a study on the experience of insomnia in a psychiatric inpatient population

COLLIER E., SKITT G. & CUTTS H. (2003)

Journal of Psychiatric and Mental Health Nursing

10,

697–704

A study on the experience of insomnia in a psychiatric inpatient population


, 2003,

10

, 697–704

©

2003 Blackwell Publishing Ltd

697

Blackwell Science, LtdOxford, UKJPMJournal of Psychiatric and Mental Health Nursing1365-2850Blackwell Publishing Ltd, 200310654Insomnia in a psychiatric inpatient populationE. Collier

et al.

10.1046/j.1365-2850.2003.00654.xOriginal ArticleBEES SGML

A study on the experience of insomnia in a psychiatric inpatient population

E . C O L L I E R

1

B S

c

M S

c

R M N

P G C E

, G . S K I T T

2

R G N

R M N

& H . C U T T S

3

R M N

B A

(

H

o n s )

1

Lecturer in Mental Health, School of Nursing, Peel House, Eccles, UK,

2

CPN, Central CMHT, Urmston Council offices, Urmston, Manchester, UK, and

3

Adult Day Services Manager, Manor House, Davyhulme, Manchester, UK

Correspondence:

School of Nursing

Peel House

Albert Street

Eccles M30 ONN

UK

E-mail: [email protected]

Complaints of insomnia among psychiatric inpatients are high. Many technical studiesabout insomnia are available in the literature, but few make reference to individual expe-rience. This study examines the subjective experience of insomnia for psychiatric patientsin one mental health unit. A random purposive sample of seven subjects was selectedfrom the population of patients complaining of insomnia. Subjective experience wasexamined using a tape-recorded semistructured interview. The data were analysed usingBurnard’s content analysis framework. Ten categories were identified: control, wants anddesires, holistic, assessment, individualisms, beliefs, conflict, communication, resignationand sleep signatures. Biographical data, and data from clinical notes about sleep werealso collected. Results show that the impact of insomnia should not be underestimatedand that attention to this aspect of a patient’s experience could have a general effect ontheir mental health and well-being.

Keywords

: inpatient, insomnia, mental health, psych, sleep

Accepted for publication

: 30 May 2003

Introduction

Insomnia is a common complaint and has particular impli-cations for both individual mental health issues and servicedelivery. It is an important indicator in the diagnosis of psy-chiatric disorder (Benca

et al

. 1992, Nofzinger

et al

. 1993)and it can contribute to deterioration of pre-existing men-tal disorder (Weisman

et al

. 1997), or be a response to psy-chological distress. Different sleep patterns are associatedwith particular mental disorders (Nofzinger

et al

. 1993)and substances, including illegal drugs, alcohol and pre-scribed medication, can affect our experience of ‘refresh-ing’ sleep (Krahn

et al

. 1997). Ageing is also implicated ina reduction of refreshing sleep (Morin

et al

. 1993), and thiswill lead many to complain of insomnia. This experience isimportant even though it may not achieve a clinical diag-

nostic criterion of insomnia where it is required there is‘prolonged sleep latency, increased frequency of nocturnalwakening or no refreshing sleep for a duration of at leastfour weeks’ (ICD-10; WHO 1994). Experiences of insom-nia which fall outside this criteria should not be negated. Abroader definition of insomnia is:

If one takes more than 30–45 minutes to get to sleep,wakes up many times during the night, wakes up veryearly and cannot get back to sleep or doesn’t feelrefreshed after a night’s rest, he/she is said to haveinsomnia (Duke University 1994; more details are avail-able at http://healthydevil.studentaffairs.duke.edu/info/selfcare/sleeples.html).

Standard 1 of the National Service Framework for Men-tal Health (England; DoH 1999) requires the practice ofmental health promotion. Attention to the findings of this

http://healthydevil.studentaffairs.duke.edu/info/

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study provides one way of addressing this standard. Ford

et al

. (1989) suggest that primary care workers should focuson complaints of sleep disturbance with a view to prevent-ing mental health problems. They found that a large pro-portion of the 7954 subjects (out of 10 534) who reportedinsomnia in a household survey also had psychiatric diag-nosis, and many others had undiagnosed symptoms.

Literature review

Research concerning the effects of sleep disturbance ismostly quite technical and often utilizes experimentaldesigns to examine the physiology of sleep. Literaturewhich may contribute to an understanding of the impactthat insomnia has on individual experience is reviewed here.

