Research

DIMENSION

Effects of Relaxation and

Imagery on the Sleep of
Critically Ill Adults
Stephanie Richardson, PhD, RN

The purpose of this study was to determine the effects of relaxation and imagery on the
sleep of critically ill adults. The study was an experimental clinical trial with random assign-
ment to two groups. Analysis used repeated measures ANOVA. Thirty-six adults (17 males
and 19 females) with a variety of physical diagnoses in three critical-care units in two large
metropolitan hospitals were studied. Outcome measures were scores on a visual analog
sleep scale, measured on three mornings. The intervention was a combination of relaxation
and imagery, delivered on two evenings. All subjects’ sleep improved over time. There
were significant interaction effects between the intervention, gender, and time, with males’
scores improving rapidly, and females’ scores first dropping, then improving rapidly. A
combination of relaxation and imagery is effective in improving the sleep of the critically ill
adult, with men responding immediately to relaxation and imagery with improved sleep,
and women taking more time to respond to the intervention.
[DIMENS CRIT CARE NURS 2003;22(4):182–190]

Sleep disturbance is a source of distress. Humans func-
tion poorly or become ill when deprived of sleep, when
sleep is fragmented, or when sleep is not sufficiently deep.
Most nurses who work in an intensive care unit (ICU)
agree that sleep is important for maintaining or recover-
ing health. Symptom control, which would include assis-
tance with sleep disturbances, has been identified as a
research priority by ICU nurses.1 Unfortunately, adults in
ICU continue to experience severely disturbed sleep pat-
terns.2-6 Disturbed sleep patterns have been attributed to
the noise, light, interruptions, and emotional distress
experienced by patients in ICU.5-9 Some different ap-
proaches are needed to ensure sleep and rest in the
unusual physical and emotional environment of the ICU.
Progressive relaxation has improved coping and
physiologic symptoms and functions in various popula-
tions.6,10-14 It has improved the sleep of elderly women in
their homes15 and healthy insomniacs.16-21 Guided
imagery has been shown to decrease depression,22 post-
operative pain,23 and improve skill acquisition24 and test
anxiety.25 In adults with pulmonary disease, imagery
improved the quality of life26 and decreased anxiety.27 In
combination, relaxation and imagery has improved
wound healing and emotional states and decreased
hypertension and nausea in various populations.28-30
Relaxation and imagery has boosted the immune
response in persons with compromised immune sys-
tems.31 Although not all of these studies of relaxation
and imagery had large sample sizes, and designs were
not all experimental, there is a growing body of evidence
that relaxation and imagery may provide the approach
needed to improve the sleep of adults in intensive care.
The self-regulation model proposed by Leventhal and
Johnson (1983)32 provides a theoretical framework to
guide the design, methods, and analysis of this study. In
self-regulation, the patient initiates strategies to modify
emotional and sensory responses to unusual stimuli. The
noises, lights, interruptions, and emotional distress expe-
rienced in ICU constitute unusual stimuli preventing sleep
and requiring modification. The modification strategies

