Adapting and Implementing Guidelines for Managing Sleep Disturbances in Incarcerated Youths

Providers working in Utah Juvenile Justice Youth Services (JJYS) lack specific guidelines for managing sleep disturbances in the high-risk incarcerated youth population. Guidelines can give providers a consistent, effective, and evidence-based approach to managing sleep disturbances. Sleep disturbances are heightened in incarcerated youths, and providers working in Utah JJYS do not have guidelines for managing sleep disturbances. For this project, an educational presentation was developed, and sleep management guidelines were adapted and implemented for providers to use when addressing sleep disturbances in incarcerated youths. Sleep guidelines were adapted and implemented using evidence from literature, content experts, and findings from the pre-implementation team interview. The implementation team meeting included an educational presentation on sleep in incarcerated youths and the sleep management guidelines. A post-implementation team interview along with a retrospective chart review gathered information on the feasibility, satisfactoriness, usability, and effectiveness of the sleep management educational presentation and guidelines. Sleep management guidelines were implemented and provided JJYS providers with a guided, evidence-based approach for managing sleep disturbances in incarcerated youths. The retrospective chart review demonstrated an increase of 29.41% use of the components of the guidelines. There was insufficient evidence from the retrospective chart review to conclude that the providers changed their sleep management behavior following the educational presentation and implementation of the guidelines. The post-implementation team interview demonstrated the educational presentation and guidelines' feasibility, satisfactoriness, usability, and effectiveness in managing sleep in incarcerated youths. The educational presentation and guidelines were valuable in providing standardized, evidence-based sleep management practices for incarcerated youths. The implementation of the sleep management guidelines demonstrated provider satisfaction and the future sustainability of the guidelines.

1 Adapting and Implementing Guidelines for Managing Sleep Disturbances in Incarcerated Youths Elizabeth L. Jacobs, Jennifer Clifton, Valois Feneziani, Sara Hart College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III May 7, 2023 2 Abstract Background: Providers working in Utah Juvenile Justice Youth Services (JJYS) lack specific guidelines for managing sleep disturbances in the high-risk incarcerated youth population. Guidelines can give providers a consistent, effective, and evidence-based approach to managing sleep disturbances. Local Problem: Sleep disturbances are heightened in incarcerated youths, and providers working in Utah JJYS do not have guidelines for managing sleep disturbances. For this project, an educational presentation was developed, and sleep management guidelines were adapted and implemented for providers to use when addressing sleep disturbances in incarcerated youths. Methods: Sleep guidelines were adapted and implemented using evidence from literature, content experts, and findings from the pre-implementation team interview. The implementation team meeting included an educational presentation on sleep in incarcerated youths and the sleep management guidelines. A post-implementation team interview along with a retrospective chart review gathered information on the feasibility, satisfactoriness, usability, and effectiveness of the sleep management educational presentation and guidelines. Interventions: Sleep management guidelines were implemented and provided JJYS providers with a guided, evidence-based approach for managing sleep disturbances in incarcerated youths. Results: The retrospective chart review demonstrated an increase of 29.41% use of the components of the guidelines. There was insufficient evidence from the retrospective chart review to conclude that the providers changed their sleep management behavior following the educational presentation and implementation of the guidelines. The post-implementation team interview demonstrated the educational presentation and guidelines’ feasibility, satisfactoriness, usability, and effectiveness in managing sleep in incarcerated youths. 