The assessment of sleep has implications for the diag-nosis, health and recovery of a patient. Krahn

et al

. (1997)compared patient and nurse assessment with wrist acti-graph measurements of sleep and found that nurses tendedto overestimate sleep in some cases, and patients tended tounderestimate sleep. However, they suggest that in psychi-atric units, nursing reports of sleep are generally moreaccurate than patients’ self-reports, but their results werenot significant and their conclusions are based on data col-lected over only three nights. They do note, however, thatrelying on nurses’ data alone is insufficient in sleep assess-ment as patients have different concerns.

People with insomnia have been shown to consistentlyoverestimate their sleep problem (Frankel

et al

. 1976).Frankel

et al

. (1976) found that insomniacs tended tounderestimate their total sleep time and sleep efficiency,although they indicate that many people are able to reportany changes in their normal patterns. Frankel

et al

. (1976)suggest that night-to-night variability is a crucial element ofinsomnia and state that ‘the clinical correlate of this vari-ability for insomniacs is typically an attitude of pessimisticuncertainty about how bad any given night is going tobe . . .’. The absence of ‘delta’ sleep (stage 4, refreshingsleep) is suggested as a reason for the bitter complaints byinsomniacs. Frankel

et al

. (1976) report that older people,insomniacs and people in psychological distress, more con-sistently lack any delta sleep, which is the period of sleepimplicated with restoration and ‘somatic recovery’. Diaz-epam and chlordiazepoxide are thought to be suppressantsof delta sleep, which has important implications in psychi-atric settings.

Daytime functioning has been found to be associatedwith insomnia (Van Diest & Appels 1992). Measures offunctioning have determined significant impairment afterfragmented sleep (Martin

et al

. 1996).O’Connell

et al

. (1999) investigated subjective reportsof insomnia in a population of people diagnosed with

schizophrenia, although, as with the other studies, stan-dardized tools were utilized to determine the patientreports which arguably does not reflect the whole picture ofexperience. Levey

et al

. (1991) include reference to subjec-tive report in a case study, and others attempt to comparesubjective report with objective reports (Van Diest &Appels 1992, Edinger

et al

. 2001). The study by Van Diest& Appels (1992) perhaps illustrates a fundamental prob-lem with ‘professionals’ attitude to subjective report, wherethey report that ‘. . . in the case of one man, the experts didnot agree.’

Cognitive and behavioural interventions are popularin relation to insomnia (Espie

et al

. 1989, Chambers &Alexander 1992, Morin

et al

. 1992, 1993, Choliz 1995,Murtag & Greenwood 1995, Bachaus

et al

. 2001,Edinger

et al

. 2001). Although these studies determineeffectiveness of cognitive and behavioural therapies,potentially this is more promising as the principles of thetherapies themselves will be centred round patient subjec-tive perception and understanding of their problem. Espie

et al

. (1989) suggest that reducing anxiety and increas-ing confidence is key to mastery of the problem. Levey

et al

. (1991) note that intrusive cognitions in insomniaare related to increased anxiety and depression, butEdinger

et al

. (2001) found that reduction in dysfunc-tional beliefs about sleep may not always be associatedwith improvements.

Singareddy & Balon (2001) suggest that suicidalpatients’ self-report sleep quality as more disturbed thanothers, and they state that ‘poor sleep is a stressor that mayindependently increase risk of suicide’. As Reid (2001) con-cludes in a review of sleep studies, ‘sleep is a subjectiveexperience.’

The issue of sleep and sleep assessment is complex andhas important implications in psychiatric care. However,there is an unresolved issue. Nofzinger

et al

. (1993) state:

. . . sleep research on mental disorders has focused littleon the subjective distress or impaired social or occupa-tional functioning associated with the commonlyobserved sleep disruptions in patients with mental dis-order (p. 251).

From current literature, this does not appear to havealtered. In an attempt to address this gap in the literature,the present study focuses on the subjective complaints bypatients, which may be contrary to practitioner’s question-able ‘objective’ assessments.

Aims of the study

The study had two aims:

1.

to identify the subjective experience of insomnia in apsychiatric inpatient population;

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699

Insomnia in a psychiatric inpatient population

2.

to provide information that would enable practitionersto reflect on their interventions with patients who com-plain of sleep problems.

The research question was ‘What is the subjective experi-ence of insomnia for psychiatric inpatients?’

