Safety versus sleep – is a lack of protected sleep time on psychiatry wards bad for mental health?

Posted in Essay,Sleep Series,Special Feature on 1st Oct 2019

David Veale, MD, MPhil, BSc, FRCPsych, FBPsyS, Hon FBABCP, is a Consultant Psychiatrist and Visiting Professor in Cognitive Behavioural Therapies at the Institute of Psychiatry, Psychology and Neurosciences, King’s College London. He leads a national outpatient and inpatient service for people with severe treatment refractory OCD and BDD at the Maudsley Hospital, London and the Priory Hospital, North London. He was a member of the group revising the diagnostic guidelines for ICD11 for Obsessive Compulsive and Related Disorders for the World Health Organisation. He was a member of the group that wrote the NICE guidelines on OCD and BDD in 2006 and chaired the NICE Evidence Update on OCD in 2013.

Dr A Felix de Carvalho, MBBS BSc MRPsych, is a specialty doctor in Psychiatry at South London and Maudsley Trust. He is originally from Lisbon and completed his undergraduate training at the University of Lisbon and at the Autonoma University of Barcelona. He has a particular interest in Psychological Therapies and their importance in various psychiatric conditions. He aims to become a Child and Adolescent Consultant Psychiatrist and focus on Neurodevelopmental Disorders.

Dr Jessica Coffin, MA (Cantab), MBBS, LGSMD, ATCL, DipABRSM is a Psychiatry Core Trainee (Year 3) doctor, currently working at the National Anxiety Disorders Residential Unit, South London and the Maudsley NHS Foundation Trust. She studied medicine at Cambridge University and University College London, graduating in 2015. She has a special interest in OCD-related disorders and adolescent mental health

Correspondence to: David Veale, Centre for Anxiety Disorders and Trauma, The Maudsley Hospital, London SE5 8AZ. Email: David.Veale@kcl.ac.uk
Conflict of interest statement: None declared.
Provenance and peer review: Submitted and externally reviewed.
Date first submitted: 12/8/19
Date submitted after peer review: 1/9/19
Acceptance date: 9/9/19
To cite: de Carvalho AF, Coffin J & Veale D. ACNR 2019;19(1):16-17
Published online: 1/10/19

Surveys of psychiatric in-patients find that the large majority experience insomnia because of the noise and light on the ward, and from nursing observations.1,2 This is a bidirectional relationship, as insomnia is a symptom of psychiatric disorder and sleep deprivation also makes most psychiatric disorders worse.3 Importantly, sleep duration is negatively correlated with subsequent length of time in hospital4 and leads to negative changes in the neuroendocrine, immune and inflammatory systems, as well as hypertension. Furthermore, evidence from correlational and experimental studies have demonstrated that reduced and/or disturbed sleep has a severe effect on emotional regulation.5 Thus sleep deprived individuals experience an increase in anxiety and depression which is especially relevant in those who do not tolerate distress. This article aims to explore the negative impact of routine intermittent nursing observations on the quality of patients’ sleep whilst on inpatient units, and the subsequent effect this has on their mental wellbeing and length of stay.

Psychiatric nursing observation is defined as ‘…regarding the patient attentively, minimising the extent to which they feel they are under surveillance, encouraging communication, listening, and conveying to the patient that they are valued and cared for.’6 National Institute for Health and Care Excellence guidelines7 define various levels of observation determined by a risk assessment, especially for severe self-harm, suicide, violence and absconding. Despite this, typically in psychiatric hospitals general observations which occur hourly or intermittent observations  which occur up to four times an hour are still used as standard during the day and night times.  The importance of ‘engagement’, that is, emotional and psychological containment of distress and giving of hope is emphasised as a genuine, not just linguistic alternative to observation.8 National guidance and local policies assume that nursing observation operates over 24 hours. As we believe, this is where part of the problem lies: ‘engagement’ is not required at night when a patient needs to sleep and to be kept safe.