182 Dimensions of Critical Care Nursing Vol. 22 / No. 4


chosen for this study are relaxation and imagery. Modifi-
cation of emotional/cognitive responses and sensory
responses would allow the adult in ICU to sleep.
PURPOSE OF THE STUDY
The purpose of this study was to examine the effects of
relaxation and guided imagery on sleep in critically ill
adults. The problem addressed by this study is the sleep
disturbance that most critically ill patients experience. The
main research hypothesis posed was that subjective sleep
scores of critically ill adults who use relaxation and guided
imagery will improve over time, when compared to simi-
lar critically ill adults who do not use these interventions.
METHOD
Design and Sample
The study setting was three intensive care units in two
teaching hospitals in Salt Lake City, Utah. Within these
hospitals, units were selected that had single-patient
rooms, were of similar size, census, and acuity, and
employed similar numbers of nurses.
The study used a repeated measures experimental
design, useful for examining change between pre- and
post-treatment observations in the same subject.33,34
From a convenience sample, subjects were randomly
assigned to experimental and control groups. For the
experimental group, the dependent variables were mea-
sured three times, once as a pretest and following each
of two treatments of relaxation and imagery. The con-
trol group also had dependent variables measured three
times, at the same times as the experimental group, but
without the two treatments.
The target population for this study was all adult
patients admitted to medical, surgical, and coronary
intensive care units. Criteria for inclusion were adults
(18 years or older) admitted to ICU with nurse-patient
acuity ratio of 1:1 or 1:2. Patients who could not speak
(eg, intubated) but could point to an alphabet board or
write in response to questions were eligible.
Criteria for exclusion were unstable patients with
an acuity ratio of 2:1 or more (such as patients on an
intraaortic balloon pump or a left ventricular assist
device); patients with a history of Alzheimer’s disease,
dementia, psychoses, central neurological impairment
(cerebrovascular accident, head injury, cranial surgery,
coma), severe bradycardia, severe hypotension; and
non-English-speaking patients.
Instruments
A paper-and-pencil test, the Verran and Snyder-Halpern
(VSH) Sleep Scale35 was chosen to measure the concept
of sleep quality. This instrument is an 8-item visual ana-
log instrument using a 100-mm response line. Subjects
Sleep
place a mark on the 100-mm line for each item at a
point that best reflects their feelings about that item.
The VSH Sleep Scale is easy to administer, score, and
understand, and provides interval-level data. Based on
recommendations from Snyder-Halpern and Verran
(1987),35 three items were added to the tool for this
study, and one item was revised, resulting in an 11-item
visual analog instrument. These 11 items were: numbers
of awakenings, hours awake, hours of sleep, concern
with interruptions, time to first sleep, concern with time
to first sleep, depth of sleep, sufficiency of sleep, refresh-
ment upon awakening, number of naps taken during the
previous day, and good or bad night.
Validity of the VSH Sleep Scale has begun to be estab-
lished. Factor analysis has resulted in the extraction of one
factor, Disturbance, which accounted for 44% of the vari-
ance in sleep quality.35 This is evidence that all the items
may address a single concept, sleep quality.36
The VSH Sleep Scale has been compared with two
other instruments, the Baekeland and Hoy Sleep Log37
and the St. Mary’s Hospital Sleep Questionnaire.38,39 The
format and wording of items in the three tools are suffi-
ciently different to provide a multimethod compari-
son.40,41 (The St. Mary’s Hospital Sleep Questionnaire
requires recording specific times related to sleep and
awakening, and answers to some forced-choice ques-
tions scored on 8-point scales. The Baekeland and Hoy
Sleep Log consists of forced-choice questions scored
dichotomously or on a 3-point scale. The VSH Sleep
Scale consists of visual analog items scored on a 100-
point scale. The questions on the three scales are not
identical.) The Baekeland and Hoy Sleep Log has been
successfully compared to EEG sleep recordings, partic-
ularly regarding sleep latency and prolonged awaken-
ings.37 Other self-reports of sleep have also significantly
correlated with polysomnography.42
Pearson correlation coefficients between items on the
VSH Sleep Scale and the Baekeland and Hoy Sleep Log
ranged from 0.53 to 0.68, with one exception being the
measure of sleep latency (r
0.22).35 Although the corre-
lations between items on the Sleep Scale and Sleep Log are
not very high, they demonstrated beginning evidence for
convergent construct validity. Pearson correlation coeffi-
cients between items on the VSH Sleep Scale and the St.
Mary’s Hospital Sleep Questionnaire ranged from 0.50 to
0.74.35 Although these values are not extremely high, they
indicate some evidence for convergent construct validity.