3 Conclusions: The educational presentation and guidelines were valuable in providing standardized, evidence-based sleep management practices for incarcerated youths. The implementation of the sleep management guidelines demonstrated provider satisfaction and the future sustainability of the guidelines. Keywords: guidelines, incarceration, sleep disturbances, sleep management, providers, youth(s) 4 Adapting and Implementing Guidelines for Managing Sleep Disturbances in Incarcerated Youths Problem Description Adolescent sleep disturbances are a nationwide public health problem, and sleep disturbances in incarcerated youths are exacerbated (Ireland & Culpin, 2006). In Utah’s Juvenile Justice and Youth Services (JJYS) facilities, youths frequently request interventions for sleep disturbances. The most prevalent mental health diagnosis in JJYS facilities is a sleep disorder, with 37% of youths having been diagnosed with a sleep disorder and 33% having been prescribed a sleep aid (Butler, 2019). Sleep disturbances in the Utah JJYS setting are inconsistently addressed across facilities. Furthermore, providers are not utilizing evidence-based practices to manage sleep disturbances. Providers working in JJYS facilities in Salt Lake City, Utah, do not have a guided approach to assessing and managing sleep disturbances in the high-risk JJYS population. When youths are transferred among JJYS facilities, their treatment plans for sleep disturbances often do not follow. Because providers manage sleep differently, continuity of care is compromised, and incarcerated youths can experience further sleep disruptions. The lack of guidelines for sleep management has led to an absence of consistent, effective, and evidence-based sleep management for youths across Utah JJYS facilities. Owens et al. (2014) discusses how sleep disorders are treatable with medical and behavioral interventions and are important for primary care healthcare providers to recognize and diagnose. Given the prevalence of sleep disturbances in Utah’s JJYS youths, providers need standardized assessment tools to perform sleep management interventions. Providers play a 5 critical role in promoting and addressing the health needs of incarcerated youth, including sleep management (Committee on Adolescence et al., 2011). Available Knowledge The adolescent population faces a higher likelihood of experiencing sleep disruptions compared to adults, with an estimated 20% of adolescents in the general population experiencing sleep-related issues (Kansagra, 2020; Owens et al., 2014). The prevalence and effects of sleep disturbances are heightened in high-risk adolescents (Owens et al., 2014); therefore, incarcerated youths in JJYS facilities are vulnerable and have a high propensity for sleep disturbances. Incarceration can disrupt sleep and lead to poor health outcomes. According to Berger et al. (2018), at least 40% of incarcerated individuals report poor sleep. Despite ongoing efforts and litigation to improve sleep in US jails and prisons, inadequate sleep is a large-scale health concern that disproportionally affects incarcerated individuals (Morris et al., 2021). According to the Utah Department of Human Services (2015), all youths must receive a medical assessment and physical exam by a nurse practitioner within 30 days of entering Utah JJYS facilities. During a health encounter, a provider must be competent in screening and educating youths and treating sleep disturbances. According to Stojanovski et al. (2007), less than half of providers feel competent screening for sleep disturbances, with only 25% feeling comfortable treating sleep problems in youths. A health encounter between a youth and a JJYS provider allows the provider to educate the youth about normal sleep, discuss interventions to prevent sleep problems, or work with the youth on sleep disturbances (Owens et al., 2014). The National Commission on Correctional Health Care (NCCHC; 2019) states, “there is little evidence to support the safe and effective management of sleep disturbance in incarcerated adolescents.” Due to this lack of evidence, the NCCHC upholds that JJYS facilities should 6 develop and maintain a comprehensive approach to managing sleep disturbances (Centers for Disease Control and Prevention, 2020). The NCCHC provides general treatment recommendations for incarcerated youths based on treatments in the community and treatments for incarcerated adults. However, these recommendations lack specific information regarding assessment tools, instances of use, medication dosages, treatment failure options, and alternative considerations. Incarcerated youths tend to sleep poorly, and there are no guidelines tailored to the JJYS population. Providers need evidence-based sleep management guidelines with a multifactorial approach that incorporates psychoeducation, cognitive behavioral therapy (CBT), and medication (Elger, 2007; NCCHC, 2019). There are existing evidence-based guidelines for managing sleep in incarcerated adults, nonincarcerated adults, and the pediatric population (Dewa et al., 2018; Mindell & Owens, 2015; NCCHC, 2019; Sateia et al., 2017). However, these guidelines cannot be applied to the JJYS setting, as incarcerated youths do not fit exactly into any of the aforementioned categories (Dewa et al., 2018; Mindell & Owens, 2015; NCCHC, 2019; Sateia et al., 2017). Existing guidelines can be adapted to fit the needs of the JJYS population, providing appropriate interventions to improve sleep. Rationale The Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework guided this project, which used the PARIHS methodology to implement evidence into practice (Birken et al., 2017; Kitson & Harvey, 2016). The PARIHS framework has