Method

Design and procedure

The study is a qualitative piece of research. As the literaturereview highlights, there is a lack of information about theexperience of insomnia. Therefore, an exploratory designwas appropriate in order to determine what this experiencemight be. The resulting data were necessarily personal tothe subjects, hence a qualitative design.

Ethical considerations

The local research ethics committee gave ethical approval.Consent was judged by capacity, using guidelines pro-vided in the Mental Health Act Code of Practice (Depart-ment of Health and Welsh Office 1999). An informationsheet was provided and confidentiality and anonymitywas maintained throughout the study. The right to with-draw at any time without affecting future treatment wasmade clear.

The researchers are all practising Registered MentalNurses, and as such conducted themselves within theframework of the Code of Professional Conduct (UKCC1992).

Sample

A random purposive sample of seven subjects was takenfrom one mixed-sex acute psychiatric admission unit that ispart of a district general hospital in the north-west ofEngland. Sample characteristics are presented in Table 1.Of the eight randomly selected subjects admitted to the unitbetween January and September 2001, data for seven sub-jects are presented here as one tape recording was inaudi-ble. Inclusion criteria required that they had been in apsychiatric unit for at least 1 week and complained ofinsomnia. Exclusion criteria used were:

•

cannot speak fluent English;

•

unable to give valid consent;

•

their relatives objected;

•

they were experiencing hypomania;

•

the reason for admission was alcohol or drugdetoxification;

•

they had been involved in other research in the last6 months.

Tab

le 1

Sa

mp

le c

har

acte

rist

ics

Bio

gra

ph

ical

in

form

atio

n

Sub

ject

12

34

56

7

Gen

der

Mal

eM

ale

Mal

eFe

mal

eM

ale

Fem

ale

Fem

ale

Ag

e (y

ears

)36

2828

3428

3447

Emp

loym

ent

No

Yes

Yes

No

Yes

No

Yes

Eth

nic

ity

Bla

ckW

hit

eW

hit

eB

riti

shW

hit

eB

riti

shW

hit

eEn

glis

hEn

glis

hEn

glis

hPa

kist

ani

Eng

lish

Paki

stan

iJe

wis

hPr

escr

ibed

med

icat

ion

Zop

iclo

ne

7.5

mg

,Fl

uo

xeti

ne

20 m

gPR

N,

Tem

azep

amPa

roxe

tin

e 40

mg

, Pr

op

ran

olo

l 80

mg

,M

eth

od

on

e 40

mg

,Zo

pic

lon

e 7.

5 m

g

Lith

ium

800

mg

,D

oth

epin

15

0 m

g,

PRN

, C

PZ

Paro

xeti

ne,

PR

N,

Zop

iclo

ne,

M

eth

od

on

e,

Pro

pra

no

lol

Lith

ium

, D

oth

epin

,PR

N,

Ch

lorp

rom

azin

e

PRN

, Lo

raze

pam

,Te

maz

epam

Cu

rren

t su

bst

ance

use

Cig

aret

tes,

tea

an

d

coff

ee,

?ille

gal

dru

gs

Alc

oh

ol,

cig

aret

tes,

tea

and

co

ffee

Alc

oh

ol,

cig

aret

tes,

ca

nn

abis

No

Alc

oh

ol,

cig

aret

tes,

ca

nn

abis

, te

a an

d c

off

ee

Tea

and

co

ffee

o

ccas

ion

ally

Cig

aret

tes,

tea

an

d c

off

ee

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Data collection

Biographical and clinical data were recorded (Table 1).Secondly, semistructured tape-recorded interviews wereconducted.

Data analysis

The interview data were analysed using a content analysisframework modified from Burnard (1991). This was con-ducted in seven stages:

1.

All tape recordings were transcribed verbatim.

2.

Each transcript was studied by each researcher indepen-dently and initial themes noted.

3.

The themes were open coded while researchersimmersed themselves in the data.

4.

The researchers then met to discuss the independentanalysis, clarify meaning, terms and phrases used byeach, and to agree a common understanding. Differ-ences in coding were discussed and agreed for each sen-tence and/or part of a sentence for each transcript. Thisresulted in enabling a process of collapsing any similarcategories into one category and noting themes withineach category.

5.

The list of categories was then worked through again toproduce a refined list of categories.

6.

The transcripts were then revisited and worked throughsentence by sentence, to check coding, to ensure all partsof the transcript were accounted for in the analysis.

7.

Finally, after peer review comments were considered(from various presentations of the research method andanalysis), the researchers agreed all final categories andthemes.

