Research and Development
Improving sleep quality for
patients after cardiac surgery
Aaron Conway is Registered Nurse in Cardiac Catheter Theatres, The Wesley Hospital, Auchenflower, Queensland,
Australia; Monica Nebauer is Senior Lecturer/Nursing Masters Courses Coordinator, School of Nursing and Midwifery,
Australian Catholic University, Banyo, Queensland; Paula Schulz is Senior Lecturer, School of Nursing and Midwifery,
Australian Catholic University. Email: Aaron.conway@uchealth.com.au
leep is recognized as an essential requirement for
S health and recovery as the sleep-wake cycle
influences and regulates physiological function and
behavioural responses (Crisp and Taylor, 2001). Post-
cardiac surgery patients experience disturbed sleep, which
consequently inhibits their recovery through disruption to
their physical and psychological function (Redecker,
2004a; Friese 2008). Furthermore, daytime fatigue caused
by sleep disruption is a contributing factor to post-cardiac
surgery patients not participating in and benefiting to the
full extent from rehabilitation programmes while in
hospital (Richards, 1998). A study by Barnason et al
(2008) reported that patients who are fatigued after
cardiac surgery experience significantly poorer ratings for
psychosocial scores such as mood, emotional wellbeing
and social function compared with those who are not
Abstract
Research has consistently described that patients after cardiac
surgery experience disturbed sleep yet there has been limited
investigation into methods to improve this experience. Complementary
therapies may be a method of addressing this issue.
Aim: To determine if using progressive muscle relaxation improves
self-rated sleep quality for patients following cardiac surgery.
Methods and Results: Thirty-five participants’ quantitative data on
sleep quality were obtained via questionnaire during their first post-
operative week after cardiac surgery. Qualitative data were obtained
through written responses to open-ended questions. No significant
differences in sleep quality scores were found between pre and post-
intervention of progressive muscle relaxation using the Wilcoxon
Signed Ranks Test. However, the qualitative analysis discovered the
intervention aided some participants in initiating their sleep by
diversion of thought, inducing relaxation or alleviating pain and
anxiety.
Conclusions: Qualitative findings suggest that progressive muscle
relaxation may help patients who have undergone cardiac surgery
initiate their sleep.
Key words
w Complementary therapies w Sleep w Cardiac surgery
w Recovery w Mixed methods study
Submitted for peer review 5 November 2009. Accepted for publication 22
February 2010. Conflict of interest: None
142
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fatigued. Therefore, to promote recovery from cardiac
surgery, it is important to consider interventions that will
limit fatigue through an improved sleep experience.
Complementary therapies may be one method of
improving sleep for this population of patients. However,
there is a lack of research into this topic. This study there-
fore aimed to identify if one such complementary therapy,
progressive muscle relaxation (PMR), could improve sleep
quality. PMR was pioneered by Edmund Jacobson and
uses a method of ‘tense and release’ of the muscle groups
to induce the relaxation response (Payne, 1995). Relaxation
has been described as counteracting stress in a non-phar-
macological, non-invasive way by producing a state of
physiological and psychological rest (McCabe, 2001). The
process of PMR involves tensing one specific muscle
group for a short period of time (less than 10 seconds),
with conscious thought focusing only on the tense feeling
of that muscle group. After the period of tension, the mus-
cle group is relaxed with the feeling of relaxation greatly
enhanced by the immediate contrast between the two
states of tension and relaxation. The procedure then moves
on to tension followed by relaxation of the next muscle
group. A popular sequence moves from the lower body to
the upper starting at the feet.
Contemporary health-care practices have driven a reduc-
tion in hospital stay for all types of surgery (Farrell, 2005),
however the complicated nature of cardiac surgery still
necessitates an extended length of stay in hospital. These
practices are reflected in Australian length-of-stay data with
the Australian Institute of Health and Welfare (2005)
reporting the average length of stay for the most common
cardiac surgery, coronary artery bypass grafting, of seven
days. Although this article reports on a study conducted in
Australia, it is likely that these length of hospital stay figures
are somewhat similar to other western countries that pro-
vide a cardiac surgery service, and therefore relevant to
nursing practice in the United Kingdom.
