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Seven ways to improve sleep on mental health wards

Collaborating with service users on sleep issues is crucial to care outcomes, says occupational therapist Jessica Oglethorpe
Picture is partial shot of woman’s face with her eye closed. Collaborating with service users on sleep issues is crucial to care outcomes, says occupational therapist Jessica Oglethorpe

Collaborating with service users on sleep issues is crucial to care outcomes, says occupational therapist Jessica Oglethorpe

  • There is growing understanding that poor sleep is a major contributor to mental health deterioration
  • Poor sleep may be a symptom of disorders such as depression, bipolar affective disorder and schizophrenia
  • Dream Big project focuses on how to improve sleep for patients in an inpatient mental health ward

Sleep is an area of our lives that has received increasing attention in recent years as we understand more about how it interrelates with mental health. In our treatment of mental illness, the diagnostic-led view is that poor sleep is a symptom and consequence of disorders such as depression, bipolar affective disorder and schizophrenia (Freeman et al 2017) .

However, there

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Collaborating with service users on sleep issues is crucial to care outcomes, says occupational therapist Jessica Oglethorpe

  • There is growing understanding that poor sleep is a major contributor to mental health deterioration
  • Poor sleep may be a symptom of disorders such as depression, bipolar affective disorder and schizophrenia
  • Dream Big project focuses on how to improve sleep for patients in an inpatient mental health ward
Picture is partial shot of woman’s face with her eye closed. Collaborating with service users on sleep issues is crucial to care outcomes, says occupational therapist Jessica Oglethorpe
Picture: iStock

Sleep is an area of our lives that has received increasing attention in recent years as we understand more about how it interrelates with mental health. In our treatment of mental illness, the diagnostic-led view is that poor sleep is a symptom and consequence of disorders such as depression, bipolar affective disorder and schizophrenia (Freeman et al 2017).

However, there is a growing understanding that poor sleep is a major contributory cause of mental health deterioration and increased experiences of psychosis and mania (Hurley and MacQueen 2015). In light of this, addressing patients’ sleep issues should, wherever possible, be central to treatment plans. Yet this can be challenging for nurses managing mental health wards.

‘In Dream Big, staff and patients work together to explore and implement environmental, behavioural and procedural changes’

I am an occupational therapist working in inpatient mental health. One of my nursing colleagues and I led a quality improvement project on how to improve sleep for patients on a male acute inpatient mental health ward.

The project, called Dream Big, has been running for two years, and over this period staff and patients have worked together to explore and implement environmental, behavioural and procedural changes, not only to support patients to sleep better but also to nurture a consideration of sleep as central to treatment and care. This article explains seven useful tips that came out of our project on how best to improve sleep on mental health wards.

1. Educate staff and patients on the importance of sleep

The first important step in improving sleep is to raise awareness among staff and patients of its importance: educate staff so they can bring about change to their care delivery and behaviour, and educate patients to take appropriate measures themselves.

Empowerment through understanding is the key message here, and while we are used to patient empowerment being central to the recovery approach (Mezey et al 2010), it is also important to think about how we can empower nursing staff through training and education to make confident decisions around care.

‘We aimed to educate staff about the importance of improving their own sleep’

As part of our quality improvement project we held regular teaching sessions with ward staff in which we focused on enabling the nurses to think about their own sleep and to relate their experiences to the evidence on sleep. As many readers will know from personal experience, nurses are often chronically in need of rest themselves, so we aimed to educate staff about the importance of improving their own sleep through behavioural and environmental change that they could then use to support patients.

2. Start putting sleep on the agenda

Teaching staff and patients about the importance of sleep is the best way of starting to put sleep on the agenda. In many ways a change in ward culture to ensure that sleep is central to treatment can be a huge challenge, so it needs to be supported. Simple but effective measures include dedicating a section of the ward round to sleep and for nursing staff and patients to provide feedback on this.

‘A “sleep champion” role supported nursing staff to have ownership of the issue’

In Dream Big we also found that the introduction of a ‘sleep champion’ role, rotating among those on each shift, supported nursing staff to have ownership of the issue and helped ensure that sleep was constantly a topic of conversation.

This was also helped by putting up posters on the ward with sleep facts and having sleep on the agenda for the ward’s community meetings so that patients could share insights into what affected their sleep.

Ways of promoting collaboration

  • Provide patients with adequate information and support them to educate staff on the reality of sleeping on an inpatient ward
  • Promote conversations on sleep in every forum
  • Give patients the power to adapt their own environment to promote sleep
  • Encourage feedback on how medication affects energy and sleep patterns
  • Invite patients to contribute to forums involving members of the multidisciplinary team
  • Collaborate on a timetable of daytime activities that is meaningful and stimulating

3. Create a sleep-friendly environment

Wards are often active and noisy places, so it can be difficult to achieve the peace and quiet needed to encourage restful sleep. Patients may feel they are constantly bothered or interrupted, given that guidelines require observations to be carried out at least every 60 minutes, even throughout the night (National Institute for Health and Care Excellence 2015).

‘Observations at night clearly contribute to sleep disturbance’

Observations at night, and the associated noise and light, clearly contribute to sleep disturbance (Horne et al 2018), which raises questions about whether they are counterproductive by hindering recovery (Horne et al 2018).

We are required to carry out regular nighttime checks, but it can be a challenge for nursing staff to strike a balance between safety and promoting restful sleep. Simple strategies can help, such as using a key pouch to reduce key jangling, using an infrared torch for a less intrusive light, speaking with facilities staff about soft-close mechanisms on doors, and getting feedback from patients about how they find the temperature at night so this can be adjusted to support sleep.

