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XAP2 Joyce Marrero Student ID # 000569190 Western Governors University February 10, 2017

Evidence Based Practice and Applied Nursing Research, C361, Course Mentor: Lori Adams

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2 Significance and Background Relative to Insomnia in a Local Jail The objective of this assignment is to identify a healthcare problem relevant to the

nursing profession, to develop an answerable question utilizing a PICO template, and to evaluate both research and non-research sources related to the problem, with the goal of developing a plan to implement evidence-based practice (EBT) interventions to improve outcomes relative to the problem. In choosing the topic for this assignment, I considered that in my experience as an RN in a local jail, one of the most common complaints among inmates is insomnia. This facility has no current practice guidelines to treat sleep. The current administration has indicated both to inmates and to nursing staff that difficulty sleeping in jail is considered a normal response to a stressful situation, and therefore, no treatment will be provided. Their stated view is that sleep habits will accommodate over time. Notwithstanding, sleep deprivation is associated with an exacerbation of multiple health and mood disorders, including reduced immune function, increased resistance to insulin, prolonged recovery from illness, and increased mortality (Tamrat, Huynh-Le, & Goyal, 2013). According to the American Academy of Sleep Medicine (2015), insomnia may lead to irritability, impulsiveness, aggression, and accidents. Incarcerated individuals tend to be mentally, emotionally and behaviorally volatile and are prone to suicidal ideation and attempts. Sleep deprivation exacerbates such tendencies (Chien, Chung, Yeh, & Lee, 2015). Consequently, finding alternative therapies for improving sleep quality is relevant to this population, particularly when taking into account the lack of choices and educational resources available to inmates. By implementing non-pharmaceutical methods, it may be possible for nurses to empower inmates to improve their own sleep status by instructing them on sleep hygiene and relaxation techniques. It is my hope that finding and implementing interventions to combat insomnia may have the added benefit of reducing anxiety, violence, and self-harm

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attempts by increasing quality of life and sense of well-being through improved sleep. Such improvements would likely have the added impact of heightened safety, reducing injuries among both staff and inmates due to a reduction of fights and violent outbursts. With that in mind, I wanted to explore methods which could realistically be implemented in a jail setting. There are many factors which can be beneficial to sleep hygiene, but are beyond the inmate’s control, such as the comfort of the sleeping surface, over-crowding of cells, room temperature, excessive noise, and lighting. In the facility where I work, inmates are provided with 1-inch mats which are placed on concrete platforms. These are uncomfortable, do not provide adequate cushioning for thin inmates with bony prominences, and can exacerbate chronic pain, hindering onset and continuity of sleep. Blankets have a rough, abrasive surface, and can be irritating to the skin. Noise levels in some units are high and nurses occasionally have to remove compressed toilet paper from the ear canals of inmates who attempt to block out noise, as not all modules allow earplugs, and not all inmates can afford to buy earplugs from commissary. In some modules, the lights are left on 24 hours per day so that guards can easily see into cells, further impeding sleep. Since manipulation of the environment is not a realistic goal in such a regimented, rule-oriented setting, only techniques that do not require any equipment and that have the potential to help inmates cope with a hostile sleep environment were explored. Educating the population about exercise, relaxation and meditation techniques seemed the most attainable interventions for this population. With these factors in mind, an initial PICO question was developed using the PICO table below.

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PICO Table Adult inmates incarcerated in a local county jail suffering from sleep deprivation due to insomnia and a hostile sleep environment. I (Intervention/Indicator) Education and implementation of relaxation techniques C (Comparison) Currently, in this facility, no treatment or interventions are utilized. Current best practice first line treatment per the American College of Physicians is cognitive behavioral therapy for insomnia (CBT-I) (Qaseem, Kansagara, Forciea, Cooke, & Denberg, 2016). O (Outcome) Reduction in time for onset of sleep and improved continuity of sleep as reported by participants after a three week trial utilizing a recognized sleep quality assessment tool to measure results. P (Patient/Problem)