Findings and discussion

Ten categories were identified: control, wants and desires,holistic, assessment, individualisms, beliefs, conflict, com-munication, resignation and sleep signatures.

Holistic

It was initially surprising that there seemed to be a moreholistic representation of the problem from the patient’spoint of view than had been expected. The themes thatemerged within this category included a social, medical andpersonal history of insomnia and described sleep as a partof a whole mental health picture. One subject describedinability to sleep in childhood; another, when asked aboutproblems with sleep, continually clarified ‘you mean mydepression’. This subject seemed to view insomnia as asymptom of the ‘bigger’ problem of depression not a prob-

lem in itself, and indicated that a lack of sleep was indis-tinguishable from depression. This is congruent with someof the suggestions in the literature (Ford

et al

. 1989, Weis-man

et al

. 1997). The issue of stigma also raised by theseauthors was reflected where one subject described insomniaas the problem she took to the general practitioner whenshe was becoming depressed, as it was more acceptable.

Assessment

This included themes of self-assessment, reflection andproblem solving. There seemed to be some thoughts givento looking for explanations for insomnia and factors affect-ing sleep. One subject recognized a link between smokingand insomnia despite having initially believed smokingwould help him. Other comments included ‘since I’ve beenon these new tablets, antidepressants I’ve not slept’, ‘ittakes a hell of a lot to knock me out’, ‘I just want sleepingtablets, I only sleep with them’. Subjects seemed to have aclear picture about their own needs.

Information taken from the multidisciplinary teamnotes on sleep assessment was compared to the self-assess-ment that came through the interviews. It was interestingthat in some cases the patient assessment in the interviewdiffered from the records. For example, one subject indi-cated that she ‘never slept at all’, where the practitionersassessment included only their perceived quantity. Anothersubject was reportedly sleeping well over 2 weeks and itwas documented that the patient ‘sleeps well on Zopiclone,doesn’t need anything stronger’, whereas the patientreported chronic and acute insomnia and assessed currentsleep as 2.5–3 h a night, which was described as ‘notenough’. Krahn

et al

. (1997) highlight such a dichotomywhere insomniacs tend to underestimate their sleep andnurses overestimate it, which could negate any observa-tional assessments by staff and the patient’s report of theirown experiences would be the more reliable measure iftheir feelings were taken into account.

One subject reported poor sleep since admission, whichwas congruent with the report; however, it was docu-mented that the patient was ‘encouraged to use relaxation’and the perspective of the patient was that this was impos-sible for him.

Individualisms

This included individual definitions of insomnia, individualnorms, personality traits and personal aims and expecta-tions. All the subjects seemed to define some kind of indi-vidual understanding of their own insomnia, which isreflected in the other categories. There seemed to be recog-nition of their own coping strategies and also personal

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traits that affected sleep. Comments included: ‘smokingcannabis helps ease anxiousness. I’d just smoke on my ownwhich isn’t the way forward, is it’, ‘usually get up and makea brew’, ‘I try to avoid certain situations’, ‘its best just toignore me’, ‘I’m impatient to get better’, and ‘its a big prep-aration for me before I go to bed you know, two cups ofthis herbal tea, sleeping tablets, and then I’ll have a ciga-rette’. Also in one case, the need to have personal affairs‘sorted out’ before being able to consider sleep.

One subject had spent a lot of time trying to understandthe problem indicating reflection on the long history ofdrug use, saying:

you never know, do you, cos they’ve still not got any errinformation back off you know how this ecstasy harmsyou know in the long term so that could be an issue.

Nursing teams may give some tacit acknowledgement toindividual differences in sleep patterns, but there remains apressure for patients to conform to our notions of ‘accept-able’ sleep patterns, reflecting institutionalized patterns ofthinking that should be challenged by the findings shownhere. One subject described a coping mechanism of ‘pacing’if insomnia got intolerable, and this was after trying ‘writ-ing’. Her experience was that she would be told to go backto bed. This increased her distress because as far as she wasconcerned, the only way to cope was to pace.

Beliefs

The theme of beliefs included health, magico-religious andother general beliefs. One subject, after describing a longand complicated history of drug taking involving a varietyof drug cocktails from age 14 years, noted that herbal teawas at present helping him to sleep but that he was con-cerned about this as he didn’t want to dependent to herbaltea for the rest of his life. Another subject believed that ‘notsleeping is the worst thing for you’ and ‘getting some sleepis probably the biggest medicine’. This subject alsodescribed a belief that affected his ability to engage in treat-ment. The subject stated that staff:

offered sleeping tablets at first but I didn’t want them asI worried I would have a nightmare and not be able towake up from it, thinking that I may fall back to sleepcos of the sleeping tablets.