Background
Research in the use of PMR after cardiac surgery is limited
with only one previous study investigating the topic. This
was a small study with 25 participants using a randomized
controlled trial that did not achieve significant results for
their measurements of pain, anxiety, calm, rest and relaxa-
tion (Hattan et al, 2002).
British Journal of Cardiac Nursing March 2010 Vol 5 No 3

However, a number of studies present evidence to sup-
port the conduct of this study. First, patients who have
undergone cardiac surgery experience their most dis-
turbed sleep during the first post-operative week (Redecker
et al, 2004a). Second, disturbed sleep in cardiac surgical
patients has been correlated with poor ratings for psycho-
logical and emotional wellbeing (Edéll-Gustafsson et al,
1997; Edéll-Gustafsson and Hetta, 1999; Edéll-Gustafsson
et al, 1999; Hunt et al, 2000; Edéll-Gustafsson, 2002;
Redecker et al, 2004b). Finally, PMR has demonstrated
effectiveness in improving anxiety and depression scores
and quality of life in a variety of patients in the clinical
setting (Collins and Rice, 1997; Cheung et al, 2001; Yoo et
al, 2005).
Aims
The aims of this study were first, to determine if patients’
responses for self-rated sleep quality are improved after
using PMR in the early post-operative period, and second,
to obtain qualitative information regarding the partici-
pants’ experiences of using PMR and of their sleep whilein
hospital. The following hypothesis was tested.
Hypothesis: Use of progressive muscle relaxation during
the first post-operative week after cardiac surgery will result
in a positive change in self-rated sleep quality scores.
Methods
Study design
A mixed methods design was employed. Participants were
administered a questionnaire which was completed daily
from the third to the seventh post-operative day. The quan-
titative component of the study gathered data from partici-
pants to determine self-rated sleep quality through daily
completion of a number of scales. A within-group design
was used with data collected from the same group of par-
ticipants both before and after implementing PMR (Polit
and Beck, 2010). The PMR intervention was administered
by audio-recorded instructions played on a personal port-
able CD player with earphones. Table 1 outlines the times at
which the intervention was administered and data collected.
The qualitative component explored the participants’
experiences of sleep and their use of PMR through written
responses to open-ended questions at the conclusion of
the study on the seventh day after surgery (Denzin and
Lincoln, 2008). All of the data were collected from May
2008 to August 2008 in one 430-bed private acute care
hospital in a city in Australia.
Participants
A convenience sampling method (Polit and Beck, 2010)
was employed for this study. Participants were required to
be over 18 years of age, and able to speak and understand
English. A total of 67 patients gave their consent to par-
ticipate in the study over a two and a half month period.
Forty of the participants who provided consent fulfilled
the requirement of admittance to the cardiology ward
from the intensive care unit (ICU) on the second post-
operative day, and were eligible to enter the study. However,
British Journal of Cardiac Nursing March 2010 Vol 5 No 3
Research and Development
data from five of the participants were incomplete and as
such, 35 participants’ data were used for analysis.
Instrument
To test the hypothesis, an instrument to measure sleep
quality was required. Yi et al (2006) describe six factors
that comprise sleep quality in their instrument, the Sleep
Quality Scale. A single scale was used in this study to
measure each of the factors of the sleep quality scale as this
approach enabled the written responses to be limited to
one page per day to reduce participant fatigue and maxim-
ise the participants’ response rate (Polit and Beck, 2010).
Scales are widely used as a measure of sleep quality and
daytime functioning and are easy to understand and com-
plete (Zisapel and Nir, 2003).
Participants were asked to mark a numerical value on a
scale from 1 to 10 in response to a question about their
Table 1.
