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Pielęgniarstwo Chirurgiczne i Angiologiczne/Surgical and Vascular Nursing
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vol. 17
Review paper

Non-pharmacological nursing interventions to promote sleep quality after coronary artery bypass graft surgery: a systematic review

Burcu Totur Dikmen
Fondness Inemesit Akpan

Near East University, Faculty of Nursing, Department of Surgical Nursing, Nicosia, Turkish Republic of Northern Cyprus
Swansea University, Faculty of Medicine, Health, and Life Sciences, Department of Public Health and Health Promotion, Swansea, United Kingdom
Online publish date: 2023/07/25
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Patients with coronary artery bypass graft (CABG) more than often struggle with alterations in their sleep pattern, especially in the post-operative period [1, 2]. These patients have changed their sleep pattern over the recovery period and are accompanied by poor quality perception and frequent awakenings [3–5]. As a result of inappropriate sleep pattern, patients encounter fatigue, irritability, daytime sleepiness, mortality, and prolonged duration of hospitalization and associated costs [1, 6]. Various variables such as age, gender, health, medications, environment, or previous sleep disorders affect the consistency, duration, and depth of sleep in acute cases [7, 8]. Adequate quality of sleep has been shown to decrease immediately after with patients due to elevated blood pressure, irritability, depression, and a decrease in the overall satisfaction of their life [1, 7, 9]. Researchers have found a correlation between sleep quality and daily life activities among the patients with CABG [2, 4, 10]. Therefore, the creation of therapeutic successful techniques, including environmental regulation, as well as reducing sound and light, is critical for understanding the possible multifactor causes of sleep disorder [9].
Different techniques for promoting sleep have been tested in hospitalized patients. Studies have shown that a mixture of treatments that can alleviate anxiety, pain, and environmental factors effectively is successful at decreasing sleep disorders [9, 7, 11]. Therefore, the objective of this study is to review the available literature evidence of effective non-pharmacological nursing interventions to promote sleep quality in patients who underwent CABG surgery.

Material and methods

The PICO (population, intervention, comparator, and outcome) framework was used in this systematic review. It is a staple of evidence-based practice pedagogy in nursing. It is used to develop literature search strategies, for systematic review, and to answer clinical or health care-related questions [12]. Using the PICO method, the guiding question was formulated wherein P (Problem/ Population) refers to certain patients, I (Intervention) refers to non-pharmacological interventions to promote sleep quality, C (comparison/control) refers to regular care, and O (outcomes) refers to enhanced sleep pattern [12, 13]. This systematic review followed the preferred reporting items for systematic reviews and meta-analyses checklist and the flow diagram for conducting systematic reviews (Fig. 1) [14].
Primary studies were included in the design, namely randomized controlled trials. With respect to the date of publication, no time limits were set. The following criteria were considered in the selection of articles.
Inclusion criteria

• Publication language being English,
• Accessibility of full text,
• Being randomized control, and clinical study,
• Studies performed in CABG patients,
• Studies measured the quality of sleep,
• Studies discussed non-pharmacological nursing interventions,
• Individuals aged 18 years and older.
Selection of the studies
A search was conducted in the National Library of Medicine-National Institutes of Health (PubMed/MEDLINE), Science Direct, Scopus, Cochrane Central Register of Controlled Trials (Cochrane Central), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases by using keywords such as “non-pharmacological”, “nursing interventions”, “sleep quality”, “coronary artery bypass graft”, and “surgery”. The literature search was conducted between June and July 2022. These articles were outlined accordingly to include the author/s, year, title, study design, sample, method, result, conclusion, and limitations. The selected papers were evaluated (Fig. 1).
Risk of bias assessment
The bias risk was assessed as recommended by the Cochrane Collaboration Guidelines (Fig. 2) [15].
The current study has some limitations. It was limited to published English language studies. There were not enough studies to evaluate non-pharmacological nursing interventions to promote sleep quality in patients who underwent CABG surgery.


The studies are distributed between 2010 and 2021 for the year of publication. These data show that changed sleep patterns are a more recent issue. According to the sort of intervention, 2 general groups were assigned to the study, these being relaxation strategies and education technique. Four of the studies studied relaxation method effectiveness, and one study examined educational approach effectiveness. The relaxation methods included in these reviews were massage, acupressure, Benson Relaxation Technique, and deep breathing exercises (Tab. 1).


Evidence shows that the quality of sleep is often poor in the postoperative period among CABG surgery patients, particularly after the surgery patients have high sleep interference [3, 4, 16]. Poor postoperative sleep quality may be attributed to many causes, including surgical incision pain, the presence of a chest drain, excessive bedtime discomfort, and high rates of anxiety [7, 17]. Sleep should be an integral component of nursing practice to guarantee patient recovery and to decrease complications, costs, and hospital stay. It is important that nurses have an understanding of the sleeping habits of the patients because this can help improve the sleep quality [5, 18].
All research included in this review indicate that patients’ sleep can be improved by non-pharmacological treatment. Many approaches have facilitated decreased sleep duration while others have enhanced sleep quality perception [19, 20]. The following are the 2 key category of studies addressing relaxation techniques, which made up the highest number of studies followed by investigation addressing educational strategies [19, 21]. The relaxation technique category was effective in improving sleep quality. Statistically significant results have been reported in preventing a decline in the score concerning sleep quality in the studies. A study revealed that the baseline score for sleep quality post operation increased in patients who received deep breathing exercises [22]. Another study mentioned that massage therapy is beneficial for improving sleep quality and decreasing fatigue among patients after CABG surgery [23]. This is similar to the study that stated that foot bath and massage therapies improved sleep quality in patients [17, 24].
A paper included in this review examined the use of Benson Relaxation Technique [10]. In the Benson Relaxation Technique, sleep quality, sleep latency, sleep efficacy, and sleep disturbances were significantly better than in the control groups [10, 25]. Also, acupressure 15 minutes before bedtime substantially promoted sleep quality among patients following CABG, highlighting that acupressure is a harmless and inexpensive approach [26].
The studies classified as education strategies provided new insights into sleep hygiene practices, healthy nutrition, and physical activity [19, 21, 27, 28]. Patient education should be widely promoted in clinical practice for sleep quality, which is a resource of low cost, easily accessible, and which reinforces the value of individualized patient and family care [29].
It is therefore important that nurses have knowledge on sleep-enhancing care so that factors that deteriorate sleep quality and therefore affect the recovery of patients, particularly with regard to educational contents, can be actively decreased [24, 30]. To achieve this aim, implementation of strategies that are low cost or without cost should be encouraged.


The result of this study show that measures such as massage, acupressure, relaxation techniques, deep breathing exercises, and education on self-care activities have been assessed, and sleep rating scores have dramatically improved. Nurses can develop a definitive plan of care that incorporates these interventions so as to provide quality care to a patient during the postoperative period of CABG surgery. Identifying gaps in knowledge on the subject will be helpful in encouraging future studies.
The authors declare no conflict of interest.
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