4. Don’t go straight for the medication

Pharmaceutical treatment is of course a primary form of treatment for complaints and symptoms of mental illness on inpatient wards, and nurses are tasked not only with administering regular medication but also with making decisions about whether to give medication when necessary to patients who complain of agitation or difficulty sleeping.

‘We sought to understand how patients’ sleep patterns correlated to when they took medication’

It is common to see hypnotic drugs such as zopiclone or promethazine prescribed, yet there is little evidence for the clinical effectiveness of such pro re nata (PRN) medication, which often provides only a short-term solution and in turn may contribute to poor long-term health outcomes (Mugoya and Kampfe 2010).

It is understandable that using PRN is often the most immediately effective solution, especially when thinking about safety and the need to contain agitated or aggressive patients quickly (Mugoya and Kampfe 2010). However, it could be advantageous in the long term to explore other effective means of improving sleep, such as environmental change, as mentioned above, and supporting behavioural change.

In terms of medication, it is also crucial to consider the sedating effects of many antipsychotic drugs, which may contribute to the difficulties some patients have in remaining awake during the day and subsequently in sleeping well at night.

Our project sought to understand how patients’ sleep patterns correlated to when they took medication. We worked with front-line staff to change the administering time of medication, to early evening for example, to diminish its detrimental sedating effects but also harness these effects at night to help re-establish healthy sleep routines. 

5. Use the expertise of the multidisciplinary team

Nurses are in an excellent position to recognise and address sleep issues for patients, but this cannot be done by nurses alone, and it is important to work closely as teams to be as effective as possible. The medical team can use important information from nurses about patients’ sleep patterns to make changes to prescriptions and administration time, for example.

Nurses can also collaborate with ward psychologists to develop interventions and identify patients who might benefit from psychological and behavioural work.

‘The work of the multidisciplinary team will ultimately support consistent and holistic treatment of sleep issues’

Cognitive behavioural therapy (CBT), for example, is identified as one of the most effective treatments for insomnia and sleep issues (Freeman et al 2017), by promoting behaviours such as reducing the use of technology before bed, remaining out of the bedroom during the day and keeping a regular bedtime.

Nurses on the ward can support patients with these behavioural changes, and can also link up with occupational therapists, who can work on the implementation of structured routines and engagement in daytime activities to promote better rest at night. The work of the multidisciplinary team (MDT) will ultimately support consistent and holistic treatment of sleep issues, contributing to better recovery outcomes.

6. Sleeping a lot in the day does not equal good sleep

Insomnia is often the first thing that comes to mind when we think of poor sleep, but it is worth considering the detrimental effects of sleeping too much. It is common in practice to hear staff report that a patient has been sleeping well when they are seen to be sleeping more than nine hours.

However, there is strong evidence associating long sleep time with obesity, diabetes and cardiovascular disease (Léger et al 2014), conditions for which mental health service users are already at greater risk due to side effects of their lifestyle and medication.

‘There are things that can be done to support a shift back to a healthier circadian rhythm'

Sleeping more during the daytime may be a symptom of psychotic illness. Schizophrenia, for example, can compound the development of shifts in the circadian rhythm, so that people with this condition may sleep more during the day and be awake at night (Hurley and MacQueen 2015).

Nevertheless, there are things that can be done to support a shift back to a healthier circadian rhythm, such as exposure to natural light. A study by Wulff et al (2012) concludes that correcting sleep patterns can improve a person’s mental state, and in Dream Big we found that promoting daytime activity, especially physical exercise, and ensuring that there was plenty of light on the wards during the day were crucial to bringing about this shift.

7. Work with patients when making decisions

Finally, the most important tip for improving sleep on inpatient mental health wards is to work collaboratively with patients when making decisions around sleep. Patients are likely to have a better insight into and understanding of their own experiences with sleep, and are good at identifying potential problems, causes and individualised solutions.

By approaching problems with this idea of patients as ‘experts by experience’ we can hope to be more effective at improving sleep and promoting recovery through empowerment and self-management (Mezey et al 2010).

‘We worked with our patients to create ‘sleep packs’, which included lavender, eye masks, earplugs and guided relaxation texts’

One of Dream Big’s most valuable team members was a peer worker with experience of acute inpatient admission who was able to provide some of our most valuable insights and change ideas, and was instrumental in linking with and motivating our patient group.

During the project we worked with our patients to create ‘sleep packs’, which included lavender, eye masks, earplugs and guided relaxation texts. We also facilitated interactive sessions, such as taste tests to identify differences between caffeinated and decaffeinated coffee, which resulted in patients deciding that they would prefer to have non-caffeinated drinks offered to them after 6pm.

Nevertheless, we must always remember to consider the individual in all of our approaches. No two patients will have the same experience of sleep, so we must strive as much as possible to understand each person’s experience so as to meet their particular recovery goals.

A collaborative approach is the most important aspect

Addressing and improving sleep issues can be immensely challenging for nurses on inpatient mental health wards, yet it is a collaborative approach that is the most important aspect when attempting to improve sleep for patients. As far as possible we must make decisions with and not for patients, supporting and empowering them to make decisions for themselves.

In all seven tips, collaboration plays a crucial role (see box). In this process, looking after their  own sleep will only serve to benefit and support nurses to do the same for their patients.


Picture of Jessica Oglethorpe, interim lead occupational therapist for forensic services at South West London and St George’s Mental Health NHS Trust.Jessica Oglethorpe is interim lead occupational therapist for forensic services at South West London and St George’s Mental Health NHS Trust

@JessOgle_OT @DreamBigQI_ELFT

 

View the RCNi sleep resource centre

References

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