Do hospitals need to get more serious about sleep?

Sleep is known to be closely connected to physical and mental health, and yet hospital environments are far from conducive to high quality rest. Noise, light, disturbances for treatment or tests, other patients, staff noise and temperature can all reduce the odds of a good night’s sleep. Overnight observations can also be extremely disruptive

At some trusts, efforts are being made to address this situation. The ultimate aim? Not only to improve the patient experience, but to potentially the speed with which they heal –so reducing the likes of length of stay. Others, meanwhile, are exploring whether supporting better sleep could even reduce the need for hospital admission in the first place.

Harnessing technology to improve patient sleep in hospitals offers promising solutions for enhancing wellbeing and recovery

When Kirstie Anderson stresses the importance of good quality sleep in hospitals, she is aware of the risk it will be dismissed as something “touchy feely” – divorced from the challenging reality of running a hospital in current times. But according to Dr Anderson, a consultant neurologist at The Newcastle upon Tyne Hospitals Foundation Trust, it couldn’t be more relevant.

“People think that it is just nice to have, sleeping well; that it’s just a bit miserable to sleep badly. What people don’t think about is the rock solid science that tells you, for instance, that the single most important modifiable risk factor for whether you will get delirium following your elective surgery is how well you slept the night before the operation.

“They don’t think about the fact that patients could have a low dose of melatonin if they’re sleeping badly – that’s a very safe drug – and then you would have less delirium. That’s huge.”

Poor sleep also affects, for instance, the effectiveness of wound healing and of the immune system. And the link to mental illness is strong too.

“Our sleep and our biological rhythms, like our circadian rhythm, are really connected to our mental health. They influence each other bi-directionally,” explains Nicholas Meyer, consultant in psychiatry and behavioural sleep medicine at University College London Hospitals FT. In other words: poor sleep can cause poor health, poor health can cause poor sleep. And for mental illness, a lack of sleep can be a predictor of an exacerbation or episode.

It follows that supporting patients to sleep better – and intervening when there are signs they are not – has the potential to improve outcomes. Reduced lengths of stay, and in the case of mental illness perhaps even a reduction in admissions, are among the possible benefits on offer.

Rarely restful

And yet it is difficult to imagine an environment less conducive to good quality sleep than a hospital. Excessive noise from equipment, staff or other patients; poorly regulated temperatures; and even deliberate interruption of sleep for observations, treatments or tests all mean hospitals are rarely restful places.

“Of course everyone wants a therapeutic, relaxing, calm environment for recuperation and healing,” stresses Dr Meyer. “But my experience of psychiatric wards, particularly in London but also across the country, is anything but that. They’re under huge pressures in terms of space, and staffing, and risk, and that tends to dominate and drive a lot of the decisions.

“Services – through no fault of their own – are having to juggle whether this is an environment where risk is minimised, where patients can’t hurt themselves or others.”

Poor sleep also affects, for instance, the effectiveness of wound healing and of the immune system. And the link to mental illness is strong too.

This has serious consequences for sleep. Some mental health patients are on constant observation, meaning a member of staff is with them at all times – including in the room overnight. Others will be woken overnight to have observations taken. As Dr Meyer puts it: “Your environment becomes constrained to meet risk, and it often paradoxically becomes quite un-therapeutic.”

For Dr Anderson, this is a way in which healthcare has worsened during her career, despite stunning medical breakthroughs. “It’s incredibly exciting to work as a neurology consultant in a hospital and look at someone who’s got multiple sclerosis and, unlike 20 years ago, be able to give them phenomenal, life-changing, effective immunotherapy.

“So many things have undeniably got better – medical devices, medical technology, incredible advances – and yet staying in the hospital has got progressively worse. It’s more and more miserable for patients and it’s destructive to physical and mental health.”

At Cumbria, Northumberland, Tyne and Wear FT there has been a very conscious effort to reverse this trend. The SleepWell programme, initially piloted on seven mental health inpatient wards, was accompanied by a range of resources to support better rest. When deemed safe for a patient, it also introduced six hours of protected sleep – so in a six-hour overnight period, these patients were not woken for the purposes of observations.

The pilot was greeted with universally positive feedback from patients and staff. On the wards involved, there was an associated 41 per cent total decrease in the use of hypnotics (sleeping tablets).

This is not the only trust at which staff are considering ways of improving sleep. And there is a broader discourse on observations practice in mental health settings – the question of how to strike a balance between sleep and safety is an ongoing dialogue, with some considering how technology might help here.

