Hepatocellular Carcinoma (HCC) is the third leading cause of mortality worldwide [1]. The challenging nature of HCC, characterized by compromised liver function and extensive tumor involvement, renders Transarterial Chemoembolization (TACE) the preferred treatment option over surgery. TACE is a two-step process: initially, one or more chemotherapeutic agents are emulsified in a viscous carrier such as lipiodol; then, embolic agents are introduced into the artery that supplies the tumor [2]. While TACE effectively limits tumor cell growth and improves survival rates, its success depends on regular monitoring and repeated interventions [3]. A significant side effect of TACE is Postembolization Syndrome (PES), which includes symptoms such as abdominal pain, nausea, vomiting, and fever, arising from mechanisms different from those associated with chemotherapy [2].

PES frequently induces disruptions in daily life that are difficult to alleviate, including fatigue, poor sleep quality, and activity impairment [4]. PES typically appears 1 to 3 days after TACE, but sleep disturbances can occur both immediately after TACE and last until 2 weeks afterward [3]. PES is a physical symptom, and poor sleep quality is both a physical and psychological symptom that interferes with daily life due to PES [5]. Improving sleep quality is an important strategy to improve overall patient comfort. Poor sleep quality encompasses various aspects, including difficulty falling asleep, night-time awakenings, short sleep duration, and shallow sleep [6], all of which constitute both physical and psychological health problems. Many patients undergoing TACE have also reported poor sleep quality [3]. Additionally, they exhibit a pattern of symptoms similar to those observed in patients receiving chemotherapy, including elevated levels of depression, anxiety, fatigue, and low levels of energy and concentration [7]. While 89.3% of patients with HCC [8] and the majority of those undergoing TACE experience frequent poor sleep quality [9], this is not considered life-threatening due to its short duration and mild severity [3].

Multiple factors, including clinical characteristics, therapeutic factors, and health status, influence sleep quality in patients undergoing chemotherapy. The clinical characteristics that influence PES include serum albumin and bilirubin levels [10]. Moreover, therapeutic regimens employed in the TACE procedure or in the treatment of patients with PES affect sleep quality. High doses of lipiodol and doxorubicin can result in severe PES, and PES and sleep disorders share common risk factors and symptoms [8]. The use of analgesics for pain management can induce daytime drowsiness and nocturnal sleep disturbances [11]. Chemotherapy-induced or postoperative symptoms have been found to disrupt nocturnal sleep [12], and the use of antiemetics and antipyretics has been shown to have an indirect impact on the status of nausea/vomiting and fever, respectively. Furthermore, antiemetics combined with analgesics reduce effective sleep [13]. The psychological status of the patient, including the presence of depression and anxiety, has also been reported to be associated with sleep quality [14]. Furthermore, physical health status, including PES, can influence sleep quality. Fatigue has been recognized as both a cause and a consequence of impaired sleep quality. However, a recent study reported that objective sleep measures were not related to general fatigue, and that mental fatigue resulted in reduced subjective sleep quality [15]. Because patients undergoing TACE may feel mental fatigue due to anxiety and depression, fatigue may be a relevant factor influencing sleep quality.

Based on the conceptual model of perceived symptoms and comfort care grounded in comfort care theory, the role of nurses in providing comfort care is a critical variable [16]. Comfort care encompasses nursing activities that address the physical, psychological, social, and environmental needs of patients during stressful situations [17]. Nurses who care for patients undergoing chemotherapy must provide comprehensive care, including continuous comfort, once specific symptoms are identified [9]. Assisting patients in overcoming stress-inducing conditions, such as poor sleep quality, is an essential aspect of nursing care [17]. For instance, environmental factors such as lighting and noise significantly contribute to nursing care and can impact sleep quality. The degree of symptom awareness among nurses can influence the care provided and help reduce symptoms; however, patients undergoing TACE often report symptoms passively, believing they can endure the pain [8], which poses challenges in delivering comfort care. Interestingly, nurses caring for patients undergoing TACE were found to have lower awareness of sleep quality issues than the patients themselves and provided less physical, psychological, and environmental care [18]. Both patient characteristics and nurse awareness were identified as significant factors in enhancing sleep quality, though further research is needed [16]. Therefore, this study aimed to assess the symptoms experienced by patients and nurses' perceptions of these symptoms, and to identify the factors influencing sleep quality in patients undergoing TACE.

