الفهرس 
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Abstract
Type I diabetes mellitus (TIDM) is a chronic autoimmune disease; over the long term it may causes life-threatening complications.TIDM can lead to microvascular complications namely; (nephropathy, retinopathy, and neuropathy), cardiovascular disease, and mortality. Moreover; DM produces a negative effect on sleep quality and reverselyimpaired sleep quality can disrupt glycemic control leading to a profound impact on health-related QoL.
The interactions between quality of sleep (QoS) and glycemic control are complex and likely bidirectional relation; where poor QoS is associated with poor glycemic control. Noticeably, insufficient sleep is an international problem, in which short sleep duration and disruptions are associated with impaired glucoregulation. Whether sleep optimization will improve glycemic control which reducing microvascular complications of DM.
A better understanding of health care providers specially nurses to the physiological mechanisms by which QoS habits contribute to metabolic disorders; whichever help them to emphasize their effort not only to treat diabetes or it is complications; but also to correlate among factors of sleep habits and other influences attribute to poor diabetes control.
Additionally, the significant role of nursing staff appears not only in patients assessment; but also in teaching the diabetic patients about self-management through frequent self-monitoring of blood glucose level, as it is an essential and integral part of intensive management in TIDM. Also, aims to achieve the main goals of optimizing good metabolic control, as well as improving their glycemic control and sleep quality. As,the relation between the diabetic patients’ sleep and glycemic control is not fully understood, the researcher found it necessary to conduct this study which aimed toassess the QoS habits among TIDM patients and assess the relation between QoS habits and glycemic control amonginsulin dependent diabetes mellitus (IDDM) patients.
Research questions:
1. What are the quality of sleep habits among type I diabetes mellitus patients?
2. What is the relation between quality of sleep habits and glycemic control among insulin dependent diabetes mellitus patients?
Materials and method:
Research design:
A descriptive correlational research design was utilized to meet the aim of the present study.
Setting:
The study was conducted atthe Inpatient Medical Department and Medical Outpatient Clinic of Matrouh General Hospital, Matrouh governorate.
Subjects:
Based on the Epi Info program, convenience samples of 120 adult patients with TIDM were selected from the above-mentioned setting according to the following criteria:
1. Free from psychological disorders(stress-anxiety),
2. Have controlled associated chronic conditions, i.e. hypertension, respiratory disorders …etc.
3. Patients are not receiving anti-histamines or allergy medications.
Tools of the study:
In order to fulfill the aim of the study, three tools were used for data collection.
Tool (I): Sociodemographic and Clinical Data Structured Interview Schedule.
This tool consists of two parts:
Part I: Socio-demographic data:
This part included data related to patients’: age inyears, gender, marital status, area of residence, level of education, occupation and income.
Part II: Clinical data:
This part was used to collect data about: patient’s diagnosis, number of years with diabetes, patient’s health history which was divided into:
- Associated diseases such as: hypertension, respiratory, kidney, or ischemic heart disease, retinopathy, neuropathy, cancer and cerebrovascular accident.
- Medications which contained items related to; prescribed medications such as: type of insulin, dose and frequency of insulin; and over the counter medications which included: diuretics, anti-arrhythmic, beta blockers, corticosteroids and analgesics.
Tool (II): Parameters for Glycemic Control Sheet:
This tool was developed by the researcher based on reviewing of relevant literature(Beck et al., 2017; Frye et al., 2019; Pinto et al., 2020; Tomić et al., 2020),and was used to assess the studied patients’ blood glucose level.
It was composed of five parameters namely; fasting blood glucose level, random blood glucose level, glycated hemoglobin measurement (HbA1C), signs and symptoms of hyperglycemia occurrence, as well as signs and symptoms of hypoglycemia occurrence.
Tool III: Pittsburgh Sleep Quality Index (PSQI):
This tool was adopted from Buysse et al., 1989; it consisted of 24 questions; from which 19 are self-rated questions. It aimed to assess quality of sleep habits during the last month only in relation to seven components namely: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, consumption of sleep medication, and daytime dysfunction. It also included “5” questions are rated by the bed partner or roommate (if one is available).