It is up to the nursing staff to determine what fulfils ‘reasonable’ observation when patients are sleeping at night. A variety of practices and frequency of observations are used at night to document that a patient is safe at a certain time. Policies usually require the staff member to clearly see the patient is breathing which can involve either opening the window hatch in the door or entering the bedroom and shining a torch on the patient’s face or switching on a light or waking the patient by shaking them. There are many complaints by patients about the practice as it disturbs their sleep and they are frequently unable to get back to sleep. However, the documentation of a patient’s safety has become the only metric of importance to regulators and managers. No research or discussion has ever been published into the effectiveness for risk management of nursing observations at night. Sleep deprivation and worsening of symptoms for the many might be justified if it significantly reduced the frequency of suicide or severe self-harm. However, the effectiveness of intermittent observations at night in preventing suicide is highly questionable. Only a small number of suicides in mental health patients occur during inpatient stays (114 suicides per annum, compared to 1600 suicides per annum by people known to psychiatric services in the community). Furthermore, between 2011 and 2016, only 54 of the 338 inpatient suicides of patients known to mental health services occurred between the hours of 23:00 and 07:00 (16%).9 Unfortunately, there are no statistics collected on the frequency of severe self-harm. However, it would be surprising if the pattern of self-harm was very different to the reduced risk of suicide between 23:00h and 07:00h.

What is also known is that 91% of inpatient deaths by suicide occur under intermittent, rather than constant, observations.10 Furthermore, about two out of the 13.7 per 10,000 mental health admissions that result in suicide, die at night between 23:00h and 07:00h, and the overwhelming majority of these occur under intermittent observations.11 However, it is true that, because there are no randomised control trials, we therefore do not know how many deaths have been prevented (or delayed until the day) by intermittent observations. This is due to the very low rate of suicide at night, which would therefore lead to a requirement of about 250,000 patients, to demonstrate non-inferiority between patients on intermittent vs general observations at night.

Our impression is that routine intermittent observations at night currently cause sleep deprivation for the majority of inpatients. They also appear to do little to prevent suicide and severe self-harm, and are just as likely to increase the risk of this during the day. This is because insomnia increases the severity of mental health conditions, and specifically increases the risk of emotional dysregulation. Furthermore, suicide is far less common at night time, and staff are not expected to engage with the patient during the night, which further reduces the value of intermittent observations during the night. For these reasons, night time observations cannot be justified on the grounds that they keep patients safe.12

Understandably, a policy of placing a patient under intermittent observations at night because they are rated at low or medium risk of suicide allows an institution to feel they are doing something to manage risk and protect themselves from criticism, from regulators or negligence claims. However, there is no evidence for differentiating between low, medium and high risk in psychiatric inpatients, and no evidence that intermittent observations prevent suicide, as outlined above.13 It would make more sense to differentiate between those patients at immediate risk of suicide, and place them on constant observations, and patients who are not at immediate risk, and leave them on general observations during the night. It also makes more sense for patients to receive individualised care plans, in which their observations can differ during the day and night, depending on their risk profiles.14

In conclusion, optimising the sleep of patients on psychiatric wards should be a priority for staff, in order to prevent worsening of mental health conditions, improving the wellbeing of patients and thereby reduce the risk of patients dying by suicide whilst an inpatient.

References

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  10. Flynn S, Nyathi T, Tham SG, Williams A, Windfuhr K, Kapur N, et al. Suicide by mental health in-patients under observation. Psychol Med 2017; 47(13): 2238–45.
  11. Powell J, Geddes J, Deeks J, Goldacre M, Hawton K. Suicide in psychiatric hospital in-patients. Risk factors and their predictive power. Br J Psychiatry 2000; 176: 266–72.
  12. Malik A, Sim LA, Prokop LJ, Wang Z, Benkhadra K, Murad MH. The association between sleep disturbance and suicidal behaviours in patients with psychiatric diagnoses: a systematic review and meta-analysis. Syst Rev 2014; 3: 18.
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  14. People with Mental Illness. National Confidential Inquiry into Suicide and Homicide. Health Quality Improvement Partnership, 2017.
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