The Professor Marie Bashir Centre sleep program: a work-shop and ward-based program for psychiatric in-patients to improve sleep quality

Nterventions The intervention is an integrated Sleep Program. It comprises of two main components, thrice weekly group sessions and ward environmental initiatives. The overarching aim is to improve sleep through; 1. Increase daytime activity, particularly in the morning if possible, with use of the balcony and outdoor areas. It has the ultimate aim of establishing routine. Many patients in a hospital setting experience a lack of activity. For example, patients may spend a lot of time in bed watching TV or napping throughout the day. 2. Setting regular rhythms – enhanced light/dark exposure to stabilize circadian rhythms. 3. Stimulus control and relaxation – simple breathing techniques, relaxing music through headphones, relaxation on bean bags 4. Encourage patient-driven management through psychoeducation, ongoing sleep quality monitoring and feedback, and driving behavioural change in the ward milieu. The total duration of a patient’s participation in the Program is flexible. Normally, the participation ends when a patient is discharged from Acute Unit, or a total of 6 weeks, whichever is shorter. However, we consider a 2-week duration as the minimum dose. Ward environmental initiatives A number of initiatives are adopted. They are specific to the participants of the study. Bean bag and visual cues (ward posters) are made available to the participants in their own rooms; while headphones are pre-existing equipment available to all patients in the Acute Unit. Stimulus Control Therapy: • Consistent wake time at 7am encouraged by ward staff • Beanbags: an alternate place to sit other than the bed Sleep Psycho-education • Visual cues regarding specific sleep hygiene strategies around patient room and ward area. • Reinforcement, encouragement and further psychoeducation provided by nursing staff Increased light exposure (regulating circadian rhythm) • Using available open spaces wherever possible enhanced with early morning retimertm blue-green light goggles for those with sleep-phase delay Relaxation • Calming music during wind down • Quiet space with dim lights and beanbags Activity Groups Each participant will be invited to participate in thrice-per-week, 30-minute workshops in the program, which aim to provide psychoeducation about sleep, debriefing and sleep-promotion related activities. It is also aimed at increasing daytime activity and enforcing a regular circadian rhythm. This is conducted on a repeated weekly cycle as outlined below. These sessions will take place on the outdoor area of the acute unit (the balcony) where possible such that participants will receive continuous daylight exposure during these sessions. Each session will take place in mid-morning to lunchtime. Session 1 Session 1 are on Mondays. They are facilitated by a senior Occupational Therapist and a peer-support worker and is designed to instil a routine of activity (via a Cooking group). Initial consenting and program information will be provided to a patient who is commencing. As well, actigraph watch and sleep diary will be provided to the commencing participant, allowing for ongoing record and feedback of their sleep parameters throughout their time in the program. Qualitative feedback regarding sleep will be collected during these sessions. Session 2 Second sessions are held on Wednesdays, on the balcony of the Acute Unit. They are facilitated by two psychiatry registrars. Prior to the sessions, participants’ actigraph watches are collected and sleep data analysed by the research assistant. A visual representation of sleep duration and activity for each patient will be printed prior to the session and given to the registrars, and printouts are identifiable only by participant ids. These sessions are held as a mini picnic with healthy snacks. During these sessions, printouts will be discussed individually with participants, especially with respect to their self-evaluation in their Sleep Diaries. This aims to increase insight and empower the participants to take a proactive role in their management. As a group, the registrars will give further psychoeducation about sleep, with a focus on sleep hygiene, and addressing specific stimuli which affect sleep. Wednesday sessions are also repeated in a weekly cycle. Patients in their initial and final weeks of the program will be asked to complete the Pittsburgh Sleep Quality Index, modified to reflect the quality of sleep within one week. Session 3 Session three are held on Fridays and are repeated on a weekly basis. It is split into two components. Firstly, the morning session is in the form of a breakfast barbeque – which is open to the entire ward to participate. Facilitators of sessions 1 and 2 are able to join. This session is an informal way for participants and clinicians to freely exchange ideas and feedback, as well as to reinforce sleep psychoeducation provided in earlier sessions. Secondly, there will be a booster session on Friday evenings, which is self-directed by the participants and is optional. It entails participants making use of the ward measures made available to them – to enhance relaxation and stimulus control. Measurement instrument: An Actiwatch is provided for patients to wear continuously for the logging of sleep and activity data. The Actiwatch is manufactured by Phillips Respironics. The watch body measures 48mm x 37mm x 14mm and weighs 30g, and it is fitted on a standard, adjustable, soft TPU watch band with titanium buckle. Measurement can be conducted reliably provided the back of the watch makes contact with skin: thus, patients are expected to wear it the same way they wear a normal watch. Patients are requested to wear the watch continuously throughout the study, and particularly throughout sleep. They are required to take the watch off once a week for charging and downloading of data, and during any leave from the ward which is greater than 30 minutes in duration. Monitoring of fidelity and compliance: Numerous methods are used to monitor compliance to the sleep program. Continuity of wearing the Actiwatch is monitored directly through data collected. Attendance to the workshops is logged; overall engagement is recorded qualitatively by trained facilitators, with specific feedback sought from patients to enhance this process. Actual change in sleep behaviour and observations of sleep will be recorded by nurses; and electronic medical record for this is reviewed during the study.