A coefficient theta of 0.82 provided evidence of reliability
for the VSH Sleep Scale.35
Intervention
The independent (treatment) variable was a nursing inter-
vention. The intervention was a combination of relax-
July/August 2003 183
 Sleep
ation and guided imagery. The relaxation portion of the
intervention required that the subject focus on relaxing
muscle groups from toe to head on the cue of a comfort-
ably deep breath. The imagery portion of the interven-
tion was selected by the subject, in response to, “What is
your favorite place in the whole world to relax?” The
subject was asked to describe in detail what was seen,
heard, smelled, and felt in this image, which eliminated
the need for the researcher to be familiar with the image
selected. An example of one image selected by the subject
was floating in a boat in the middle of a blue lake under
a light blue sky, and included a cool breeze, warm sun,
the smell of water on wood, and the sound of children’s
happy voices on the distant shore.
Initial relaxation sessions conducted in-person have
resulted in deepest relaxation.43-45 Over time, taped ses-
sions can be employed in lieu of in-person sessions, for
clinical economy44,46 and uniformity across subjects in
research.10,12-15,20,47-50 For this study, the intervention was
delivered twice only, requiring in-person sessions for
maximum effect. It was decided to take advantage of
the in-person delivery and personalize the intervention
so the subject could choose an image most vivid and
familiar for them.45
Interruptions to and variations in delivery of the
treatment can be treated as variables. Two ordinal-level
scales were used to measure how well intervention pro-
tocols were carried out. These scales evaluated the
degree of implementation of the protocol and the effect
of the environment on the delivery of the intervention
(Figures 1 and 2).51
Procedures
Approval to conduct the study was obtained from the
university Institutional Review Board and review
boards of the two hospitals involved. The charge nurse
Rate the degree to which you were able to carry
out protocol established for the intervention.
1
Unable to do the intervention.
2
Minimal elements of intervention done or for
short time or had many interruptions.
3
Some deviations from protocol or able to do
intervention for about half of the time or a
few interruptions.
4
Minimal deviations from protocol or few
interruptions.
5
Complete protocol carried out.
FIGURE 1. Rating scale for degree of protocol implementation.
(Reprinted with permission from Egan, Snyder, and Burns, 1992.51)
184 Dimensions of Critical Care Nursing Vol. 22 / No. 4
Rate the degree to which disruptions interrupted
the delivery of the intervention.
1
Many additional disruptive variables (patient
toilted just before beginning protocol,
restrained, hyperactivity on unit) present.
2
Some additional disruptive variables present.
3
No identified disruptive variables present.
FIGURE 2. Rating scale for environment in which protocol was
implemented. (Reprinted with permission from Egan, Snyder, and
Burns, 1992.51)
on each unit was initially consulted, to discover which
patients were eligible for inclusion. Coin toss was used
to assign a potential subject to either group before
recruitment. The investigator approached each eligible
patient on the morning of prospective inclusion in the
study. At that time, informed consent was obtained, fol-
lowing guidelines for obtaining consent with humans.
For an experimental group subject, day 1 began
with recruitment into the project, followed by measure-
ment of dependent variables, all between the hours of
0800 and 1100 (Table 1). That evening, between the
hours of 1700 and 1900, the subject received the inter-
vention. On day 2, the dependent variables were again
measured in the morning, and the intervention was
experienced in the evening. On day 3, the dependent
variables were measured for the last time in the morn-
ing. For a control group subject, measurement times
were identical to the experimental group, minus the
intervention. For each subject, the exact time of mea-
surement of dependent variables on day 1 was noted,
and measures on days 2 and 3 took place within 30
minutes of that time.
The investigator was responsible for recruitment
and was the individual who presented the tool to the
subject on day 1. The research assistant, without know-
ing group membership of the subject, presented the tool
to the subject on days 2 and 3.
The Sleep Scale was presented to the subject on a clip-
board and held perpendicular to the subject’s line of
sight. Those subjects who could read the scale indepen-
dently were encouraged to do so. For those subjects who
preferred, each item was read to the subject. Those sub-
jects who could mark the visual analog scales indepen-
dently did so. Those who could not grip to mark the scale
were asked to hold their finger on the place on the visual
analog scale where they wanted their mark to be placed,
and the mark was placed for them before their finger was
removed from the scale. Correct placement of each mark
was confirmed with the subject at that time.