Participant involvement in study
Day Participant involvement
Day prior to Consent to participate in the research
surgery
Day of surgery Participant in cardiothoracic ICU. Nothing
required of participant
Day one after Participant in cardiothoracic ICU. Nothing
surgery required of participant
Day two after Participant transferred to cardiology ward
surgery during the day. Nothing required of participant
Day three Participant provided with questionnaire,
after surgery recording and CD player. Participants to fill in
the first page of questionnaire, rating their
previous night’s sleep quality on scales
provided
Day four after Participants to fill in the second page of the
surgery questionnaire, rating their previous night’s
sleep on scales provided. Participants to
perform progressive muscle relaxation prior to
going to sleep
Day five after Participants to fill in the third page of the
surgery questionnaire, rating their previous night’s
sleep on scales provided. The participants to
perform progressive muscle relaxation prior to
going to sleep
Day six after Participants to fill in the fourth page of the
surgery questionnaire rating their previous night’s
sleep on scales provided. The participants to
perform progressive muscle relaxation prior to
going to sleep
Day seven Participants to complete the questionnaire,
after surgery rating their previous night’s sleep using the
scales provided and answering the ‘experience
of sleep’ questionnaire. Once completed, the
participants to return the questionnaire in an
envelope to their registered nurse
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Research and Development
How hard was it for you to fall asleep last night?
1 2 3 4 5 6 7 8 9 10
Easy Hard
Figure 1. Scale used to measure participants’ difficulty in falling asleep
sleep quality. At each end of the scale was an explanation
of the range of experience being measured (an example for
sleep initiation is given in Figure 1).
Ethical considerations
This study was conducted with approval from the relevant
hospital and university human research ethics committees.
Participation in the research was voluntary and did not
impact on the patient’s care as the research studied the
effects of PMR in addition to current standard nursing care
practices at the study hospital. None of the researchers held
a clinical role in the department where participants were
recruited or data collected. Participants provided written
informed consent for participation in the study (National
Health and Medical Research Council, 2007).
Data analysis
Quantitative data analysis
Pre and post-intervention analyses of scores for each of the
six aspects of sleep quality were used to test the hypothesis
that PMR will improve sleep quality. All data were numeri-
cally coded and entered into the SPSS computer software
package and screened for missing values by variable and by
case. This process identified that data from day seven sleep
scores were missing from 37% (n=13) of questionnaires.
Day seven sleep scores were excluded from analysis so that
sleep scores from day three and day four post surgery com-
prised the pre-intervention data (before PMR intervention)
and sleep scores from day five and six post surgery com-
prised post-intervention data. The data did not meet the
requirements of the assumptions underlying the use of
parametric tests and hence the non-parametric alternative,
Wilcoxon Signed Rank Test, was used (Pallant, 2005).
Qualitative data analysis
The qualitative data analysis process used to identify
themes in the data was based on a thematic analysis
framework provided by Braun and Clark (2006). The steps
taken to identify the themes include familiarizing with the
data, identifying interesting features, searching for themes
and naming themes.
Results
Demographic data
The participants ranged in age from 48 to 87 years with a
mean age of 67.2 years (SD=9.589) and a median age of
66.5 years. The majority of participants were male com-
prising 66% (n=23) of the study sample, while female
participants were 31% (n=11) of the cohort. One of the
144
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participants did not identify his/her gender. For the
majority of participants it was their first experience of
cardiac surgery (88.6%, n=31).
Descriptive statistics
The majority of participants perceived PMR as being easy
to complete with 60% of the total participants rating PMR
as 3 or less on a scale with 1 being easy and 10 being hard.
Only 23% (n=8) of participants involved in the study had
previously used relaxation techniques.
Hypothesis testing
The results from the analysis using the Wilcoxon Signed
Rank Test for the six aspects of sleep quality measured are
presented in Table 2. Overall, the analysis of the six sleep
quality factors using the Wilcoxon Signed Rank Test did
not reach statistical significance (P<0.05). Therefore the
hypothesis that PMR will improve self-rated sleep quality
of patients during their first week after cardiac surgery was
not supported.