Dr Anderson is in no doubt that this is all work worth doing. “You need to think of sleep as part of recovery,” she concludes.

“You need to think of it as something that you interrupt at your peril. It’s physically bad for health and it will increase length of stay. It will increase risk of falls. It will delay wound healing. And, in some cases, it will stop your therapy being as effective.”

Some trusts are introducing specific programmes to support better quality sleep – with encouraging results

While sleep is a complex and multifaceted issue, improving its quality in hospitals does not have to be a massively expensive or complicated undertaking. So says Kirstie Anderson, a consultant neurologist who leads The Newcastle upon Tyne Hospitals FT’s paediatric and adult neurological sleep service.

Dr Anderson was one of the team involved in the SleepWell initiative, introduced at Cumbria, Northumberland, Tyne and Wear FT. The work was accompanied by a range of resources for staff and patients on how to support good sleep.

Each ward selected a lead for the project, with that person taking responsibility for a sleep plan for the specific area. “It was always simple actions,” says Dr Anderson. “It was looking at the space, looking at the noise and light levels day and night. Looking at whether easy-to-treat sleep disorders were being missed.”

Clearly it will never be possible to entirely eliminate noise from hospital settings. “Nobody is saying that if somebody acutely deteriorates overnight that there won’t be clatter and noise. But that’s very different to somebody talking loudly within two metres of you rather than standing somewhere else,” says Dr Anderson.

“It’s [about] turning down the volume on bleeps and buzzers, or putting in a request to estates to fix the fire door with the broken hinge that bangs rather than soft closes. These aren’t budget breaking. These aren’t things you don’t already have a system to fix.”

The project also involved changing observations practice where appropriate. “The default standard for years across healthcare, with absolutely no science behind it, is that every single mental health patient is checked on at least once an hour,” says Dr Anderson. “In the day, that’s part of the care [of a patient]. But it’s utterly different to walking into the room overnight [and waking a patient].”

Following a successful pilot on seven wards, all areas of the trust now have protected sleeping hours for any patient for whom it’s deemed safe. The reported result is decreased use of medications to help patients sleep, a reduction in agitation, and improved staff and patient experience.

There is a challenging balance to be struck between ensuring patients’ wellbeing overnight and giving them appropriate time to rest

Ade Odunlade neatly sums up the challenge of overnight observations for mental health inpatients.

“On the one hand, you want people to get a good sleep,” says Mr Odunlade, who practised as a mental health nurse for several years and is now chief operating officer at South London and Maudsley FT. “Equally you want to make sure that you keep people safe. And you’re constantly trying to strike that balance.”

“Personally, I think the word ‘observations’ is not the right terminology,” says Angie Fletcher, associate director of quality improvement and clinical effectiveness at Oxford Health FT. “What we need to be looking at is ‘therapeutic engagement and activity,’ but that has a different meaning at night.”

That’s because, realistically, the most therapeutic activity for a patient at that point could well be sleep – which is, ironically, interrupted for the very observation that is meant to be therapeutic. “I view observation as a highly restrictive practice in terms of privacy and dignity. We really closely govern our use of restraint, seclusion, long-term segregation. However, this is the ultimate invasion of privacy and dignity,” argues Ms Fletcher, who fears it can “morph into something custodial” as opposed to therapeutic.

Risking the relationship

That isn’t only a potential risk to a patient’s recovery. It also risks the quality of the therapeutic relationship between a patient and a healthcare professional. Moving between having to observe someone using the bathroom, or having to sit and watch them sleep, to then trying to get them engage in the likes of a therapeutic art activity is an exceedingly difficult transition.

Says Mr Odunlade: “When you have to observe people while they’re sleeping it brings a different dimension to the relationship. Because, of course, a number of patients don’t like it. They don’t like being watched. They don’t like that intrusion into their space. So that can bring irritation and there can sometimes be a hostile relationship because of that.”

He is undertaking research to explore the benefits and drawbacks of current practice. Ms Fletcher, meanwhile, is part of a National Mental Health & Learning Disability Nurse Directors Forum group which is looking at observations. This will include considering what role technology might be able to play in supporting less obtrusive practice.

It really is about knowing your individual patient, looking at their needs, their risks and how we can respond to those in the safest way possible but while promoting recovery and independence”

Ultimately, Ms Fletcher believes, the focus of observations needs to be where the focus of care should always lie: on the individual patient.

“It’s knowing your patients. It’s establishing those relationships, it’s having those conversations.

“For some people, particularly people who have had traumatic experiences such as sexual assault, to have somebody in close proximity at all times is extremely retraumatising and is not going to promote their recovery in any way.