TABLE 1 Representation of Group Procedures and Measures
Group Pretest Following Intervention,
Assignment Recruitment Evening, Day 1
Experimental X O
Control X X
The intervention was delivered according to a writ-
ten protocol and script (Figure 3). The intervention was
designed by the investigator to be from 13 to 18 min-
utes in length and was delivered in person. The relax-
ation portion of the intervention progressed from toe to
head, using comfortable breaths as a relaxation cue, and
contained multiple suggestions of well-being, control,
and comfort (eg, “You notice you feel relaxed and
secure. You are in control of your body, and how
relaxed you are.”). During the imagery portion of the
intervention, the investigator described the selected
image using five senses, in order: what could be seen,
what could be heard, what could be smelled and tasted,
and what could be felt, including kinesthetic sensations
(eg, “You can feel the path beneath your feet and your
legs are moving easily, without pain”). (Readers may
obtain the entire script from the author: Dr. S. Richard-
son, University of Utah College of Nursing, 10 South
2000 East Front, Salt Lake City, UT 84112-5880.)
“. . . With your next breath, as you exhale, relax your
belly, just let it relax completely. Enjoy that deep
relaxation, and notice how content and comfortable
you feel. You are relaxed, in control, and very com-
fortable. With your next deep breath, relax your
lower back. The tension that was there can float
away on your breath. Your lower back will feel com-
fortably warm, a little heavy, and relaxed. from your
waist down, you feel wonderful, very relaxed and
warm. If there is any tension left below your waist,
let it float away from you as you exhale your next
deep breath. Enjoy this feeling of relaxation, control,
and contentment. (Pause)
“. . . With your next breath, you feel the sun on your
arms, the perfect temperature of the breeze. You feel
your body walking along the trail as you move easily
through the meadow, past the trees. You are com-
fortable, relaxed, and happy. Use your deep breaths
to stay there and stay completely relaxed. If you
become distracted, with a deep breath you will be
able to experience the meadow vividly again. . .
FIGURE 3. Portions of script of relaxation and guided imagery.
Sleep
Posttest, Intervention, Posttest,
Morning, Day 2 Evening, Day 2 Morning, Day 3
X O X
X
Demographic data (including age, length of stay,
principle medical diagnosis, medications, invasive lines,
nurse on duty, etc.) were obtained from the patient, staff
nurses, charge nurses, and patient charts. These data
were updated (when necessary) on the mornings of day
2 and day 3.
To determine if there was a difference in sleep scores
over time on the basis of group membership, a 2 by 3
analysis of variance (ANOVA) for repeated measures
was completed, using two groups and three measure-
ments. Data were assessed for violations of statistical
assumptions. Alpha was set at 0.05.
RESULTS
Sample
The sample for this study consisted of 36 adult inten-
sive care unit patients with various diagnoses (Tables 2
and 3). The refusal rate for participation was 16% (n

