep with 12% identifying this in thepre-intervention and 4% in the intervention.

Figures 8 and 9 demonstrate that participantsevaluated eye masks and earplugs as comfortable.Very few patients described the eye masks and

Figure 6 Experiences of pain and discomfort.

Figure 7 Factors promoting sleep.



Figure 8 Evaluation of earplugs

Figure 9 Evaluation of eye masks.

earplugs as ‘very uncomfortable’ or ‘uncomfortable.’An interesting finding from this section was thenumber of patients opting out of using either the eyemask (22%) or earplugs (18%).

LIMITATIONSThe small sample size, reliance on patient recall andthe study design limit the generalisability of theresults. This service evaluation was undertaken as ateam project. There are a number of disadvantagesassociated with using a large number of inexperiencedinvestigators. This includes the possibility of greatervariation between interviews than would be found ina study using fewer interviewers. In some instances,the nurse interviewer was also the patients’ carer forthat shift. This may have introduced some participantbias to the study. Patients may have felt more reticentin divulging full and frank information for fear ofcompromising their care. The data collection wasundertaken concurrently with clinical duties. This mayhave placed pressure on nurse interviewers to completethe interviews in a timely fashion in order to return tosignificant clinical workloads, impacting on the timeallowed for patients to answer questions.

During the project, the unit underwent a 3-weekperiod of refurbishment (17 August to 5 September

2009) resulting in an alteration in the environment thatparticipants were exposed to. The environment expe-rienced by the two cohorts may have been inconsistentin terms of the type and distribution of light patientswere exposed to as they were approached at differenttimes of year – i.e. the pre-intervention group in win-ter and the intervention group in summer. Anotherimportant limitation is that we have not controlled forthe patients location in the critical care unit. A patientattempting to sleep in a side room will not experiencethe same range of disturbances experienced by patientsbeing cared for on the ICU or HDU.

The evaluation also had a clear focus on the highdependency patient. The experiences of this groupof patients may not be representative of wakefulintensive care patients. There is also a focus on night-time sleep; previous research on sleep in critical carehas highlighted that daytime sleep is an importantcomponent of total sleep in this environment; it mayhave been helpful to have included this aspect ofsleep in the audit. The data is also limited by thehigh number of participants declining to use theappliances in the intervention group (eye masks, 18%;ear plugs, 22%).

DISCUSSIONThis service evaluation demonstrated that patientsreported sleeping for longer periods using earplugsand eye masks; however, there was no reportedimprovement in patients’ perception of quality ofsleep. This suggests that although patients may havereported longer periods of sleep, sleep may have beenfragmented or disturbed. This finding would seem tobe consistent with both the findings of Richardsonet al. (2007) and with the broader discussion in theliterature which seems to point to patients beingqualitatively rather quantitatively sleep deprived asa result of abnormal sleep architecture (Gabor et al.,2003; Parthasarathy and Tobin, 2003; Friese et al.,2007; Cabello et al., 2008). However, it is at oddswith studies utilising earplugs alone (Scotto et al.,2009) or use of earplugs in a simulated critical careenvironment (Wallace et al., 1999) and the combineduse of earplugs and eye masks in a simulatedenvironment (Hu et al., 2010). This suggests thatperhaps a simulated environment is not reflectiveof multiple factors that may affect a patients’ sleepwhile critically ill or may merely reflect differing studydesign.

Noise was identified as a sleep-disturbing factorin both groups although the significance of noise asa sleep-disturbing factor in the literature is unclear.The service evaluation was predicated upon patients



recalling and then describing their sleep to us thereforethe identification of noise as a disturbing factorreflects the patients understanding of what disturbedtheir sleep, which may or may not be the factorcausing wakefulness. Our findings are consistent withstudies where patients self-report their sleep patterns(Freedman et al., 1999; Richardson et al., 2007; Scottoet al., 2009) or in studies using health volunteers(Wallace et al., 1999; Hu et al., 2010). This shouldencourage nurses to reduce noise wherever possible,but also to use simple noise reduction strategies suchas earplugs. Studies that suggest noise is less ofa sleep disturbance often involve polysomnography(Freedman et al., 2001; Gabor et al., 2003).