Thematic analysis
There were three major themes identified from the quali-
tative data: ‘effects of the relaxation process’, ‘interruptions
to the relaxation process’, and ‘suggestions for change to
the relaxation process’.
Effects of the relaxation process
There were varying responses from participants as to the
effects of PMR in the post-operative period. Improved
sleep resulting from the relaxed feeling produced by PMR
was described by 20% (n=7) of participants.
I felt more relaxed so I felt I went off to sleep easier and
stayed asleep for most of the night (Participant 2).
Seven participants (20%) described PMR as diverting
their thoughts to enable initiation of sleep. Participants
expressed this experience in several ways, such as:
The effect of the process is to divorce the mind from
external stimulation (movement, sound, light)
(Participant 33).
Similar to the thought diversion ideas were comments
from participants that the relaxation prepared their mind
for sleep. A smaller number of participants (n=2, 6%)
described their experiences in this way.
Preparation (of) one’s mind is important for this
type of surgery and muscle relaxation can be helpful.
(Participant 29).
The final explanation offered by two participants (6%)
for the improved sleep experienced after using PMR was
that it helped to relieve anxiety and pain.
(It) helped me to sleep when in pain (Participant 30).
British Journal of Cardiac Nursing March 2010 Vol 5 No 3
 Research and Development

Interruptions to the relaxation process
More than half of the participants reported an interrup-
tion that prohibited or distracted them from using PMR.
The participants felt that these interruptions detracted
from the advantages of relaxation during the stressful time
after cardiac surgery. The most prevalent of these inter-
ruptions was noise in the environment (n=8, 23%):
The continual noise—especially the drug door slams
all the time. Very annoying and hard to concentrate.
(Participant 19).
Another external factor that interrupted the relaxation
process was battery failure of the CD player which was
reported by 9% (n=3) of patients. This outcome was a dis-
appointing revelation as the comments demonstrated how
disadvantaged participants felt by the equipment failure.
(The) effect was not the same and quality of sleep was
way down on nights (compared with) when I used
the CD (Participant 1).
As well as external factors interrupting the relaxation
process, the participants reported internal factors includ-
ing pain (n=7, 20%) and coughing (n=2, 6%) that inhibit-
ed the relaxation process. Comments from a participant
suggest that relaxation would be easier to complete and be
more effective if pain was controlled.
I fell asleep several times while listening to (the) CD
except when (the) pain was really acute (Participant
24).
Suggestions for change to the relaxation process
Participants offered suggestions as to how PMR could be
more effective, be modified for use in different situations
and also what environment would best suit its use. Some
participants thought that PMR worked more effectively
with increased use, therefore they suggested that patients
undergoing similar heart surgery should use the relaxa-
tion intervention more often, with a participant also sug-
gesting its use before surgery.
The system probably needs a longer time frame. (That
is) some practice prior to surgery (Participant 33).
Other comments suggested that PMR improved with
repetitive use.
The muscle relaxation would improve the more it is
used. But it did help on three or four occasions for
me (Participant 14).
The suggestion by two participants (6%) that PMR
would be more effective in a ‘home’ environment is not
surprising due to the 23% of respondents who said that the
relaxation was interrupted by noise in the environment:
Excellent tape but bouts of coughing interrupt, also
nurses pop in and out doing necessary tests. Good to
learn when (I’m) home without interruptions.
(Participant 21).
Discussion
The results of this study do not support the introduction
of PMR to improve sleep quality in the early post-opera-

Table 2.