Also in response to the question ‘so why didn’t you wantto take the sleeping tablets?’, the subject replied ‘becauseI’ve never had them before and I didn’t believe they wouldput me straight out. I thought if I do wake up from a night-mare and I’m still drowsy I may fall back to sleep into thesame nightmare’ and finished with an illuminating com-ment for practice ‘no one explained it to me’.

One subject referred to her religious ideas: ‘some peoplesay do the magic. People do the magic. I do believe in it,

and to help sleep had a visit to a priest where he “telling methe secret, my faith”, I just do my prayer.’

Some beliefs seemed to be about how staff were per-ceived, and it was indicated that ‘I feel that they’re thinkingthat I’m not helping myself. I feel they’re being criticalof me.’ One subject believed that ‘staff don’t care’ and‘the staff just want us to be like cabbages and take ourmedication just like robots, but we’re all different.’ Thesekinds of beliefs could potentially have a huge impact onpatient mental well-being, and this has implications incommunication.

Communication

This included themes of not talking to, not being listened toand culture, both institutional and individual. One subjectafter describing her sleep problems in detail indicated thatshe had not talked to the staff about this. This illustratespotential unmet need owing to lack of engagement as shesaid that ‘I can’t talk to any of them [staff] about my prob-lems.’ However, she indicated frustration at mixed mes-sages as she said:

They know I can’t sleep, I have nightmares so if I ask formy sleeping tablets later and get four hours I’m not asirritable.

They tell me I have to have the sleeping tablets before2 am so when I go to them before 2 they say I can’t haveit as I have to try and sleep without it first.

This clearly has been worked out by the patient butfailed to be understood and harnessed by staff.

The results of this study point strongly to an issue aboutwhether we listen to patients, and the potential harm doneby ignoring or overriding their own insights and explana-tions for their problems. Such issues require practitionersto reflect on their own interactions and interventions andchallenge practice in order to provide meaningful care.Institutional practices are clear in stories about lockedkitchens and medication times. To address issues raised inthe findings of this study, creativity and flexibility is neededin addressing the problem of assessment and educationabout interventions, thus requiring practitioners to befamiliar with the evidence base for interventions. Theteaching of breathing techniques may need awareness ofskills and the intervention of physiotherapists may beappropriate. Patients will benefit from structured sleepmanagement programmes (O’Connell

et al

. 1999).

Conflict

Themes within this category included the effect of disagree-ment with practitioners and personal conflict. Quite strongfeelings about this were communicated. One subject said:

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The ward staff won’t give them to me [the tablets]. Theykeep messing about saying I can have them at 2 o’clockthen when I ask for them they say I have to take them at10 o’clock . . . They say I’m only coming in here to keepmyself hyped up and awake. I just can’t get my sleep pat-tern rights and they are messing with my head telling meone think then telling me something else.

This indicates a breakdown of communication, or asindicated within the category of beliefs, these issues maynever be communicated at all, thus neither side understand-ing the meaning behind the behaviour of each. There wasalso a feeling of added pressure in some cases as a result ofnot being ‘understood’, ‘believed’ or ‘listened to’. One sub-ject said ‘I find that sometimes that the nurses doctors areunintentionally cruel.’ Another subject, however, felt thatstaff did understand, as they had prompted and facilitatedthe use of a relaxation room which had, in the subject’sview, enabled an additional hour to be added to his sleep.

Control

Having no control was one theme illustrated, where audi-tory hallucinations and nightmares prevented sleep andalso resulted in fear and anxiety of going to bed. One sub-ject said ‘Problem is when I go to a little bit of sleep I hearthe voices you know’. Nightmares seemed to be a commonexperience but were described in different ways. Commentsincluded ‘I was having bad nightmares about killing myselfand they were bad, that’s why they took me off the anti-depressants’, ‘When I do go to sleep I have nightmares thatmaggots are crawling out my face so there’s no point.’ Also,gatekeeper issues for medication were indicated as a lack ofcontrol in terms of doctors only allowing short-term pre-scriptions, and also about when prescribed medicationwould be given. Nurses controlled the environment inother ways as well. One subject said that ‘I got up and . . . Isaid to one of the nurses can I have a cup of tea, I usuallyhave herbal tea you know to help me relax, and I wasrefused point blank.’ Noise appears as a problem for sleepin hospital in the literature, but it was mentioned only oncein the present study. However, it led to strong feelings: ‘thenoise was bad the first few nights, I felt I was going to killsomebody.’