three fundamental components, evidence, context, and facilitation. These components were used to implement the sleep management guidelines, making the PARIHS framework ideal for 7 this project and its aim to facilitate the successful implementation of sleep management guidelines for incarcerated youths at JJYS facilities. Using the PARIHS framework, the perceptions and values of JJYS providers were reconciled, and the sleep management guidelines were adapted to fit the needs and workflow of the JJYS providers. Guidelines from Mindell and Owens (2015) and Sateia et al. (2017) were adapted and implemented for the evidence component of the PARIHS framework. The providers working in the medical offices at two JJYS facilities recognized the need to improve sleep management for incarcerated youths because the lack of guidelines for consistent sleep management was causing a gap in patient care. In the PARIHS framework, context is a consideration whenever a change is implemented, as the setting and environment of a project are crucial components in change implementation (Birken et al., 2017). A barrier to sleep management in JJYS facilities is the lack of consistency across facilities, as providers do not have a set approach for addressing sleep complaints. Providers need evidence-based sleep management guidelines that consider comorbid mental and medical conditions, the unique JJYS setting, facility policies, and site-specific recourses. The final component of PARIHS is facilitation, which requires gathering evidence and synthesizing it for participants to learn and implement new knowledge in practice (Birken et al., 2017; Kitson & Harvey, 2016). The PARIHS framework suited this project, as the implementation of sleep guidelines for incarcerated youths depended on the guidelines being adapted to the unique context of the JJYS environment through facilitation. JJYS providers needed a facilitator to provide JJYS-specific education and to adapt and implement evidencebased sleep guidelines for incarcerated youths. 8 Overall, the PARIHS framework facilitated providers’ adaptations to changes and maximized their likelihood of implementing evidence-based practices to manage sleep disturbances in incarcerated youths, making the sleep management guidelines suitable for JJYS facilities (Kitson & Harvey, 2016). Specific Aims The purpose of this DNP project was to adapt and implement sleep management guidelines in JJYS facilities. Quality sleep is essential to health, and the high-risk incarcerated youth population can benefit from standardized, evidence-based sleep interventions. Education and guidelines can support JJYS providers in providing consistent, evidenced-based care for sleep disturbances in incarcerated youths across JJYS facilities. Methods Context The adapted sleep guidelines were implemented at two juvenile facilities, a secure facility and a detention facility, located in a suburban area in northern Utah. Youths at the facilities ranged from 10 to 25 years old. Utah JJYS serves youths between 18 and 25 years of age if they are under 18 years old at the time of their offense (Utah State Legislature, 2022). The Division of Juvenile Justice Services (2016) reported that the average age of incarcerated youths across Utah was 16.1, with 76.2% between 15 and 17 years old. Females accounted for 23% of all Utah JJYS youths (Division of Juvenile Justice Services, 2016). The detention facility in this project has an average of 32 juvenile offenders, and the secure facility has an average of 45 youths. The youths in the facilities come from various socioeconomic backgrounds and ethnicities. Both facilities have a clinical team that provides medical care to the youths for mental and physical health. The detention and secure facilities each have two clinical social workers, one part-time psychiatric 9 mental health nurse practitioner (PMHNP), and one part-time family nurse practitioner. The detention facility has two full-time registered nurses and three per diem nurses, while the secure facility employs one full-time registered nurse. Intervention(s) This project was completed in three phases: 1) the pre-implementation team interview, 2) the provider educational presentation meeting, and adaptation and implementation of the sleep management guidelines, and 3) the post-implementation team interview and retrospective chart review. In phase one of this project, a pre-implementation team interview was conducted with the JJYS providers to assess their perception of needs and preferences regarding sleep management in incarcerated youths (see Appendix A). Another goal of the team interview was to identify common areas of provider bias regarding sleep in the high-risk JJYS patient population. The pre-implementation team interview was conducted over Zoom and recorded for subsequent review. Following the pre-implementation team interview, common themes were identified and used to adapt existing guidelines and education to fit the setting and needs of JJYS providers (see Table 1). Phase two of this