6). There were 20 subjects in the control group (56%)
and 16 subjects in the experimental group (44%). Stu-
dent t tests and chi-square tests of association showed
that there were no significant differences between
groups for any demographic variable. In addition, there
was no pattern of administration of medications that
could have affected sleep over time for any subject.
Reliability and Validity of the Tool
Data were examined to determine the reliability and valid-
ity of the Sleep Scale. The results of the study provide evi-
dence that portions of this tool are a reliable measure of
the perception of sleep and sleep disturbance in the criti-
cally ill adult, but that the tool may not be a valid indica-
tor of sleep in this population. It may, however, be a valid
indicator of the perception of sleep in this population.
Cronbach’s alpha (0.93), inter-item correlations (m

0.59, range 0.30–0.87), and squared multiple corre-
lations provided evidence that two items, Fragmenta-
tion (r
0.77) and Depth (r
0.72), were the most
valid items of the Sleep Scale. These two items also rep-
resent the two concepts generally thought to comprise
sleep. For this study, Fragmentation and Depth were
used as the measures of sleep.
For all subjects, the sum of Fragmentation and
Depth was calculated, and named the sleep score.
July/August 2003 185
 Sleep

TABLE 2 Frequency of Selected Demographic Characteristics in Critically Ill Adults (N
36)

Intervention Control Total
Characteristic N % N % N %

Caucasian 16 44.4 20 55.6 36 100

Gender
Male 7 19.4 10 27.8 17 47.2
Female 9 25.0 10 27.8 19 52.8
Residence
Intermountain West 17 47.2 17 47.2 34 94.4
Other United States 1 2.8 1 2.8
Other (Germany) 1 2.8 1 2.8

Characteristic Range Mean SD

Age
All subjects 22–78 58.4 14.3
Control 24–78 62.4 13.0
Experimental 22–77 53.5 14.5

Higher sleep scores indicated a perception of improved
sleep. To control partially for the variance found
between subjects for these items on time 1 measure-
ment, analysis was done using the change in sleep scores
from time 1 to time 2, and the change from time 2 to
time 3. For all subjects, change scores from the first
night to the second night were: mean 2.12 (range

168–177, SD
67.45); from the second night to
the third night were: mean 47.70 (range
97–200,
SD
60.25). Measures of skewness and kurtosis, and a
visual examination of scores, showed a nearly normal
distribution for both change scores.
Research Hypothesis
The research hypothesis was the proposition that sleep
scores of critically ill patients who use relaxation will
improve over time, when compared to those who do not
use these interventions. The results of data analysis did

TABLE 3 Frequency of Group Membership, Unit, and Diagnosis in Critically Ill Adults (N
36)
Intervention Control Total
Characteristic N % N % N %

Group 16 44.4 20 55.6 36 100.0

Unit
MSICU 6 16.7 7 19.4 13 36.1
CCU 6 16.7 7 19.4 13 36.1
MICU 4 11.1 6 16.7 10 27.8
Disposition
Transferred 5 8.3 6 16.7 11 32.1
Removed 3 8.3 3 8.3 6 16.7
Diagnosis
Cardiac 3 8.3 8 22.2 11 32.1
Pulmonary 5 13.8 3 8.3 8 17.9
Other 8 22.2 9 25.0 17 50.0

186 Dimensions of Critical Care Nursing Vol. 22 / No. 4


TABLE 4 Results of Repeated Measures ANOVA to Test Effects of Relaxation and Imagery
Over Time on Sleep Scores in the Critically Ill Adult (N
29)
Source SS df
Group 1025.29 1 1563.42
Time 38333.52 1 38333.52
Group by time 603.86 1 603.86
SS, Sum of squares; MS, mean squares
*P  .05
not support this hypothesis (Table 4). The overall inter-
vention effect for sleep scores was not significant (P

.425). Independent t tests on means confirmed no dif-
ferences between control and experimental sleep scores
on day 1, day 2, and day 2. Furthermore, the interac-
tion of the intervention with time was not significant
(P
.757). There was a significant effect for time (P

.019), with scores improving for all subjects from day 1
to day 3. There were, however, other significant inter-
action effects.
There was a strong, significant interaction between
the intervention, gender, and time, with different pat-
terns of change in sleep, depending on the intervention
and gender (P
.003, Table 5). The differences between
females’ scores on time 1 approached statistical signifi-
cance when tested by independent t test (t
1.93, P