Despite being thwarted in some aspects of self-help inthe hospital environment, many strategies were describedwhich people had tried to take some control. Numerousinterventions could be described which subjects had triedand these strategies were quite personal and individual.These included: ‘I’ll try and hold out’ (from sleeping in theday), ‘smoking cannabis, that helps a bit’ (this subject alsoidentified milky drinks, breathing exercises, countingsheep, mild exercise, Nytol and, most recently, herbal tea

helped). One subject identified prayer as the only thing thathelped. Other strategies identified were breathing exercises,cutting down on tea, smoking, earphones with music whilesitting in a large relaxing chair, listening to the radio, hotwater bottle and Ovaltine. The relaxation room was foundto be beneficial by one subject, which helped to catch upwith rest in the day. One potential unhelpful strategy wastemazepam. One subject said they had been taking it for30 years and finally got it down to 80 mg, and was getting3-h sleep a night. This raises a question about reboundinsomnia.

Some planned interventions and education both bypractitioners and self-help had enabled some feelings ofempowerment. One subject had been persuaded to try therelaxation room by staff and felt positive about this: ‘I’vebeen up there ever since.’ One subject identified lack ofknowledge about effects that drugs have on sleep – in thatcase illicit drugs, although this could also be considered inrelation to prescribed drugs – particularly given the infor-mation available about the side-effects of drugs whichaffect sleep.

A few subjects indicated literature they had read hadinformed them in ways of understanding why that mightexplain their problem.

Wishes and desires

This category included themes such as hopes for the futureand a wish for normality. It is not that surprising that sub-jects wished for a good night’s sleep. One subject would‘kill for a good night’s sleep’. As well as these wishes, cer-tain moods were identified such as frustration and envy.For example, a subject reported that ‘I hate people who goround saying “I’ve had a great night’s sleep”, if I could justhave that.’ One subject wistfully noted that ‘It’d be nice tosleep at night again.’ A sad mood captured by another whosaid in a reminiscent tone, ‘I’d get up in the morning andhave breakfast . . . get a bath . . . and shave, get me niceclothes on, that’s all gone now.’ This leads on to the cate-gory of resignation.

Resignation

This category illustrated an acceptance of the reality ofinsomnia. One subject said ‘there’s no point in going to bedas I just lie awake.’ This clearly had led to disability inintervening for themselves, although they could indicatesome positive thought ‘at least I’m resting which helps’.Another subject indicated that ‘I’m so used to it, it’sbecome a way of life’ and ‘after a while you learn to copewith it, you learnt to accept it and that how you feel.’Despite the effect of insomnia on daytime functioning

© 2003 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 10, 697–704 703


(Martin et al. 1996), there is a positive slant here. One sub-ject has accommodated the problem into his lifestyle, forexample, going shopping at a quiet time when he couldn’tsleep, so developing strategies to cope with his stress.

Sleep signatures

This has a relationship to other categories such as individ-ualisms, but there seemed to be a relationship for individ-uals between their own thoughts, feelings and behavioursand nightmares as a feature of insomnia rather than acause. One subject was aware that being tired in the after-noon but resisting a nap could lead to sleep in the evening.Another indicated that ‘as soon as I get in the routine, youknow, before you go to bed I come awake’ (recognizing alink between behaviour and outcome). Two subjects couldidentify that particular worries would affect them, and alsothat not being bothered with hygiene indicated theywouldn’t sleep. One subject described when not sleeping atnight was ‘tensed up to hell’. Another subject said ‘I feltcomplete despair, the only thing about the sleep was Iwanted to sleep as bit of oblivion . . . ; my tension starts asit comes to night time.’ This could be explained in the iden-tified theme of fear and anxiety of going to bed if there is anexpectation of not sleeping congruent with the ‘pessimisticuncertainty’ described by Frankel et al. (1976).

Limitations

In terms of the methodology utilized, there are a number ofdiscussion points and recommendations as to how it maybe improved. The word insomnia itself may be confusing. Itwas wrong to assume that the interpretation and under-standing of this word was universal. The term sleep prob-lems was used interchangeably in the interviews, and thisterm seemed better understood. Also it had been assumedthat it would be possible to research the subjective experi-ence of sleep within one context, that is, that of the inpa-tient, but the holistic category refuted this.