project involved adapting and implementing the existing sleep management guidelines (see Appendix B). The resulting sleep management guidelines were underpinned by guidelines from Mindell and Owens (2015) and Sateia et al. (2017), collaborative efforts with content experts, and data from the pre-implementation team interview. Three documents were developed and adapted as part of the guidelines: a sleep hygiene handout, an RN sleep sick call questionnaire, and a sleep diary (see Appendices C, D, and E). Multiple strategic meetings were conducted with content experts to refine the guidelines prior to the implementation. The guidelines provided JJYS providers with a comprehensive, evidence-based 10 approach to managing sleep disturbances in incarcerated youths. An educational presentation was created using identified areas of need regarding sleep management in incarcerated youths (see Appendix F). The content experts approved and validated all the documents and presentations. The implementation meeting aimed to educate the providers on sleep management and the implementation of the new sleep management guidelines. The meeting focused on the utility of the guidelines in directing medical decision-making regarding sleep in incarcerated youths and helping providers recognize biases and disparities faced by incarcerated youths. The providers were also instructed on how to use the guidelines effectively. Time was allotted at the end of the meeting for providers to ask clarifying questions regarding the guidelines and education. Following the implementation meeting, the JJYS providers began implementing the sleep management guidelines in their practices. Support was given to the providers during the implementation period when they had questions or concerns. In phase three of the project, a post-implementation team interview and retrospective chart review were conducted (see Appendix G). Providers’ feedback was gathered regarding the feasibility, satisfactoriness, usability, and effectiveness of the education and sleep management guidelines. A retrospective chart review was conducted to compare the use and effectiveness of the guidelines. The chart review assessed for changes in practice by comparing pre- and postimplementation sleep management based on seven criteria (see Table 2). Study of the Intervention(s) At the time of this project, there were no similar projects or comparison groups within Utah JJYS facilities. The pre-implementation team interview elicited providers’ knowledge and attitudes, current clinical practices, and perception of sleep management in incarcerated youths. 11 Providers’ knowledge, attitudes, and perceptions after the implementation of the guidelines were used to determine the efficacy of the guidelines through a post-implementation team interview and retrospective chart review. Questions regarding feasibility and usability identified barriers and factors to facilitate the guidelines’ further implementation. Provider feedback was used to improve the guidelines and provide additional recommendations for sleep management in incarcerated youths. Measures Team interviews and a retrospective chart review were used to evaluate this project. Qualitative data was collected from JJYS providers during pre- and post-implementation team interviews. The interviews focused on the educational presentation and sleep management guidelines. After the post-implementation team interview, a retrospective chart review was performed to determine whether there were changes in clinicians’ practices for sleep management. The pre-implementation interview questions were developed from a focused review of the literature on sleep in incarcerated youths, adolescent sleep, sleep during incarceration, and biases and disparities regarding incarceration (see Appendix A). The interview questions were refined with the input of content experts and the project chair. Providers were asked 24 guiding questions divided into the themes of sleep education, sleep management, and potential biases. A live team interview format was chosen for its ability to gather qualitative information necessary to adapt the existing guidelines. During the interview, providers expressed their preferences and needs regarding the guidelines, identified areas requiring further education, and established their buy-in to the guidelines. Following the pre-implementation team interview, common themes were identified regarding the providers’ perceptions of the need for education and sleep 12 management guidelines (see Table 1). Notes were used to identify themes that were reviewed and confirmed with the content experts. A post-implementation team interview was conducted to evaluate the feasibility, satisfactoriness, usability, and effectiveness of the educational presentation and sleep management guidelines. The content experts approved all questions asked at the postimplementation team interview (Appendix G). Providers answered six questions specific to the educational presentation and 11 questions regarding the sleep management