Search Strategy Considering the limited resources and tools available to jail nurses and inmates, and utilizing the PICO table template above, the foreground PICO question this paper seeks to explore is, “In adult county jail inmates who are experiencing sleep deprivation due to insomnia, will nurse-provided education on relaxation techniques reduce the amount of time required to fall asleep, and will the quality of their sleep be improved as measured by reports from intervention participants utilizing a recognized sleep assessment tool over inmates receiving no sleep treatment or interventions?” Prior to beginning this paper, while attempting to narrow down a subject, it was noted that including “jail,” “prison,” or “corrections” as key words in the search criteria produced extremely limited results, so it was decided to look for results in other populations which could conceivably be transferable to the jail population. Research in jail settings appears to be minimal, likely due to ethical concerns of doing research on a captive population. With that in mind, to further explore this issue, I entered “sleep and relaxation techniques” in the search box of the WGU library, limiting the search to full text articles. This yielded 141,319 results. I then set the timeline for articles published within the last five years and clicked on “peer reviewed” and “clinical trials” which narrowed my results to 13,166. I then navigated to the subject sidebar and

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clicked on the subject “sleep,” which narrowed the field to 361 articles, 349 of which were from academic journals and 2 of which were reviews. I then typed nurs* on the source line, at which point the results expanded to 1038 and appeared to be less relevant to the PICO objective. I decided to explore the list of 361 articles for appropriate articles. I noted that one of the more common relaxation techniques discussed was progressive muscle relaxation (PMR), and decided to focus on this intervention. I printed off the list and highlighted articles with titles that included the words sleep and relaxation, which provided seventeen articles for consideration. After deleting duplicates, thirteen articles remained, two of which were systematic reviews. I printed these articles to facilitate ease of comparison and review, skimming over articles and highlighting relevant paragraphs. Some were found to be too broad. Others were not focused on relaxation interventions, or utilized less studied relaxation methods, so were removed from consideration. The five most relevant sources were entered into an evidence matrix, found in the pages below, to fulfill the requirements of this assignment. Of these, two were Level I quantitative, randomized controlled trials with high quality results. These two were selected for discussion in this paper. I also wanted to familiarize myself with current practice recommendations, so I performed another search using the term “insomnia management guidelines,” limiting the search to the past five years and utilizing the “full text” and “peer reviewed” parameters, searching only academic journals and reviews. This yielded 35, 598 articles. Four insomnia management and evidence-based practice guidelines were selected from the top twenty results of this list, and added to the queue for possible inclusion in the non-research section of this article. Of these, two provided little background information and lacked substance, however, a comprehensive guideline summary for management of chronic insomnia was found at the Nationals Guideline

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Clearinghouse, located at guideline.gov, which identified cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment for insomnia (Qaseem, Kansagara, Forciea, Cooke, & Denberg, 2016). Rather than only reviewing a summary, I wanted to explore the full article, so I clicked on a link from that website which provided me with the full, original publication. After further review of the article, it was disqualified from consideration, as it only contained one sentence pertaining to progressive relaxation. Search results also yielded a review article which discussed non-pharmacological management of insomnia (Vyas, 2013). This was selected as one of the two non-research articles needed to fulfill this assignment. Another reliable source for non-research documentation was found in an educational module discussing sleep disorders in a NetCE, publication (NetCE, 2016). NetCE is an organization that provides up-to-date continuing education for nurses. The sleep disorder module included a discussion on progressive relaxation, and was included as the second non-research article for inclusion in this paper. Research Evidence The strongest research article obtained was based on a one-year randomized controlled trial evaluating whether self-relaxation training can improve sleep quality and cognitive functions in older adults (Sun, Kang, Wang, and Zeng, 2013.) This article, available on CINAHL, was deemed relevant due to its focus on facilitating self-care of insomnia through education, an important concept in a facility where the administration has historically been unwilling to treat this condition. In view of the aging population in correctional facilities, the fact that this article targeted adults who were 60 years old and older was not considered detrimental to the possibility of utilizing similar techniques in a jail setting. In the article, Sun et al. (2013) notes that of the many relaxation methods that exist, progressive muscle relaxation (PMR), is the most studied, and has shown positive results in previous studies in the following variables: sleep