.074). Differences between males’ scores on time 2
also approached significance on independent t test (t

1.915, P
.075) (Table 6). When all mean group
scores by gender are compared, the scores for the exper-
imental males and females can be seen to have moved
nearly oppositely. Partial eta squared for the interaction
of group by gender by time was 0.29. Power for the
interaction of group by gender by time was 0.87.
There was a difference in sleep scores on the basis
of unit (P
.035), with scores improving depending on
the ICU to which the subject was admitted. Sleep scores
dropped on time 2 in the MICU, and consistently
improved in MSICU and CCU. There was a significant
interaction between transfer out of the unit, and time
(P
.011), with sleep scores improving with transfer
before the third night, strongly suggesting that transfer
out of ICU is important for improving sleep. Also, sleep
scores showed different patterns of change, depending
on the intervention and the diagnosis for which the sub-
ject was primarily being treated (P
.035). Subjects
with pulmonary diagnoses showed marked improve-
ment with the intervention, as compared to any other
group. However, because cell size in the analysis of
diagnosis by intervention ranged from 2 to 11, it is not
possible to interpret these findings confidently.
Sleep
MS F
.66
6.21*
.10
DISCUSSION
This study confirmed the high degree of sleep distur-
bance found by other researchers in critically ill
adults.6,8,9,52,53 The results of this study found that reports
of sleep generally improved over three nights, which
contradicts a 1988 study in which no improvement in
sleep scores over time was found.3 The sample in this
1988 study was small (n
11) and was taken from one
CCU, making it difficult to compare findings to the pre-
sent study. However, although the subjects in CCU in
the present study did show improved sleep over time,
their improvement was less marked as compared to
MICU and MSICU subjects, possibly because their sleep
was not as disrupted overall.
Unequal means on pretest scores raise questions
about sample size. Random assignment to groups plus
a larger sample size, based on the power analysis pro-
vided in this pilot, could lead to similar pretest scores.
Future studies could also limit samples to all men or all
women, considering the variability of effect on the basis
of gender. The variations in scores and changes in scores
seen in this portion of the analysis do reaffirm the frag-
ile and individual nature of sleep in the intensive care
unit environment found previously.6,8,9,52,53
Men and women responded very differently over
time to the intervention. This is an intimate intervention,
requiring a closeness and vulnerability on the part of the
nurse and patient for efficacy. It is possible that there was
some characteristic of the investigator that rendered the
intervention effective for males initially, but was less
effective when experienced a second time. Sleep scores
for the experimental females on the third night signifi-
cantly exceeded those of the control females.
Following transfer, sleep scores improved dramati-
cally. It seems apparent that routines on general units are
less intrusive at night. Also, the number of devices
attached to patients on the general unit is small, and those
devices that are present are not so frightening. Finally,
moving to the general unit indicates that the health of the
patient has improved, which is a source of relief to the
July/August 2003 187
 Sleep
TABLE 5 Results of Repeated Measures ANOVA to Test Effects of Relaxation and Imagery and
Gender Over Time on Sleep Scores in the Critically Ill Adult (N
29)
Source SS
Group 1016.68
Sex 29.59
Group by sex 85.38
Time 39494.05
Group by time 461.13
Sex by time 12696.64
Group by sex by time 47294.05
SS, Sum of squares; MS, mean squares
*P  .01
†P  .005
patient, and may be associated with enough peace of mind
that improvement of sleep naturally follows.
The differences in sleep by unit may be a result of
the level of illness in unit populations, and a reflection
of unit procedures. In the MSICU, patients were initially
treated fairly aggressively, then experienced rapid
improvement in status postoperatively and medically.
The number of devices to which these patients were
attached was initially high, and dropped rapidly. The
combination of improvement and decreased number of
devices may account for the rapid improvement in sleep
scores for these subjects. Subjects admitted to the CCU,
both males and females, experienced moderate sleep
disruption initially, were attached to few devices, and
their sleep improved mildly over time. Routines and
stressors may have been held fairly constant for these
subjects. These CCU subjects also may not have felt as
sick as other subjects, experiencing for the most part
single-system disease (cardiac); whereas, other subjects
frequently were feeling the effects of multiple system
failure. The eight subjects (seven females, one male) in
the MICU present a very different picture from other
subjects. It is most likely that this difference is a dupli-
cation of the difference attributable to gender. It is pos-
sible that women in MICU were given information or
support differently than were men in that unit. It is also
possible that the gender differences were based on the
way men and women view sleep. There is evidence that
women are more sensitive to environmental events that
influence sleep in ways that men are not; men tend to
focus on circumstantial events that influence sleep.54
IMPLICATIONS FOR PRACTICE
It is reasonable for nurses to ask patients one or two
questions about sleep. Occasionally, empathetic listen-
188 Dimensions of Critical Care Nursing Vol. 22 / No. 4
df MS F
1 1016.68 60
1 29.59 .02
1 85.38 .05
1 39494.05 8.69*
1 461.13 .10
1 12696.64 2.80
1 47294.05 10.41†
ing is sufficient to ameliorate a problem, or at least
make the patient feel that he or she is not alone in their
problem. Assessing the patient’s perception of sleep
through open-ended questions is a sensible action for
nurses providing care in clinical settings.
The documentation of sleep and sleep disturbance in
critical care units seems relatively easy to provide. Short
descriptors of sleep (approximately two words) can be
placed in assessments, much as are descriptions of mucus.
A numerical score (possibly from the Sleep Scale) would
fit, practically and philosophically, with other numerical
data recorded on flowsheets in intensive care units.
Nurses can advocate transferring patients out of
critical care units at the earliest possible moment.
Patients may be responding to interruptions in the unit,
devices to which it is customary or necessary for them
to be attached in the unit, routines, noises, and light
patterns in the unit, or the idea that they are critically
ill. Moving the patient from the ICU to the general unit
has immediate beneficial effects on sleep.
The combination of relaxation and imagery was an
effective intervention to promote sleep in the critically
ill adult for four men and women in the experimental
group (25%), based on qualitative data, which has been
reported elsewhere. Training and encouraging staff
nurses in critical care units to deliver this intervention
could improve sleep for many people in the future.
SUGGESTIONS FOR FUTURE STUDIES
It is possible that sleep in both men and women of the
experimental group would have continued to improve
over time more than the control group, given further
exposures to the dose and an extension of the measure-
ment points longitudinally. Also, a larger sample size
will answer questions about pretest variance and gen-
 Sleep