guidelines. At the end of the post-implementation team interview, providers gave feedback in their own words concerning the educational presentation and guidelines. Themes and feedback from the postimplementation team interview were confirmed with the content experts and used to adapt the sleep management guidelines (see Table 3). The sleep hygiene handout, an RN sick call sleep questionnaire, and the sleep diary were also modified (see Appendices H, I, and J). A retrospective chart review allowed for the comparison of providers’ sleep management before and after the guidelines were implemented. In the review, 16 pre-implementation charts and 16 post-implementation charts were compared to determine whether there were changes in the clinicians’ practices (see Tables 4 and 5; Figure 1). The charts were compared using a sevencomponent checklist that included steps from the sleep management guidelines (see Appendix B; Table 2). The checklist was designed to quantify the number of components completed pre- and post-implementation, thereby providing accurate, descriptive data and assessing the guidelines’ usability. The pre-implementation charts were selected using data from the nurse daily task tracking tool in Microsoft Excel, medication administration records, verbal reports from nurses and providers of youths with sleep disturbances, and provider physical exam charts. Exclusion 13 criteria were applied to charts filled out prior to January 1, 2022, to youths who had medications prescribed for conditions other than disrupted sleep, and to youths with medications brought in by an outside source such as a parent, group home, or other juvenile facility. The postimplementation charts were identified after providers and nurses wrote down the names of youths seen for sleep complaints during the implementation period. Analysis A content analysis was conducted to examine the qualitative data generated in the notes from the pre- and post-implementation team interviews. The notes were reviewed to identify common themes (see Tables 1 and 3), which were confirmed through collaboration with the content experts. The themes from the pre-implementation team interview directed the educational presentation and adaptation of the sleep management guidelines (see Table 1). The themes from the post-implementation team interview were used to refine the guidelines and make future recommendations for sleep management in incarcerated youths (see Table 3). Following the post-implementation team interview, a retrospective chart review was performed using the seven-component checklist to assess for practice changes (see Table 2). The mean number of checked boxes was calculated for both the pre- and post-implementation phases (Table 4 and Table 5). The means were analyzed using descriptive statistics and reported as frequency data to assess for changes in provider practices (see Tables 4 and 5). The usability of the guidelines was assessed by measuring the difference between the mean number of boxes checked pre- and post-implementation (see Table 5). Ethical Considerations No potential competing interests or conflicts of interest were identified in this project. According to the University of Utah, this project is determined to be a non-human subject’s 14 research quality improvement project and is thus not subject to Institutional Review Board oversight (see Appendix K). Results Phase One A thematic analysis of the pre-implementation interview with the team of providers revealed the need for guidelines to manage sleep disturbances in incarcerated youths. Common themes identified are outlined in Table 1. In the interview, two nurse practitioners reported inconsistencies among JJYS facilities in managing sleep disturbances, describing sleep management as a “free for all.” The providers noted that they tended to manage sleep differently. Both providers indicated the lack of standardization for sleep management across JJYS facilities and the resulting gap in care. One provider explained that inconsistency in sleep management and related prescriptions can lead to youths experiencing increased sleep disturbances, pushing back against new sleep regimens, and trying to get medications from different prescribers. The same provider reported a desire for resources and education on best practices and current recommendations for managing sleep disturbances in incarcerated youths. The other provider wanted standardized assessments for nurses to utilize when a youth reports a sleep disturbance, noting that a way to get more information about sleep disturbances would be helpful. Both providers agreed that a sleep diary and guidelines for managing sleep in the JJYS setting were needed. Before the guidelines were implemented, both providers reported using pharmacological and non-pharmacological therapies and emphasized the current use of non-pharmacological interventions, including sleep hygiene and behavior therapies. The providers used differing pharmacological agents for sleep, with one provider using hydroxyzine and