Method
The study was accomplished as follows:
• Official permissions to carry out the study were obtained from the Research Ethical Committee of the Faculty of Nursing, University of Alexandria, also from the responsible authorities (director) of the Matrouh General Hospital and from the director of the outpatient clinic of diabetes after explanation of the aim of the study.
• Tool I and II was developed and translated into Arabic language by the researcher based on a review of the relevant literature. Moreover; tool III was adopted from Buysse et al., 1989, and its Arabic version was adopted from Suleiman et al., 2010.
• The study tools were tested by five experts members in the field of Medical-Surgical Nursing, Faculty of Nursing- University of Alexandria, to assure the content and construct validity, completeness, clarity of items, and necessary modifications, were done accordingly.
• Reliability for the study toolsII and III was estimated using the Cronbach’s Alpha test to measure its internal consistency to evaluate how well the tools consistently measure what they were designed to measure.The correlation coefficient was (α=0.708, 0.757); respectively.
• A pilot study was conducted to ascertain the clarity, feasibility, and applicability of the study tools.It was conducted on 10% (12 patients) of the study subjects outside the sample and fulfilling subjects’ inclusion criteria, from both the Medical Departments and Medical Outpatient Clinic at the Matrouh General Hospital.In the light of the findings of the pilot study, modifications were done, accordingly.
Data collection:
• The data collection was initiated covering a period of 9 months (from March to December 2021). The total subjects were randomly enrolledconsisting of 120 adult TIDM patients who met the study’s inclusion criteria. They were interviewed twice at the Inpatient Medical Departments and Medical Outpatient Clinic.
• Patients both interviews was conducted by the researcher utilizing tool I, II and III at the above mentioned setting to collect patient’s sociodemographic and clinical data, assess their blood glucose level, and assess patient’s quality of sleep habits during the last month; respectively. The duration for collecting each tool’s data took approximately from 15-20 minutes. The researcher compared between patient’s first and second month’s data.
Ethical Considerations:
Informed written consent was obtained from patients participating in the study after explanation of the study aims.Also patients were informed that they have the right to withdraw at any time from the study without any drawbacks. In addition, patient’s privacy was assured.
Data Processing and Statistical Analysis:
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) (Qualitative data were described using number and percent. Kolmogorov-Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation, median and Significance of the obtained results was judged at the 5% level.
The main results of the study:
• Regarding age, it was noticed that more than one third of the patients (43.3%) were between 35<45 years. In relation to gender, more than half of the studied patients (55.8%) were females. Considering marital status, studied patients the highest percentages were married represented by 35%. Concerning the educational level it was evident that, almost an equal proportion of the studied patients (27.5%, 26.7%) were illiterate and university education; respectively. In relation to patients’ income the majority of the studied patients had enough income representing (98.3%). While concerning area of residence, more than half of patients lived in urban area (56.7%). Regarding occupation, about two thirds were not working (61.7%).
• In relation to number of years with diabetes it was noticed that, approximately half of patients (49.2%) were ranging from 1-less than 5 years; with a Median of 6.0 years. Concerning patients’ health history related to associated diseases it was observed that, more than half of patients (57.5%) had Hypertension. In relation over the counter medications, it was found that 12.5%of patients take Corticosteroids. Regarding prescribed medications it was found that, more than half of study patients were on Mixtard representing (52.5%), withMean ± SD of insulin dose 33.84 ± 10.86 on frequency of two to three times per day.
• Variation was noticed in glycemic control parameters (fasting blood glucose, random blood glucose) during the baseline and second assessments representing MH 4.822 , 4.213 at P 0.001, 0.013; respectively. Reflecting alteration of all glycemic control parameters linked with repeated attacks of hypo and hyperglycemia. Also, there were an observed variation in subjective sleep quality, sleep duration, habitual sleep efficiency and sleep disturbances between the baseline and second data of the researcher assessments represented by MH= 101.55, 112.00, 73.000, 110.500 at P=<0.001*, <0.001*, 0.0 01*, 0.002*; respectively. where more than half of studied patients suffered from poor QoS ranged from moderate to moderate sever difficulties in all area of sleep quality. In addition, there were a significant relation between the global PSQI components score and the HbA1C level in the baseline and second researcher’s assessments represented by p=0.008*, 0.029*; respectively.