TABLE 6 Mean Sleep Scores Over Time by Group and Gender (N
29)
Group Sex Time M N

Entire sample Time 1 67.8  48.6 29

Time 2 65.2  38.4
Time 3 113.6  54.3
Control Male Time 1 61.4  51.7 8
Time 2 49.6  30.6*
Time 3 113.1  43.4
Experimental Male Time 1 50.7  49.4 6
Time 2 85.2  33.3*
Time 3 90.3  68.8
Control Female Time 1 54.7  37.3† 9
Time 2 71.9  49.6
Time 3 108.4  61.6
Experimental Female Time 1 113.3  39.8† 6
Time 2 55.8  30.1
Time 3 145.2  34.3

Mean values expressed as  SD

*Independent t tests approached significance, P
.075
†Independent t tests approached significance, P
.074

der differences in outcomes, and give more confidence
in generalizeability of results.
The script for the intervention contained multiple
suggestions for control, intimating that the subject
could control the amount of tension retained in his or
her body and that control was pleasurable. It is possible
that the genders responded very differently on the basis
of their gender-based uses of control. Other studies on
other populations have not reported script content. It
would be helpful to repeat this study, therefore, using
two different scripts for men and women. The script for
males would contain many control suggestions, whereas
the script for females would not.
SUMMARY
Relaxation and guided imagery were found to have a
positive effect on the sleep of patients with pulmonary
disease, on the sleep of men following one exposure,
and on the sleep of women following two exposures.
Sleep in the critically ill adult improved over time for
patients in CCU and MSICU and varied according to
night in MICU. Sleep in the critically ill adult also
improved following transfer out of the ICU to a general
nursing unit. Evidence was found for the reliability and
validity of a portion of the Sleep Scale as a tool for the
documentation of the perception of sleep and sleep dis-
turbance in the critically ill adult. Although further
study is needed, for many patients, relaxation and
imagery improves the sleep of the critically ill adult.
References
1. American Association of Critical-Care Nurses Research Work
Group (AACN). Grants in support of research. Aliso Viejo,
Calif: AACN Research Work Group; 1999:22.
2. Aurell J, Elmqvist D. Sleep in the surgical intensive care unit:
Continuous polygraphic recording of sleep in nine patients
receiving postoperative care. Br Med J. 1985;290:1029–1032.
3. Culpepper-Richards K, Bairnsfather LA. A description of
night sleep patterns in the critical care unit. Heart Lung.
1988;17:35–42.
4. Edwards B, Schuring LM. Sleep protocol: A research-based
practice change. Crit Care Nurse. 1993;13:84–88.
5. Richardson SJ. Sleep Deprivation in the Critically Ill [master’s
thesis]. Salt Lake City: College of Nursing, University of Utah;
1986:176.
6. Richardson SJ. The Effects of Autogenic Relaxation and
Guided Imagery on Insomnia in the Critically Ill Adult
[dissertation]. Salt Lake City: College of Nursing, University
of Utah; 1997: 256.
7. Topf M, Bookman M, Arand D. Effects of critical care unit
noise on the subjective quality of sleep. J Adv Nurs.
1996;24:545–551.
8. Wallace C. The Effect of Earplugs on Polysomnographic
Sleep and Description of Sleep-Disturbing Factors in Criti-
cally Ill Subjects [dissertation]. Salt Lake City: College of
Nursing, University of Utah; 1998:147.
9. Wallace CJ, Robins J, Alvord L, Walker JM. The effect of
earplugs on sleep measures during exposure to simulated
intensive care unit noise. Am J Crit Care. 1999;8:210–219.
10. Gift AG, Moore T, Soeken K. Relaxation to reduce dyspnea
and anxiety in COPD patients. Nurs Res. 1992:41:242–246.
11. Griffin JP, Myers S, Kopelke C, Walker D. The effects of pro-