melatonin frequently 15 while avoiding trazodone due to compliance concerns. The other provider reported prescribing trazodone, hydroxyzine, and melatonin. The providers noted they refer patients with comorbid mental health conditions and complex sleep disturbances to the PMHNP. Questions about bias revealed providers’ awareness of potential implicit biases and the clinicians’ efforts to ensure biases do not affect the care they provide. One identified potential bias was that youths may complain of sleep disturbances in the hopes of getting medication, referred to as “med seeking.” One provider noted that they prefer to rely on objective information because catastrophizing sleep issues is common among the incarcerated youth population. Both providers noted ways in which they provide culturally competent care through understanding patients’ backgrounds and being empathetic. The providers mentioned room for continual improvement when working with incarcerated youths, including training on cultural competency. Areas identified for provider education included sleep in incarcerated youths, identification and management of sleep complaints, and biases and disparities faced by incarcerated youths (see Appendix F). Phase Two Phase two of the project involved adapting and implementing the sleep guidelines and creating an educational presentation, which was shown to the providers during the implementation meeting over Zoom (see Appendices B and F). A PowerPoint presentation was designed to cover sleep education, address concerns related to sleep management, educate providers on bias awareness, and demonstrate how to use the adapted sleep management guidelines (see Appendix F). It was critical to develop the presentation based on preimplementation findings, thereby validating providers’ perceptions, respecting their opinions, and achieving their buy-in, which promoted team cohesion. 16 Three forms were developed and adapted as part of the sleep management guidelines. The first form was a sleep hygiene handout from the Centre for Clinical Interventions (2019) to give youths when they report sleep difficulties (see Appendix C). That particular sleep hygiene handout was selected because it had the most relevant recommendations for the incarcerated and adolescent populations. Several other sleep hygiene forms were reviewed but were not found applicable to the JJYS setting. The second form was an RN sleep sick call questionnaire developed for nurses to collect information from youths reporting sleep disturbances prior to the provider visit (see Appendix D). The third form was a seven-day sleep diary (see Appendix E) derived from the Children’s Hospital of Orange County (CHOC; 2022) and specific to adolescents. Mindell and Owens (2015) emphasize that sleep diaries are “an important step in evaluating many sleep problems” and that self-reporting improves accuracy. A period of seven days was selected based on CHOC’s recommendation, and the content experts agreed that seven days was sufficient to show youth buy-in. All three forms were distributed to the providers during the implementation meeting. The sleep guidelines of Mindell and Owens (2015) and Sateia et al. (2017) were selected for adaptation due to their specificity regarding sleep onset, sleep maintenance, and nightmares as well as the use of behavioral therapies. The guidelines from Mindell and Owens (2015) are tailored to the pediatric population, while those from Sateia et al. (2017) are based on the adult population. Because of the unique JJYS setting and incarcerated youth population, the guidelines had to be adapted before the implementation. The JJYS providers were taught how to use the guidelines during the implementation meeting and were given paper copies and PDFs of the educational presentation, forms, and guidelines (see Appendix B). Additionally, a 16-inch by 24inch printout of the guidelines was placed at each facility. 17 Phase Three In phase three, feedback was collected through a post-implementation team interview, and a retrospective chart review was performed to assess the feasibility, satisfactoriness, usability, and effectiveness of the sleep management education and guidelines. Common themes identified included the need for a shorter sleep diary, more images in the sleep hygiene handout, satisfaction with the education, and the effectiveness and feasibility of the guidelines (see Table 3). One provider appreciated how “[the education] highlighted the importance of sleep in the JJYS population.” The other provider liked how “the education was organized into groups, dividing sleep onset, sleep maintenance, circadian rhythm, and psychiatric comorbidities.” They continued by saying, “[the new guidelines] made it so the sick call and sleep log results guided [my] decision-making.” Both providers expressed that the education reinforced their sleep knowledge and understanding of bias reduction, with one provider stating, “the statistics showed that individuals with lower socioeconomic status[es] are less likely to have