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quality, reduction of fatigue, sleep latency, sleep duration, sleep efficiency, daytime dysfunction, need for sleep medication, anxiety levels, daytime dysfunction, and feelings of well-being. This study utilized a multi-modal approach, beginning with pre and post study assessment tools which evaluated sleep quality, daytime sleepiness, cognition, and memory. Interventions included distribution of an educational brochure on sleep hygiene guidelines, PMR training utilizing audio tapes, and meditation training, also implemented via audio tapes, which contained guided imagery and background music. The authors determined that participants who received selfrelaxation training interventions experienced improved Pittsburg Sleep Quality Index (PSQI) and Epworth Sleep Study (ESS) scores over baseline, whereas in the control group scores worsened. Furthermore, they noted that the effect continued to improve progressively over the duration of the study. Additionally, the authors noted a side benefit of improved cognition and memory based on Mini-Mental Status Examination (MMSE) and Wechsler Memory Scale-Chinese Revised (WMS-CR) scores in the intervention group, with decreases in scores noted in the control group. The second research article selected for this paper, also available in CINAHL, was also a randomized control trial. This study was conducted over a shorter term of five days and took place in the medical ward of a hospital (Francis & Silva, 2012). Utilizing a hospital setting is relevant to the jail population due to noise levels and frequent sleep interruptions inherent in both hospitals and jails. Also, like patients in hospitals, many jail inmates have chronic or acute conditions which interfere with their sleeping comfort. Similar to the first study, Francis and Silva (2012) utilized the PSQI assessment tool and PMR techniques. Unlike the previous study, participants in this study also included younger adults, age 21 and older, and utilized in-person instruction of PMR by a qualified instructor as opposed to audio tapes. Over the course of five days, the intervention group participated in daily 20-minute relaxation sessions. As in the first

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study, the authors noted a significant improvement in quality of sleep in the intervention group based on PSQI scores. Non-Research Evidence Relevant non-research documentation was found in the body of a continuing education course for nurses regarding multiple sleep disorders, including insomnia (NetCE, 2016). In this article, the effectiveness of CBT-I is emphasized, however the authors also note that relaxation techniques, particularly PMT, can be effective adjuncts, especially in patients who experience stress in the form of physical tension. They go on to describe what the therapy entails, including tensing and relaxing muscle groups, deep breathing, and counting to subdue runaway thoughts. In a second non-research article, published in the British Journal of Medical Practitioners, and available on Medline and Pub Med databases, several non-pharmacological interventions for management of insomnia are discussed (Vyas, 2013). After a brief introduction during which insomnia is defined, and its significance is discussed, Vyas (2013) provides tables gleaned from the American Academy of Sleep Medicine articulating classification of evidence and recommendation levels for standards of practice. The author then goes on to list ten types of therapies along with their recommendation level. Per Vyas (2013), if a therapy is classified as standard, level I evidence is implied, and the practice reflects a high degree of clinical conviction. If a therapy is classified as a guideline, level II or strong level III evidence is implied, and the practice indicates a moderate degree of clinical confidence. If the therapy is listed as option, there is likely inconclusive or conflicting evidence supporting its use in a clinical setting. According to Vyas (2013), relaxation training is given the classification of standard, and is recommended as an effective strategy for treatment of chronic insomnia.

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Evidence Matrix Authors

Alparslan, G. B., Orsal, Ö., & Unsal, A.

Dayapoğlu, N., & Tan, M.

Journal Name/ WGU Library

Holistic Nursing Practice

Journal Of Alternative & Complement ary Medicine

Year of Public ation

Research Design

Sample Size

2016

Quantitative, quasiexperimental (separate intervention and control groups, but not randomized.

282 patients (47 control group and 235 interventio n group)

2012

Quantitative, quasiexperimental, quantitative (single group served as both control and intervention group utilizing a pre-test/posttest model)

CINAHL & MEDLINE

Outcome Variables Measured

Level (I– III)

Quality (A, B, C) B

Sleep quality, sleep latency, sleep time, effective sleep habits, daytime dysfunction, PSQI score

II

Some control; most references more than 5 years old B

32 patients

Results/Author’s Suggested Conclusions

Fatigue severity, sleep quality, sleep latency, sleep duration, sleep disturbances, daytime dysfunction, Global PSQI

II

Most references more than 5 years old

Statistically significant improvement in all variables (P...