This study aimed to evaluate patients' symptoms, nurses' perceptions of these symptoms, and factors influencing sleep quality. Descriptive comparisons showed that, unlike anxiety, depression, and fatigue, patients reported lower levels of PES than those anticipated by nurses. Laboratory results showed no clear relationships with sleep quality and were not considered significant. Stepwise multiple regression analysis identified patient fatigue and the number of antipyretics used as statistically significant predictors of sleep quality in patients undergoing TACE.

Patients' sleep quality, with a score of 5.04, was lower than that of general ward patients, who scored 6.42 [25], indicating poorer sleep quality. Cancer patients often experience higher rates of sleep disturbance, with over half of those undergoing chemotherapy reporting reduced sleep quality [19]. The TACE procedure, which involves the occlusion and embolization of the hepatic artery following the injection of a cytotoxic drug, leads to congestion and necrosis of the lesion [3] and disrupts nocturnal sleep due to PES. The sleep quality observed in TACE patients was comparable to that of colon cancer patients as measured using the Pittsburgh Sleep Quality Index [26], and it was relatively lower than that of patients with other cancers, including breast cancer. Additionally, factors such as light, noise, and frequent medical staff visits [25], known to disrupt sustained sleep in general wards, pose challenges for patients undergoing TACE. Despite the relatively low sleep quality observed in TACE patients in this study, this issue has received limited attention, and there is a scarcity of evidence-based research in this area, indicating a lack of focus on comfort care. Therefore, more attention should be directed toward comfort care, including sleep quality, for patients undergoing TACE.

Patients experienced PES to a lesser extent than what nurses expected, contrasting with the usual situation where nurses tend to underestimate patient pain [27]. This discrepancy may be due to nurses' improved understanding of their patients' PES, fostered by increased familiarity with TACE and the prominent role of PES within the symptom cluster. Given the significant negative impact of TACE on sleep quality [3], which subsequently affects patients' mood and activity levels, it is essential to enhance educational content and efforts to improve patient comfort [9]. Moreover, effective symptom recognition by nurses is vital for preventing sleep disorders. Implementing an ongoing clinical education model that focuses on recognition, explanation, action, and learning could resolve clinical communication issues affecting patients with physical symptoms [28]. In essence, enhancing nursing care involves timely recognition of symptoms and understanding the nature of PES, explaining these symptoms to patients, and implementing strategies for relief. Therefore, ongoing access to educational resources and training through the adoption of educational programs is necessary to enable healthcare professionals to better understand and address issues related to sleep quality, ultimately enhancing overall care and patient well-being.

Fatigue emerged as a significant factor influencing sleep quality in patients. Typically, the onset of patient fatigue occurs 1-2 days after TACE [7], persists at a moderate level for up to 6 days [29], and contributes to additional symptoms such as sleep disorders, physical weakness, and loss of appetite [30]. Previous studies have indicated that patients with breast cancer often experience a sequence of fatigue, sleep disorders, and depression, with exercise and diet programs showing potential to alleviate both fatigue and depression [31]. Numerous studies have established a negative relationship between fatigue and sleep quality, although fatigue and sleepiness were often considered synonymous in the past. Fatigue is closely associated with anxiety and depressive mood [32], which can, in turn, contribute to poor sleep quality [33]. Patients with anxiety and depression tend to take longer to fall asleep, sleep less, and take longer to reach the REM stage, all of which indicate higher levels of fatigue. While evidence supporting these results is limited, fatigue can still be a significant factor in poor sleep quality. During chemotherapy, fatigue is also linked to depression, anxiety, and distress about symptoms [5], and is expected to indirectly affect sleep quality. Since fatigue and sleep quality are key comfort-related challenges for patients undergoing TACE during hospitalization, it is crucial to implement various interventions, including psychological support, education, and counseling, to address chemotherapy-related adverse events.