their sleep treated.” The providers liked how the education was easy to follow and organized into groups (i.e., risk factors, medications, sleep maintenance, and post-traumatic stress disorder). The providers did not have any dislikes concerning the education, but one provider suggested more education on supplements, while the other wanted more information on CBT. Both providers felt the education helped inform them how to use the sleep management guidelines. Feedback on the three forms was gathered. Both providers appreciated the thoroughness of the sleep diary but felt seven days was too long and suggested shortening the diary to three days. The sleep hygiene handout was well-received for its ability to focus on critical points and provide information to youths prior to their provider visits. However, they recommended adding more images to improve its effectiveness. The RN sleep sick call questionnaire received positive 18 feedback from both providers; however, one provider suggesting combining redundant questions. The other provider stated, “[the questionnaire] provided details before I saw the youths, helping me make informed decisions and [standardize] care.” During the post-implementation team interview, the providers expressed satisfaction when asked about their experience with the sleep management guidelines. One provider described the guidelines as “effective for basic sleep disturbances and standardizing sleep in juvenile corrections.” Both providers found the guidelines feasible and usable, emphasizing their specificity to the juvenile corrections environment. The providers found the guidelines easy to learn and follow and expressed satisfaction with the guidelines’ appearance. After a consultation with the content experts, several revisions were made to improve the usability and effectiveness of the sleep management guidelines. A sleep hygiene handout predominantly consisting of pictures would be the most effective (see Appendix H). The sleep diary was revised to be used for four days, including two weekend nights and two weeknights (see Appendix J). The RN sleep sick call questionnaire was revised to eliminate redundancy (see Appendix I). To simplify the guidelines, one comorbid section was removed, resulting in a single comorbid section (see Appendix L). The providers appreciated the non-pharmacological section of the guidelines but did not implement it in their practices. One provider explained that “youth[s] cannot control the temperature, lights, or noise [in their environments]. I also ignored [the non-pharmacological section] as not all youth[s] can do CBT due to resources.” Nevertheless, both providers emphasized the importance of the non-pharmacological section, with one provider stating, “the non-pharmacological section is great. Do not remove it, as it will help ensure that all providers incorporate non-pharmacological interventions.” 19 The providers expressed satisfaction with the pharmacological section of the guidelines as well, describing it as straightforward and helpful for selecting appropriate pharmacological interventions. The providers inquired about the possibility of using other supplements, such as magnesium, for sleep. After consulting with the content experts, it was decided not to include additional supplements in the guidelines due to their limited use in the population and the need for further investigation into their potential benefits. Nonetheless, both providers expressed their intention to use the guidelines, with one provider specifically mentioning their plans to use the pharmacological section. Chart Review A retrospective chart review was conducted to compare the providers’ sleep management pre- and post-implementation of the guidelines. A seven-component checklist was filled out for 16 charts of patients seen for sleep disturbances before the guidelines were introduced (see Table 2). Of the seven boxes, the “follow-up visit with NP or PMHNP” box was checked the most frequently, and the “documentation of the social worker being notified” box was checked the least frequently (see Table 4). The average number of boxes checked before the implementation was 2.125, signifying the providers’ room for growth in providing standardized, evidence-based care (see Table 5; Figure 1). The post-implementation chart review was conducted on 16 charts of patients seen for sleep disturbances following the implementation of the guidelines. Of the checkboxes, the “RN sleep sick call questionnaire, sleep diary, and sleep hygiene” box was checked most frequently, and the “documentation of the social worker being notified” box was checked the least frequently (see Table 4). Four of the pre-implementation charts had medications prescribed at doses different from the guidelines recommended, while zero post-implementation charts had 20 differing doses (see Table 4). The average number of boxes checked after the implementation was 2.75 (see Tables 4 and 5). The average number of checked boxes increased by 29.41% from 2.125 to 2.75, signifying the utility