Online Exclusive Article

Sleep Disturbance, Chronic Stress, and Depression in Hospice Nurses: Testing the Feasibility of an Intervention

Patricia A. Carter

Kathleen A. Dyer

Sabrina Q. Mikan

sleep, sleep disturbance, chronic, stressors, depression, hospice
ONF 2013, 40(5), E368-E373. DOI: 10.1188/13.ONF.E368-E373

Purpose/Objectives: To test the feasibility of a cognitive-behavioral therapy for an insomnia (CBT-I) intervention in chronically bereaved hospice nurses.

Design: Five-week descriptive correlational.

Setting: Nonprofit hospice in central Texas.

Sample: 9 agency nurses providing direct patient and family care.

Methods: Direct care nurses were invited to participate. Two intervention group sessions occurred at the hospice agency and included identification of dysfunctional thoughts and beliefs about sleep, stimulus control, sleep hygiene, and relaxation techniques to promote sleep. Measurements were taken at baseline and three and five weeks postintervention.

Main Research Variables: Sleep quality, depressive symptoms, and narrative reflections on the impact of sleep quality on self-care.

Findings: Participants reported moderate-to-severe sleep disturbances and moderate depressive symptoms. The CBT-I intervention was well accepted by the participants, and on-site delivery increased participation.

Conclusions: Additional longitudinal study is needed to investigate the effectiveness of CBT-I interventions to improve self-care among hospice nurses who are at high risk for compassion fatigue and, subsequently, leaving hospice care.

Implications for Nursing: Hospice nurses are exposed to chronic bereavement that can result in sleep disturbances, which can negatively affect every aspect of hospice nurses' lives. Cognitive-behavioral sleep interventions show promise in teaching hospice nurses how to care for themselves by getting quality sleep.

Knowledge Translation: Identifying the risks for sleep disturbances and depressive symptoms in hospice nurses will allow for effective, individualized interventions to help promote health and well-being. If hospice nurses achieve quality sleep, they may remain in the profession without suffering from chronic bereavement, which can result in compassion fatigue. A CBT-I intervention delivered at the agency and in a group format was feasible and acceptable by study participants.

Jump to a section


    Buysse, D. J., Reynolds, C. F., III, Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193-213. doi:10.1016/0165-1781(89)90047-4
    Carpenter, J., & Andrykowski, M. (1998). Psychometric evaluation of the Pittsburgh Sleep Quality Index. Journal of Psychosomatic Research, 45, 5-13. doi:10.1016/S0022-3999(97)00298-5
    Frank, M. G. (2005). The function of sleep. In T. L. Lee-Chiong (Ed.), Sleep: A comprehensive handbook (pp. 45-48). Hoboken, NJ: John Wiley and Sons. doi:10.1002/0471751723.ch7
    Germain, A., Caroff, K., Buysse, D. J., & Shear, M. K. (2005). Sleep quality in complicated grief. Journal of Traumatic Stress, 18, 343-346. doi:10.1002/jts.20035
    Kiresuk, T. J., Smith, A., & Cardillo, J. E. (Eds.). (1994). Goal attainment scaling: Applications, theory, and measurement. Hillsdale, NJ: Lawrence Erlbaum Associates.
    Koenigsberg, M. R., Bartlett, D., & Cramer, J. S. (2004). Facilitating treatment adherence with lifestyle changes in diabetes. American Family Physician, 69, 309-316.
    Lacks, P., & Rotert, M. (1986). Knowledge and practice of sleep hygiene techniques in insomniacs and good sleepers. Behaviour Research and Therapy, 24, 365-368. doi:10.1016/0005-7967(86)90197-X
    Li, L. W., Seltzer, M. M., & Greenberg, J. S. (1997). Social support and depressive symptoms: Differential patterns in wife and daughter caregivers. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 52, S200-S211. doi:10.1093/geronb/52B.4.S200
    Minarik, P. A. (2009). Sleep disturbance in midlife women. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 38, 333-343. doi:10.1111/j.1552-6909.2009.01031.x
    Monk, T. H., Germain, A., & Buysse, D. J. (2009). The sleep of the bereaved. Sleep and Hypnosis, 11, 18-26.
    Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York, NY: Guilford Press.
    Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). Sleep, 29, 1398-1414.
    National Sleep Foundation. (2011). 2011 Sleep in America® poll: Communications technology in the bedroom. Retrieved from
    Pasternak, R. E., Reynolds, C. F., III, Hoch, C. C., Buysse, D. S., Schlernitzauer, M., Machen, M., & Kupfer, D. J. (1992). Sleep in spousally bereaved elders with subsyndromal depressive symptoms. Psychiatry Research, 43, 43-53. doi:10.1016/0165-1781(92)90140-X
    Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. doi:10.1177/014662167700100306
    Rittman, M., Paige, P., Rivera, J., Sutphin, L., & Godown, I. (1997). Phenomenological study of nurses caring for dying patients. Cancer Nursing, 20, 115-119. doi:10.1097/00002820-199704000-00006
    Sabo, B. M. (2006). Compassion fatigue and nursing work: Can we accurately capture the consequesnces of caring work? International Journal of Nursing Practice, 12, 136-142. doi:10.1111/j.1440-172X.2006.00562.x
    Shilts, M. K., Horowitz, M., & Townsend, M. S. (2004). Goal setting as a strategy for dietary and physical activity behavior change: A review of the literature. American Journal of Health Promotion, 19, 81-93. doi:10.4278/0890-1171-19.2.81
    Singareddy, R., Vgontzas, A. N., Fernandez-Mendoza, J., Liao, D., Calhoun, S., Shaffer, M. L., & Bixler, E. O. (2012). Risk factors for incident chronic insomnia: A general population prospective study. Sleep Medicine, 13, 346-353. doi:10.1016/j.sleep.2011.10.033
    Steeves, R. H. (2002). The rhythms of bereavement. Family and Community Health, 25, 1-10. doi:10.1097/00003727-200204000-00004
    Vandekerckhove, M., & Cluydts, R. (2010). The emotional brain and sleep: An intimate relationship. Sleep Medicine Reviews, 14, 219-226. doi:10.1016/j.smrv.2010.01.002
    Wakefield, A. (2000). Nurses' responses to death and dying: A need for relentless self-care. International Journal of Palliative Nursing, 6, 245-251.
    Weissman, M. M., Sholomskas, D., Pottenger, M., Prusoff, B. A., & Locke, B. Z. (1977). Assessing depressive symptoms in five psychiatric populations: A validation study. American Journal of Epidemiology, 106, 203-214.
    Wenzel, J., Shaha, M., Klimmek, R., & Krumm, S. (2011). Working through grief and loss: Oncology nurses' perspectives on professional bereavement [Online exclusive]. Oncology Nursing Forum, 38, E272-E282. doi:10.1188/11.ONF.E272-E282