5 November 2019

Dream big: Improving sleep on a mental health ward

When Jacob Clark was working as a Clinical Psychologist in the Community Mental Health Team at East London NHS Foundation Trust, he noticed that a lot of the inpatients on the Lea Ward weren’t sleeping well and many of them slept a lot during the day. Jacob and his team came up with some simple but effective solutions to the ward’s sleep issues.

Lea Ward treats patients with a range of mental health difficulties, including high levels of anxiety and psychosis. Staff members are required to make regular night-time checks on patients, shining a torch on them to assess they are safe. Jacob’s Health and Wellbeing group discovered that many patients found these checks difficult to sleep through, and in some cases quite unnerving.

The checks were not the only obstacle to good sleep: a TV in the common area would often be watched with the volume up; there was the sound of the nurses’ keys jangling; conversations between staff and other patients could be heard; the radiators would gargle; doors would slam and bang.

Gathering patient and nurse feedback

Jacob’s team realised they needed to start with ascertaining an overview of how well (or poorly) patients were sleeping, so they began surveying patients regularly.

The nurses reported many patients sleeping as little as a couple of hours per night and up to six hours during the day, spending most of their waking hours in their rooms. They found direct correlations between people with more complex mental health issues and those who were not sleeping well. They also found that quality of sleep was connected to length of stay on the ward, with poor sleepers staying on the ward for significantly longer periods.

They observed that many patients thought their ‘normal’ sleep on the ward was ‘good’ sleep – no matter how long they actually slept. They found that those patients that thought they were sleeping poorly didn’t think this could be changed.

A survey of staff by Jacob’s team revealed 100% of staff thought that sleep was important to patient recovery, but only 60% thought they could help. Jacob and his team came up with some simple but effective solutions to the ward’s sleep issues.

Pouches, red lights and sleep packs

One of the barriers to the project was that the hourly night checks are non-negotiable, but Jacob’s team reasoned that they didn’t need to be as disruptive as they currently were. Nurses were given pouches to keep their keys in to stop them jangling as they walked through the ward and the torches used to check on patients at night were replaced with red lights, which don’t disturb sleep patterns. They also created sleep packs that would be given to patients on admission and included items such as sleep masks; herbal teas; ear plugs and smelling salts.

Stimulating activities and exercise

Another problem the ward needed to address was patients spending all day, inactive, in their rooms. They introduced structured daytime routine that involved stimulating activities and exercise, ending with a winding down ritual. Jacob didn’t simply want patients relying on sleep medications, he wanted to implement sustainable behaviour change that could be transferred into patients’ lives outside of the ward.

Consulting patients

It was also important to implement ideas that would be simple to carry out as any further burden to the nurses’ workloads would most likely result in failure to progress. The team brought in an ex-patient to consult on the project voluntarily and this proved so useful, he has since been made a permanent member of staff who contributes as a patient perspective in the Health and Wellbeing group.

The plan going forward is that all nurses will be trained up to a level of competence in Cognitive Behavioural Therapy to address insomnia, and patients will be equipped with Fitbits to monitor their activity and their sleep more accurately.

The project has been nominated for an NHS parliamentary award and noted for excellence, particularly pertaining to its implementation of service-user participation at all stages.

You can find QI resources related to this project on the ELFT QI site:  https://qi.elft.nhs.uk/resource/dream-big-improving-sleep-on-lea-ward/

Jacob Clark was a participant on the UCLPartners Aspiring Improvers programme