Characteristics of the Nighttime Hospital Bedside Care Environment (Sound, Light, and Temperature) for Children with Cancer

Lauri A. Linder, PhD, APRN, CPON; Becky J. Christian, PhD, RN


Cancer Nurs. 2011;34(3):176-184. 

In This Article

Review of the Literature

Characteristics of the Inpatient Hospital Bedside Environment

Maintaining a nighttime care environment that is conducive to sleep is of particular importance for the child with cancer. Children with cancer not only must recover from the effects of their illness and its treatment but also must sustain normal growth and development. A disruptive nighttime care environment can compromise both sleep quantity and quality in acutely ill children.[1,4,8] Compromised sleep, in turn, can lead to impaired immune function and neuroendocrine regulation of hormones, which can affect growth and healing.[9–11] Altered sleep also is associated with other cancer-related symptoms, including fatigue, which can impact their quality of life.[12] As such, attention to the nighttime care environment is warranted. Identifying characteristics of the care environment can guide the development of interventions to promote a restful environment that can promote children's recovery and, ultimately, quality of life.

Sound Intensity Elevated sound levels are recognized by WHO as significant sources of environmental pollution with adverse outcomes on health and well-being.[13] Sustained indoor levels greater than 45 dB interfere with normal activity and with communication. Individual events generating sound levels of 45 dB or greater are associated with disrupted sleep. Possible alterations in stress hormone secretion and immune function are associated with sustained exposure to sound levels of 65 to 70 dB.1fs3

The WHO has established recommended sound levels for health care settings. The recommended average sound level for hospital rooms in which patients are being actively treated is 35 dB or less. The recommended maximum intensity for individual events at the patient's bedside is 45 dB.[13]

To date, studies investigating sound intensity in pediatric health care settings have been limited to critical-care settings. In pediatric intensive care units (PICUs), mean nighttime sound levels at the child's bedside were consistently reported as greater than 50 dB, with spikes to 120 dB.[1–4] For adults, similar findings have been identified in both critical-care and medical-surgical units, with mean sound levels ranging from 42 to 56 dB, with spikes in excess of 80 dB.[5–7]

In both pediatric and adult critical-care settings, greater nighttime sound levels are associated with reduced total sleep minutes and greater fragmentation of nighttime sleep.[1–4,8] Children and adolescents with cancer have described noises and frequent disruptions in the hospital care environment as contributing to disrupted sleep as well as to fatigue.[12] In a recent study of 25 school-aged children and adolescents receiving inpatient chemotherapy, counts of room entries and exits ranged from 3 to 22, with an average of 11.3 during an 8-hour night shift.[14] Although this study measured counts of staff and family-reported room entries and exits, it did not measure sound and light levels associated with these entries and exits.

Light Elevated light levels create an environment that is not conducive to nighttime sleep. The Illuminating Engineer Society recommends daytime light levels of 10 to 30 lumen/ft2 for hospital rooms.[15] The upper limit of this range, 30 lumen/ft2, represents the recommended light level for reading printed material. Complete darkness is measured as 0 lumen/ft2.

Although light levels have been investigated less frequently in the nighttime health care environment, PICU studies identified average nighttime light levels at the child's bedside of 23.4 lumen/ft2, with mean levels ranging from 45.3 lumen/ft2 early in the evening to 17.1 lumen/ft2 after midnight.[4] Light levels ranged from relatively low levels at 5 lumen/ft2 to a high of 140 lumen/ft2, a value exceeding recommended levels for close work in laboratories. Increased bedside light levels were associated with decreased and fragmented nighttime sleep in the PICU.[4,8] However, nighttime light levels at the bedside in patient rooms have not been investigated except for the intensive care unit, which is a different environment.

Temperature Excessive temperatures have the potential to disrupt sleep continuity and therefore may contribute to an adverse care environment. The upper threshold of recommended room temperature for healthy sleep is 75°F.[16] Previous studies have not investigated temperature variation within the patient's room as a component of the nighttime care environment.


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