The semistructured interview was problematic with thisclient group. At times there was difficulty eliciting data andit may be more useful to use a more structured approach,which could include the use of a measure such as the Pitts-burgh Sleep Quality Index (Buysse et al. 1989) with sub-jective and objective information. The distress that talkingabout insomnia had for some people was unexpected, andthe frustration with not actually making anything differentfor themselves could have been helped by this process. Ithad not been anticipated that there were any risks, how-ever, distress, agitation and anger were emotions expressedin relation to their experiences. This was potentially com-pounded by the realization that the researchers were unable

to offer solutions to their problems. In this instance,researchers addressed it by attempting to provide supportafter the interview had finished, but this issue would needto be planned for in future research of this kind.

Conclusions and recommendations

This study has provided original data on the subjectiveexperience of insomnia within an acute psychiatric inpa-tient unit. One important finding was that subjects wereaware of their personal difficulties with sleeping, andattempted to rectify this independently. In addition, there isa suggestion that the difficulties with sleeping are not dis-cussed with clinical staff, but suffered silently. Differenceswere also noted in the help subjects had received, leading toquestions about consistency in nursing practices. One solu-tion to this could be to develop a care pathway for care ofpeople who complain of insomnia.

The holistic picture of sleep and mental health problemspresented in this article is perhaps useful to consider in rela-tion to the recovery of a patient. Sleep viewed as an isolatedproblem may hinder recovery, and time could usefully bespent helping the patients to accommodate the sleep prob-lem into daily life. Also, institutional practices need to bechallenged, practitioners need to ‘hear’ the patient, not justlisten to, and there needs to be a focus on insomnia as aquality, rather then a quantity issue (Collier & Skitt 2003).An issue that also seems to be important is access toresources, such as an open kitchen and a relaxation room.Other points for reflection that have emerged from thisstudy include: the issues of being ‘cruel’, asking the rightquestions, discovering the patients’ ‘truth’, not makingassumptions and engaging in the patients’ self-examinationof their problems. Essentially, these points have implica-tions for the provision of therapeutic interventions, all ofwhich tie in with current policy, practice and service devel-opment initiatives that call for an improvement in the qual-ity of acute care (e.g. Sainsbury Centre for Mental Health1998, DoH 1999).

It would be useful to replicate this study with a differentsample group such as 65–75-year age group. As noted inthe introduction, Morin et al. (1993) note possible differ-ences in experience of older people. Also, given that Krahnet al. (1997) note differences in patients and staff assess-ments, this area of research could be developed from thisstudy, where staff perceptions of sleep problems could becompared to the subjects.

In addition, the whole area of research into assessmentof sleep needs developing, to ensure that the qualitativenature of the experience is not excluded. There is a dichot-omy in the assessment of sleep and the question needs to beasked about whose problem this is. An acceptance of the

E. Collier et al.

704 © 2003 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 10, 697–704

patient’s own assessment will minimize conflict and hencepotential barriers to effective care. This research supportsan intervention that enters into collaboration with thepatient, using self-assessment as the basis for discussionsand decision making. It is suggested that any sleep assess-ment should be led by the patient, where they identify theirown definitions of insomnia and their personal goals inrelation to sleep.

Acknowledgments

The authors are grateful to all staff and patients in theMoorside unit for their cooperation and patience, TraffordUsers Group (TUG), who supplied tape recorders, andPrem Conhye and Jane Kavanah for their assistance withtranscribing.

References

Bachaus J., Hohagen F., Voderholzer U. & Riemann D. (2001)Long term effectiveness of a short term cognitive-behavioralgroup treatment for primary insomnia. European Archives ofPsychiatry and Clinical Neuroscience 251, 35–41.

Benca R.M., Obermeyer W.H., Thisted R.A. & Christian Gillin J.(1992) Sleep and psychiatric disorders. A meta-analysis.Archives of General Psychiatry 49, 651–670.

Burnard P. (1991) A method of analysing interview transcripts inqualitative research. Nurse Education Today 11, 461–466.

Buysse D.J., Reynolds C.F. III, Monk T.H., Berman S.R. &Kupfer D.J. (1989) The Pittsburgh sleep quality inventory: anew instrument for psychiatric practice and research. Psychia-try Research 28, 193–213.