Results of Wilcoxon Signed Rank Test for aspects of sleep quality
Sleep factor Z score P value Mean Std deviation
Sleep initiation -1.88 0.06 (not significant) Pre 6.71 Pre 3.50
1=Higher sleep quality Post 5.66 Post 2.72
10=Lower sleep quality
Daytime tiredness -1.65 0.96 (not significant) Pre 7.12 Pre 2.97
1=Lower sleep quality Post 7.94 Post 2.31
10=Higher sleep quality
Sleep satisfaction -0.16 0.88 (not significant) Pre 8.23 Pre 3.87
1=Lower sleep quality Post 8.20 Post 2.86
10=Higher sleep Quality
Sleep restoration -1.17 0.25 (not significant) Pre 7.14 Pre 3.25
1=Lower sleep quality Post 8.00 Post 3.04
10=Higher sleep quality
Waking after sleep -1.26 0.21 (not significant) Pre 4.99 Pre 2.92
1=Higher sleep quality Post 4.23 Post 2.16
10=Lower sleep quality
Sleep maintenance -0.60 0.55 (not significant) Pre 6.90 Pre 3.57
1=Higher sleep quality Post 6.47 Post 3.12
10=Lower sleep quality

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Research and Development
tive period for patients after cardiac surgery. However,
conducting this research has offered insight into a group
of cardiac surgical patients’ experiences of the effects of
PMR, their perceived ease or difficulty in using the tech-
nique as it was applied in this study with an audio record-
ing guiding their sessions and their perceived inhibiting
factors to the relaxation process. Finally the research also
elicited suggestions for improvements to the use of this
particular complementary therapy in the clinical setting to
consider in further studies.
Although improved self-rated sleep quality scores for
patients after using PMR did not occur at a statistically
significant level some participants described various posi-
tive effects of the relaxation process, which suggest that
PMR warrants further study to determine its effectiveness
in improving sleep for this population of patients. The
positive effects of PMR identified by some participants in
this study included aiding initiation of sleep by bringing
about a sense of relaxation, diversion from negative
thoughts resulting in calm thought processes, providing a
method for relaxing a specific body part thus facilitating
comfort or simply making it easier to ‘switch off ’ and pre-
pare the mind for sleep.
The theme ‘suggestions for change to the relaxation
process’, provides insight into possible methods of improv-
ing the relaxation technique. One suggestion was that
PMR would work better for participants if they were able
to use the relaxation technique more often. The literature
on PMR supports an early introduction of the relaxation
technique. For example, Yoo et al (2005), who investigated
PMR with patients receiving chemotherapy for breast can-
cer, found that PMR had more of an effect during the fifth
and sixth sessions while Haase et al (2005), when research-
ing patients who have had colorectal resections, imple-
mented the relaxation technique before surgery continu-
ing through to the post-surgical period. Therefore, more
practice using the relaxation technique may be required
before effective use is achieved.
To address this issue in the future, the technique can
either be introduced before surgery, so that patients can
become more comfortable with PMR, or patients could be
allowed to use PMR on more than one occasion through-
out the day. Introducing the technique before surgery may
make patients more comfortable using the technique and
therefore they may experience fewer interruptions to the
relaxation process. Only 22.9% of participants had used
relaxation techniques before this research, which further
strengthens the argument for earlier introduction and use
of the technique to allow patients more time and practice
to become familiar with it.
Previous research into the use of PMR has not described
the interruptions to the relaxation process expressed by
participants in this study, although these interruptions
may appear to be self-evident. Examples of interruptions
reported included equipment failure of the CD player,
noise from the surrounding environment as well as pain
and other associated symptoms. While previous stud-
ies—for example Haase et al (2005), Cheung et al (2001)
146
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and Hattan et al (2002)—used similar techniques in apply-
ing PMR using a recording to guide participants through
the relaxation, none raised the issue of difficulties or inter-
ruptions experienced by participants. This is an important
finding as it provides guidance to address these issues for
future studies using PMR in the clinical setting.
Results from the quantitative component of this research
found that 60% (n=21) of the participants found the tech-
nique easy to complete. Therefore to make it easier for
patients to use PMR and benefit from the state of relaxation
it can induce, strategies to address the interruptions to the
relaxation process that were identified by this research
could be implemented.