There is some disparity between the pre-interventionand intervention group in their identification of painas a sleep-preventing factor, 4% of the pre-interventiongroup identify this as a sleep-preventing factor against22% in the intervention group. This may reflectthe higher proportion of surgical patients in theintervention group, who on their first post-operativenight can be expected to experience pain.

In the pre-intervention group, 16% identified anxietyas a sleep-preventing factor against only 2% in theintervention group. The pre-intervention group alsoseem more likely to identify environment (28%)as a sleep disturbing factor than the interventiongroup (14%). It may be that this discrepancy resultsfrom the higher number of medical patients in thepre-intervention group. This cohort of patients willtypically have unplanned emergency admissions tocritical care following presentation to the accident andemergency department or an acute deterioration on theward. Therefore, it seems reasonable to surmise thatthey may be more anxious and less able to rationalisetheir surroundings.

It is interesting that 24% of participants in the pre-intervention group felt that simply ‘nothing’ couldassist them to achieve sleep in the critical careenvironment. This result may highlight the lonelinessand frustration of a sleepless night, but also thestress of an admission to critical care coupled withongoing concerns about health and well-being. Thestudy indicates that the introduction of eye masksand earplugs helped to modify this response withonly 6% of participants in the post-intervention groupidentifying ‘nothing’ as a sleep-promoting factor. It ispossible that the act of offering these products providespatients with a sense that they are being cared for andthat they have an element of control over a strange andoften distressing environment.

Eye masks and earplugs were identified as factorspromoting sleep in the intervention group, this wouldsuggest a positive evaluation of these products. There

is a slight difference in relation to lighting as a factorpromoting sleep with 12% identifying this in the pre-intervention and 4% in the intervention group; this mayreflect the efficacy of the eye masks. It was interestingto note the number of patients opting out of usingeither the eye mask (22%) or earplugs (18%) despiteaccepting them to trial. This supports the suggestionthat these small devices may offer some level ofcontrol, in that patients may just choose not to usethem.

Although our pre-intervention data is uniform,the intervention group did effectively select into theintervention group as those patients who declined theeye masks and earplugs have not been included thisstudy. There is a possibility that those participantsaccepting eye masks or earplugs may have disruptedsleep as a baseline. Or it may be that the group ofparticipants that accepted eye masks and earplugsmay represent a group of people who are more willingto ‘trouble-shoot’ their sleep disruption by adoptingpositive sleep-promoting strategies. This may explainthe marked reduction in the number of people whofelt that simply ‘nothing’ could help them to sleep incritical environment.

It is notable that very little of the literature isdirected at understanding what patients think willimprove their sleep in the critical care environment.It is important that this information is collected andreported.

CONCLUSIONSleep in the critical care unit is disturbed by anumber of physiological and environmental factors,currently we do not fully understand the complexrelationship between these. However, it appears thatsimple interventions such as eye masks and earplugsmay be a valuable addition to patients attempting tosleep in a critical care environment. They may offerpatients a level of control in an otherwise hostileenvironment and also remind staff that patients areattempting to sleep. Therefore, we will continue tooffer this simple intervention to patients in our criticalcare unit.

ACKNOWLEDGEMENTSThank you to Arlene Domingo Senior Staff Nurse,the nurses of the red team who undertook the datacollection for this service evaluation and the auditdepartment that helped with analysis. Thanks also toBACCN – Southern region for funding the purchaseof the eye masks and earplugs used in the serviceevaluation.



WHAT IS KNOWN ABOUT THIS TOPIC

• Critical care patients have abnormal sleep architecture.• Patients perceive noise as a sleep disturbance in critical care.

WHAT THIS PAPER ADDS

• Patients perceive noise as a significant sleep-disturbing factor.• Eye masks and earplugs offer patients a positive strategy to promote sleep.

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eye masks and earplugs improve patient's perception of sleep

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