• Moreover,significant relationswere noticed between age, level of education and income as a sociodemographic characteristics and PSQI score during the baseline and second assessmentsrepresenting P= 0.015, 0.001*, <0.001*; respectively. As regards the relation between clinical data and PSQI score during the baseline and second assessments, significant relationswere noticed regarding years of DM where (P= <0.001*), presence of associated diseases (hypertension, retinopathy, and respiratory diseases) where (P= 0.001*, <0.001*, 0.026*); respectively, use of over countered medications (diuretics, corticosteroids, anti arrhythmic and, analgesics) where (P= <0.001*, 0.002*, 0.002*, 0.021*); respectively and prescribed medications as Mixtard, Teujeo, Levemir, Apidra and, Novorapid where (P= <0.001*, <0.001*,0.001* 0.008*, 0.009*); respectively.
Based on the results of the present study, it can be concluded that:
• Variation was noticed in glycemic control parameters (fasting blood glucose, random blood glucose) during the baseline and second assessments; reflecting alteration of all glycemic control parameters linked with repeated attacks of hypo and hyperglycemia. Also, there were an observed variation in subjective sleep quality, sleep duration, habitual sleep efficiency and sleep disturbances between the baseline and second data of the researcher assessments; where more than half of studied patients suffered from poor QoS ranged from moderate to moderate sever difficulties in all area of sleep quality. In addition, there were a significant relation between the global PSQI components score and the HbA1C level in the baseline and second researcher’s assessments.
• Moreover, significant relationswere noticed between age, level of education and income as a sociodemographic characteristics and PSQI score during the baseline and second assessments. As regards the relation between clinical data and PSQI score during the baseline and second assessments, significant relationswere noticed regarding years of DM, presence of associated diseases (hypertension, retinopathy, and, respiratory diseases), use of over countered medications (diuretics, corticosteroids, anti arrhythmic and, analgesics) and prescribed medications as Mixtard, Teujeo, Levemir, Apidra and, Novorapid.
Recommendations
Based on the findings of the present study the following recommendations are suggested:
A-Recommendations for patients:
• Increase diabetic patients’ awareness about the disease and the importance of following proper sleep quality practices in glycemic control; through developing and applying educational sessions.
• Family members have to be involved in their TIDM patients’ management in order to improve their health outcomes.
• Also, a colored illustrated booklet about the complications of DM and glycemic control instructions should be available and distributed for each TIDM patient.
• All TIDM patients should be involved in diabetes control program concerning: compliance with medical regimen, importance of periodical follow up, diet, exercise, warning signs of hypoglycemia or hyperglycemia and daily healthy sleep habits; which should initiated as early as possible to improve patient’s QoL.
B-Recommendations for nurses:
• Provide personnel in the diabetic unit with Arabic and English version of QoS assessment and make it available for health team members as well as patients.
• Organize workshops and courses for nurses about the effect of over countered medications and type of insulin on sleep quality for diabetic patient.
• Nurses should attend update conferences and in-service training program or workshops, about emphasizing the mutual effect of QoS and DM on each other.
• Nurses should be aware of the consequences and the measures to control poor QoS and poor glycemic control on their patients.
• Nurses have to prepared to provide type I diabetes mellitus patients and their families with suitable information and practices regarding diabetes, blood glucose level control as well as the QoS habits affecting glycemic control; through videos, models and printed materials.
C-Recommendations for future researches:
• Replication of this study using a large study sample in different geographical area.
• Implementing further studies to identify factors predisposing to poor QoS and its relation to poor glycemiccontrol.
• Study the effect of sleep hygiene program on TIDM patient’s QoS.
D-Recommendations for the organization
• Develop sleep instructional guidelines regarding importance of sleep quality.
• Simple illustrated booklets including how to control DM, healthy sleep habits and the relation between QoS habits and glycemic control, have to be available in medical nurses.
• Nursing education institutes should include the recent innovative interventions and monitoring tools for blood glucose level, early detection of diabetic complications, in addition to identifying the high risk groups.