July/August 2003 189

 Sleep
gressive muscular relaxation on subjectively reported distur-
bance due to hospital noise. Behav Med. 1988;14:37–42.
12. Guzzetta CE. Effects of relaxation and music therapy on patients
in a coronary care unit with presumptive acute myocardial
infarction. Heart Lung. 1989;18:609–616.
13. Lerman C, Riner B, Blumberg B, Cristinzio S, Engstrom PF,
MacElwee N, O’Connor K, Seay J. Effects of coping style and
relaxation on cancer chemotherapy side effects and emotional
responses. Cancer Nurs. 1990;13:308–315.
14. Miller KM, Perry PA. Relaxation technique and postoperative
pain in patients undergoing cardiac surgery. Heart
Lung.1990;19:136–146.
15. Johnson JE. Progressive relaxation and the sleep of older nonin-
stitutionalized women. Appl Nurs Res. 1991;4:165–170.
16. Edinger JD, Hoelscher TJ, Marsh GR, Lipper S, Ionescu-Pioggia
M. A cognitive-behavioral therapy for sleep-maintenance insom-
nia in older adults. Psychol Aging. 1992;7;282–289.
17. Engle-Friedman M, Gootzin RR, Hazlewood L, Tsao C. An
evaluation of behavioral treatments for insomnia in the older
adult. J Clin Psychol. 1992;48:77–90.
18. Espie CA, Lindsay WR, Brooks DN, Hood EM, Turvey T. A
controlled comparative investigation of psychological treatments
for chronic sleep-onset insomnia. Behav Res Ther.
1989;27:79–88.
19. Friedman L, Bliwise DL, Yesavage JA, Salom SR. A preliminary
study comparing sleep restriction and relaxation treatments for
insomnia in older adults. J Gerontol. 1991;46, P1–P8.
20. Lichstein KL, Johnson RS. Relaxation for insomnia and hyp-
notic medication use in older women. Psychol Aging.
1993;8:103–111.
21. McClusky HY, Milby JB, Switzer PK, Williams V, Wooten V.
Efficacy of behavioral versus triazolam treatment in persistent
sleep-onset insomnia. Am J Psychiatry 1991;148:121–126.
22. Leja AM. Using guided imagery to combat postsurgical depres-
sion. J Gerontol Nurs. 1989;15:6-11, 40–41.
23. Daake D, Guildner SH. Imagery instruction and the control of
postsurgical pain. Appl Nurs Res. 1989;2:114–120.
24. Maring JR. Effects of mental practice on rate of skill acquisition.
Phys Ther. 1990;70: 165–172.
25. Stephens RL. Imagery: A treatment for nursing student anxiety.
J Nurs Ed. 1992;31:314–320.
26. Moody LE, Fraser M, Yarandi H. Effects of guided imagery in
patients with chronic bronchitis and emphysema. Clin Nurs Res.
1993;2:478–486.
27. Royle JA, Blythe J, Ingram C, DiCenso A, Bhatnager N, Potvin
C. The research utilization process: The use of guided imagery
to reduce anxiety. Can Oncol Nurs J. 1996;6:20–25.
28. Bridge LR, Benson P, Peitroni PC, Priest RG. Relaxation and
imagery in the treatment of breast cancer. Br Med J.
1988;297:1169–1172.
29. Carey MP, Burish TG. Providing relaxation training to cancer
chemotherapy patients: A comparison of three delivery tech-
niques. J Consult Clin Psychol. 55:732–737.
30. Holden-Lund C. Effects of relaxation with guided imagery on
surgical stress and wound healing. Res Nurs Health.
1988;11:235–244.
31. Eller LS. Guided Imagery: A Nursing Intervention for Symp-
toms Related to Infection with Human Immunodeficiency Virus.
Cleveland, Ohio: Case Western Reserve University; 1994:308.
32. Leventhal H, Johnson JE. Laboratory and field experimentation:
Development of a theory of self-regulation. In: Wooldrige PJ,
Schmitt JK, Skipper J, Leonard RC, eds. Behavioral Science and
Nursing Theory. St. Louis: Mosby; 1983: 189–262.
33. Ellett ML. Data analysis for repeated measures studies. Gas-
troenterol Nurs. 1994; 17:116–118.
34. Sidani S, Lynn MR. Examining amount and pattern of change:
Comparing repeated measures ANOVA and individual regres-
sion analysis. Nurs Res.1993;42:283–286.
35. Snyder-Halpern R, Verran JA. Instrumentation to describe sub-
jective sleep characteristics in healthy subjects. Res Nurs Health.
1987;10:155–163.
190 Dimensions of Critical Care Nursing Vol. 22 / No. 4
36. Pedhazur EJ, P, SL. Measurement, Design, and Analysis: An
Integrated Approach. Hillsdale, NJ: Lawrence Erlbaum; 1991.
37. Baekeland F, Hoy P. Reported vs. recorded sleep characteristics.
Arch Gen Psychiatry. 1971;24:548–551.
38. Ellis B, Johns MW, Lancaster R, Raptopoulos , Angelopoulos
N, Priest R. The St. Mary’s Hospital Sleep Questionnaire: A
study of reliability. Sleep. 1981;4:93–97.
39. Leigh TJ, Bird HA, Hindmarch I, Constable PD, Wright V. Fac-
tor analysis of the St. Mary’s Hospital Sleep questionnaire. Sleep.
1988;11:448–453.
40. Campbell DT, Fiske DW. Convergent and discriminant valida-
tion by the multitrait–multimethod matrix. Psychol Bull.
1959;56:81–105.
41. Ferketich SL, Figurueredo AJ, Knapp TR.. The multitrait-multi-
method approach to construct validity. Res Nurs Health.
1991;14:315–320.
42. Richards KC. The Effect of a Muscle Relaxation, Imagery, and
Relaxing Music Intervention and a Back Massage on the Sleep
And Psychophysiological Arousal of Elderly Males Hospitalized
in the Critical Care Environment [dissertation]. University of
Texas at Austin; 1993:370.
43. Gagne JA. Commentary on the use of relaxation for the promo-
tion of comfort and pain relief in persons with advanced cancer
[original article by Sloman R et al. in Contemp Nurs.
1994;3(1):6–12]. AACN Nurs Scan Critic Care. 1996;6:2.
44. Sloman R, Brown P, Aldana E, Chee E. The use of relaxation for
the promotion of comfort and pain relief in persons with
advanced cancer. Contemp Nurs: J Austral Nurs Profess.
1994;3:6–12.
45. Warner L, McNeill ME. Mental imagery and its potential for
physical therapy. Phys Ther. 1988;68:516–521
46. Kwekkeboom K, Huseby-Moore K, Ward S. Imaging ability and
effective use of guided imagery. Res Nurs Health.
1998;21:189–198.
47. Cise JCS. Self-reflective Guided Imagery Among Middle-Aged
Obese Women in a Support Group Setting. School of Nursing,
Indiana University; 1994:213.
48. Collins JA, Rice VH. Effects of relaxation intervention in phase
II cardiac rehabilitation: Replication and extension. Heart Lung.
1997;26:31–44.
49. Gross SW. The Impact of a Nursing Intervention of Relaxation
With Guided Imagery on Breast Cancer Patients’ Stress and
Health as Expanded Consciousness. University of Texas at
Austin; 1995:302.
50. Kolcaba K, Fox C. The effects of guided imagery on comfort of
women with early stage breast cancer undergoing radiation ther-
apy. Oncol Nurs Forum. 1999;26:67–72.
51. Egan EC, Snyder M, Burns KR. Intervention studies in nursing:
Is the effect due to the independent variable? Nurs Outlook.
1992;40:187–190.
52. Fontaine DK. Measurement of nocturnal sleep patterns in
trauma patients. Heart Lung. 1989;18, 402–410.
53. Richardson S J. Sleep pattern disturbances and related factors in
the critically ill. In: Carroll-Johnson RM, Paquette M, eds. Pro-
ceedings of the 10th NANDA Conference on the Classification
of Nursing Diagnoses. San Diego, Calif: Lippincott-Raven;
1992:2218–2222.
54. Signoret P, Blois R, Merica H, Gaillard JM. Subjective assess-
ment of sleep: Statistical analysis in a population of healthy sub-
jects. Neuropsychobiology. 1994;30:79–84.
ABOUT THE AUTHOR
Stephanie Richardson, PhD, RN, is Assistant Professor, College of
Nursing, Director, Center for Teaching and Learning Excellence, Univer-
sity of Utah (e-mail: Stephanie.richardson@nurs.utah.edu).
Address correspondence to: Stephanie Richardson, PhD, RN, Assistant
Professor, College of Nursing, Director, Center for Teaching and Learn-
ing Excellence, University of Utah, Salt Lake City, UT 84112-0511.