Anxiety can negatively impact sleep quality, and depression also affects various aspects of sleep, including its architecture and efficiency, according to a previous study [15]. Moreover, poor sleep quality in patients with anxiety can lead to significant negative outcomes in daily life, including cognitive disorders, highlighting a bidirectional relationship between them [34]. In this study, depression and anxiety were not influencing factors, possibly due to the longitudinal data collection method used. The unique approach of assessing depression and anxiety at a predetermined time point, along with the immediate evaluation of sleep quality after TACE, may provide a more accurate understanding of patients' emotions. Increased levels of anxiety and depression are directly linked to the burden of a cancer diagnosis, the stress associated with ongoing checkups and hospital visits, and the side effects of various treatments. The results of this study showed relatively low levels of anxiety and depression among patients, in contrast to other studies that have relied on patients’ simultaneous recall of their mood status. This was often assessed at the same time as sleep quality before chemotherapy, which could have led to an overestimation.

An unexpected factor influencing sleep quality was the number of antipyretics used. At the study hospital, non-steroidal anti-inflammatory drugs are commonly employed as antipyretics, though they were not previously known to directly affect sleep. It is crucial to investigate whether the administration of antipyretic drugs directly or indirectly contributes to poor sleep quality. In this scenario, the primary concern is the fever itself, rather than the antipyretic drugs. Discomfort from the fever or the nursing interventions required for fever monitoring could disrupt sleep, potentially leading to the erroneous belief that sleep disturbances are directly caused by antipyretics. Considering that fever often occurs alongside abdominal pain and nausea/vomiting, it has been noted that dexamethasone, which has anti-inflammatory and anti-immune properties, can be used to manage these symptoms and reduce fever [35]. Therefore, it is important to monitor for discomfort following the use of alternative drugs, and employing a non-contact thermometer for silent monitoring could be beneficial.

Symptoms that nurses typically anticipate, such as anxiety, depression, PES, and fatigue, were not found to be influencing factors. Despite the anticipated positive correlation between sleep quality and fatigue as expected by nurses, the significant predictors differed from these expectations. Two potential explanations exist for this discrepancy. First, patients often report their fatigue and sleep quality passively [14], which may prevent nurses from accurately assessing these conditions. Second, nurses might not view fatigue as a factor that deteriorates sleep quality, nor adjust their nursing management strategies to enhance sleep during short hospital stays. Proper detection of fatigue and appropriate preparation for sleep are essential for improving sleep quality.

The strength of this study is that it offers foundational data for practical comfort care, which was achieved by gathering accurate patient information before and after TACE. However, there are some limitations to this method. First, the results may have inadequate statistical power due to the restricted data collection caused by the resurgence of coronavirus disease-19 (COVID-19). Second, the lack of wearable devices to objectively evaluate sleep quality in relation to inflammation necessitated reliance on subjective data, which may limit the generalizability of the findings. Therefore, further analysis of sleep quality using broader objective measures and longitudinal data is warranted.

This descriptive study aimed to assess sleep quality and the factors influencing it in patients with HCC who underwent TACE. The study identified patients' fatigue levels and the frequency of antipyretic drug use as significant variables affecting sleep quality. Specifically, higher fatigue after chemoembolization and more frequent antipyretic use were associated with poorer sleep quality. These findings highlight the importance of aligning nurses' perceptions of patients' symptoms in the delivery of comfort care and emphasize the need for environments that alleviate patient fatigue. Additionally, the study suggests the need for further research on the causal relationship between antipyretic use and sleep quality, as well as exploring the link between nurses' perception of anxiety and patients' symptoms, which presented conflicting results compared to prior studies.