For example, efforts should be made to introduce the
intervention at a time when patients’ pain and other
symptoms are under control, possibly by using the tech-
nique after pain medication is administered. As this study
investigated PMR as a complementary nursing therapy,
when implemented into practice the nurse would have the
ability to plan and integrate the relaxation into the holistic
care of the patient at a time selected by the patient, as
opposed to the participant using the technique at a pre-
scribed time as in the case of this research.
A significant interruption described by participants was
noise, which has been shown to negatively influence sleep
in acute care settings (Missildine, 2008). This interruption
is difficult to address as the technique is aimed at improv-
ing sleep for cardiac surgical patients when it is most dis-
turbed in the first post-operative week. Unfortunately this
means patients will be in hospital in a busy surgical ward
with noise from other patients, staff and equipment, all
contributing to a disturbing environment.
Study limitations
Due to the limited data collection time and a large propor-
tion of consented participants not transferring from the
ICU to the cardiology ward on their second day after sur-
gery (as required in the inclusion criteria for the study)
only a relatively small group of participants recruited was
eligible to enter the study. A replication study at several
different hospital sites where earlier transfer to the cardiac
surgical ward is more common would result in a larger
sample size due to an increased proportion of the con-
sented participants being allowed to enter the study on
their second day after surgery.
A longer data collection period and thus larger sample
size would also allow for a more rigorous methodology to
be used, such as a randomized controlled group design.
This type of research design would be the most effective in
determining a cause-and-effect relationship between the
use of PMR and sleep quality of patients who have under-
gone cardiac surgery (Polit and Beck, 2010). Using such a
design it is possible that PMR could be used by partici-
pants for a longer period of time than in the present study.
The experimental group could start using PMR on their
second day after surgery with data collected until discharge
or possibly for a period of time after discharge. This
approach would considerably strengthen further study of
British Journal of Cardiac Nursing March 2010 Vol 5 No 3

this topic as the literature suggests that PMR is more effec-
tive the more it is used (Haase et al, 2005; Yoo et al, 2005).
The need to keep the data collection tool as simple as
possible in this study to avoid patient fatigue made it
impractical to use an entire extensive data collection tool,
such as the Sleep Quality Scale devised by Yi et al (2006).
Nevertheless, the use of a previously tested, reliable instru-
ment such as the Sleep Quality Scale would improve the
validity of the data collected and enable comparison with
other studies using the same instrument. A different
approach would facilitate the use of such a scale later in
the post-operative period, after participants have had the
opportunity to use PMR on a number of occasions.
Conclusions
This study aimed to determine if patients who used PMR
in their first week after cardiac surgery demonstrated an
improvement in self-rated sleep quality. The results of the
quantitative component of the study did not demonstrate
an improvement in sleep quality scores after using PMR.
However, the qualitative results suggested that PMR
improved some participants’ abilities to initiate sleep
through a variety of methods including diverting thoughts
to a calm process, inducing relaxation or alleviating pain
and stress.
Strategies to improve the use of PMR with patients in
the hospital setting were identified. These strategies, which
should be taken into consideration in future studies,
include decreasing interruptions and implementing the
relaxation into the holistic nursing care plan at a time
when pain and comfort needs are addressed.
This research has also identified that future study into
this topic should use an extended data collection period to
increase the sample size and thus allow for a more rigor-
ous study design.
Acknowledgements
This study used funding from the Australian Catholic University Faculty
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Queensland Nursing Council was accepted by Aaron Conway to fund the
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Key Points
w Some patients reported that progressive muscle relaxation (PMR)
facilitated initiation of their sleep through diversion of negative
thoughts to a calm thought process, inducing relaxation or alleviating
stress or pain
w Patients also reported that they experienced interruptions to using
PMR in hospital which detracted from the benefits
w Relaxation interventions need to be implemented into the nursing
care plan at a time when pain is under control and comfort needs
have been addressed
w Further research is required to substantiate qualitative evidence that
progressive muscle relaxation could potentially improve sleep quality
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