“It really is about knowing your individual patient, looking at their needs, their risks and how we can respond to those in the safest way possible but while promoting recovery and independence.”

In technology, some researchers see a potential means of more accurately tracking sleep

For Nicholas Meyer, an interest in sleep medicine felt like something of a natural progression in his career as a psychiatrist. That’s because the connection between sleep and mental illness was quickly self-evident.

“You see patients, particularly presenting in crisis in A&E or when you’re doing your on-call, and they’re in a really bad way and they say: ‘I haven’t slept for ages.’ It’s just such a clear association,” says Dr Meyer, consultant in psychiatry and sleep medicine at University College London Hospitals FT.

“We all intuitively know if we haven’t slept, we feel terrible and it affects our processing, our emotions. If you’re particularly vulnerable, so if you have a predisposition to flipping into a psychotic state or a manic state, sleep isn’t the whole story. But it’s an important mediator in the pathway and potentially a reversible one.”

It’s why Dr Meyer is interested in the potential of tracking someone’s sleep longitudinally. Knowing the extent to which someone has regular sleep and wake times, how long they spend asleep, and the hours during which they sleep could all provide important indicators of wellbeing – and, potentially, early warning of a relapse when someone’s data starts to deviate from their usual habits.

He has already explored data collection in the community, using wearable technology which infers sleep by lack of movement. (It’s the sort of method used by FitBits and Apple Watches.)

“My work was thinking about whether you can use sleep monitoring devices to detect changes, and potentially use medication or psychological therapies to avert progression to a relapse, which ideally means preventing admission to hospital.

“Conversely lots of healthcare professionals are interested in measuring sleep once someone is in hospital, and seeing if that tracks improvement. If worsening sleep tracks deterioration in mental health, then the mirror image of that is improving sleep tracks – potentially – improvement and recovery in mental health.”

Tracking might also be useful in assessing the impact of interventions designed to improve sleep quality in hospitals.

But there is a challenge: monitoring sleep simply and objectively and non-intrusively is not currently a straightforward proposition. Self-reporting has limitations, as does a diary kept by staff – it isn’t always easy to judge whether a patient is asleep, and the process of observation itself can be disruptive.

What of technological solutions? In hospitals, vision-based patient monitoring systems using infrared cameras might – if implemented with due care – be an option. Wearable consumer technology, meanwhile, has the advantage of being suitable for long-term use and being easy for many patients to incorporate into their lives. But it isn’t yet capable of providing fully robust data.

“Currently clinical-grade devices are like wearing a black box on your wrist,” says Dr Meyer. “Most people wouldn’t do that for more than a month, whereas in my experience if you give someone a health tech wellness device [such as a smartwatch] they are quite interested and think it’s quite fun. So what we need in the end is health technology companies to develop devices that look good but also have research quality sleep data.”

The significance of a good night’s sleep can’t be overstated, including during a hospital stay. Sleep isn’t just a period of rest; it’s a crucial physiological process vital for overall health and wellbeing. During sleep, the brain consolidates memories, regulates emotions and repairs cellular damage. Lack of adequate sleep is associated with a host of physical and mental health issues including, but not limited to, weakened immune function; heightened risk of diabetes and cardiovascular disease; mood disorders; and cognitive impairment.

While the general population is increasingly embracing technologies like wearables to monitor and help enhance their sleep quality, hospitals have not generally prioritised patient sleep. Disruptions are commonplace – including from overnight observations – and measuring sleep effectively, safely and practically remains a challenge.

Technology presents a promising avenue for addressing these gaps. For example, contactless monitoring systems can provide staff with assurance of patient safety during the night so that in-person checks can be avoided.

Creating sleep-friendly environments that give patients the opportunity to get a restful night’s sleep has many potential benefits. In mental health settings, boosting sleep quality can lead to lower levels of irritability, improved attention and better mental health. In addition, it could lead to improvements in treatment engagement, reductions in aggression and suicidal ideation, and faster recovery times.

Advances in contactless monitoring technology can also contribute to increased understanding of patient sleep in hospital, allowing clinicians to highlight sleep-related issues and tailor interventions accordingly. Discussing sleep can promote collaboration between patients and staff as it’s a topic patients typically feel less inhibited addressing than other mental health symptoms.

Embracing these technological innovations supports a recognition of the fundamental role of sleep in wellbeing and recovery – paving the way for enhanced inpatient care in the future.

Learn more about the work of Oxehealth in this area.