Chambers M.J. & Alexander S.D. (1992) Assessment and predic-tion of outcome for a brief behavioral insomnia treatmentprogramme. Journal of Behaviour, Therapy and ExperimentalPsychiatry 23, 289–297.

Choliz M. (1995) A breathing re-training procedure in the treat-ment of sleep onset insomnia: theoretical basis and experimen-tal findings. Perceptual and Motor Skills 80, 507–513.

Collier E.H. & Skitt G. (2003) Non-pharmacological interven-tions for insomnia. Mental Health Practice 6, 29–32.

Department of Health and Welsh Office (1999) Mental HealthAct 1983 Code of Practice. The Stationary Office, London.

DoH (Department of Health) (1999) National Service Frameworkfor Mental Health. DoH, London.

Edinger J.D., Wohlgemuth W.K., Radtke R.A., Marsh G.R. &Quillian R.E. (2001) Does cognitive-behavioural insomnia ther-apy alter dysfunctional beliefs about sleep? Sleep 24, 591–599.

Espie C.A., Neil Brooks D. & Lindsay W.R. (1989) An evalua-tion of tailored psychological treatment of insomnia. Journal

of Behaviour, Therapy and Experimental Psychiatry 29, 143–153.

Ford D.E., Douglas B. & Kamerow D. (1989) Epidemiologicalstudy of sleep disturbances and psychiatric disorders. Anopportunity for prevention. Journal of the American MedicalAssociation 262, 1479–1484.

Frankel B.L., Coursey R.D., Buchbinder R. & Snysder F. (1976)Recorded and reported sleep in chronic insomnia. Archives ofGeneral Psychiatry 33, 615–623.

Krahn L.E., Lins C., Wisbey J., Rummans T.A. & Conner M.K.(1997) Assessing sleep in psychiatric inpatients: nurse andpatient reports versus wrist actigraphy. Annals of Clinical Psy-chiatry 9, 203–210.

Levey A.B., Aldaz J.A., Watts F.N. & Coyle K. (1991) Case his-tories and shorter communications. Behaviour Therapy 20,117–134.

Martin S.E., Engleman H.M., Deary I.J. & Douglas N.J. (1996)The effect of sleep fragmentation on daytime function. Ameri-can Journal of Respiratory and Critical Care Medicine 153,1328–1332.

Morin C.M., Gaulier B., Barry T. & Kowatch R.A. (1992)Patients acceptance of psychological and pharmacological ther-apies for insomnia. Sleep 15, 302–305.

Morin C.M., Kowatch R.A., Barry T. & Walton E. (1993) Cog-nitive behaviour therapy for late life insomnia. Journal of Con-sulting and Clinical Psychology 61, 137–146.

Murtagh D.R. & Greenwood K.M. (1995) Identifying effectivepsychological treatment for insomnia: a meta analysis. Journalof Consulting and Clinical Psychology 63, 79–89.

Nofzinger E.A., Buysse D.J., Reynolds C.F. & Kupfer D.J. (1993)Sleep disorders related to another mental disorder: non-substance/primary: a DSM-IV literature review. Journal ofClinical Psychiatry 54, 244–255.

O’Connell R., Mansell S. & Turpin G. (1999) Subjective SleepComplaints in Individuals with Schizophrenia, 3rd Interna-tional Conference on Psychological Treatments for Schizophre-nia, Oxford.

Reid E. (2001) Factors affecting how patients sleep in the hospitalenvironment. British Journal of Nursing 10, 912–915.

Sainsbury Centre for Mental Health (1998) Acute Problems: ASurvey of the Quality of Care in Acute Psychiatric Wards.SCMH, London.

Singareddy R.K. & Balon R. (2001) Sleep and suicide in psychi-atric patients. Annals of Clinical Psychiatry 13, 93–101.

UKCC (United Kingdom Central Council) (1992) Code of Pro-fessional Conduct. UKCC, London.

Van Diest R. & Appels A. (1992) Vital exhaustion and perceptionof sleep. Journal of Psychosomatic Research 36, 449–458.

Weisman M., Greenwald S., Nino-Murcia G. & Dement W.C.(1997) The morbidity of insomnia uncomplicated by psychiat-ric disorders. General Hospital Psychiatry 19, 245–250.

WHO (World Health Organization) (1994) ICD-10: Interna-tional Classification of Diseases and Related Health Problems,10th edn, vol. 3. WHO, Geneva.

a study on the experience of insomnia in a psychiatric inpatient population

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