of the sleep management guidelines (see Table 5). A two-tailed paired sample t-test was conducted to examine whether the difference between the means pre- and post-implementation was statistically significant (Intellectus Statistics, 2022; Razali & Wah, 2011; Westfall & Henning, 2013). The result of the two-tailed paired sample t-test was not statistically significant based on an alpha value of .05, z = -1.55, p = .172, indicating the null hypothesis cannot be rejected. Therefore, there is insufficient evidence to conclude there was an effect on behavior from the implementation of the sleep management guidelines. A Shapiro-Wilk test was conducted to determine whether a normal distribution could have produced differences pre- and post-implementation (Razali & Wah, 2011). The results of the Shapiro-Wilk test were not statistically significant based on an alpha value of .05, W = 0.92, p = .469. This result suggests the possibility that the differences in pre- and postimplementation means produced by a normal distribution cannot be ruled out, indicating that the normality assumption is met. The results are presented in Table 5, and a bar plot of the means is presented in Figure 1. Discussion Summary This quality improvement project demonstrates the utility of sleep management guidelines and education in improving current and future providers’ understanding and effectiveness when managing sleep disturbances in incarcerated youths. The project was successful in standardizing sleep management in the JJYS population through guidelines and an educational presentation. To increase provider utilization, the sleep management guidelines 21 considered time constraints and barriers to adopting the guidelines. To enhance dissemination, the guidelines were provided in PDF, paper, and poster formats. A strength of the project was its live educational presentation and instruction on the sleep management guidelines, allowing for real-time discussion and ensuring proper use of the guidelines. In addition, providers received resources related to sleep management in adolescent and incarcerated populations. The project identified areas of future revision to sleep management guidelines and highlighted the need for further research into sleep management in incarcerated youths. Overall, the chart review and post-implementation team interview demonstrated the utility and effectiveness of education and guidelines in improving sleep management in the JJYS environment. Interpretation The providers who manage sleep disturbances in incarcerated youths verbalized the feasibility, satisfactoriness, usability, and effectiveness of the education and sleep management guidelines. The findings of this project align with Dewa et al. (2018), who found that guidelines for sleep management in incarceration settings helped guide providers to “make better decisions for prisoners’ sleep and health needs.” Dewa et al. (2018) found that a treatment guide promotes the early detection of insomnia, reduces unnecessary prescriptions, and decreases medication misuses and diversions in prison settings. The sleep management guidelines and education developed in this project offer valuable resources for Utah JJYS providers to implement standardized, evidence-based sleep management practices, giving them the potential to improve sleep management in JJYS facilities across the state. The project interventions were costeffective and thoughtfully designed for JJYS providers. 22 Limitations This project had several limitations. The first was the small sample size of incarcerated youths with sleep disturbances, as only 16 youths across two JJYS facilities reported sleep complaints over 66 days. Therefore, the restricted ability to assess providers’ responses to the guidelines made it difficult to evaluate practice changes. Another limitation was the variable length of stay for incarcerated youths. Each youth’s length of stay depends on legal circumstances and charges. Some youths were released before being seen by a provider for sleep disturbances but still received resources such as the sleep hygiene handout, RN sleep sick call questionnaire, or sleep diary. Furthermore, a limitation was that the youths’ parents could bring supplements, including melatonin, without a provider assessment. In two instances, youths reported sleep disturbances and were supposed to be assessed by a provider but were brought over-the-counter melatonin by parents. Efforts were made to ensure that youths received the sleep hygiene handout, RN sleep sick call questionnaire, and sleep diary as soon as they reported a sleep disturbance in an effort to follow the guidelines. Efforts were put in place by the nurses and PMHNP to encourage the youths to complete the sleep diary, including rewards such as candy and hygiene products. The confounding variable of rewards could have led to more youths completing a sleep diary and complaining of sleep disturbances. Furthermore, when the providers had youth follow-up with the PMHNP instead of the provider, that could have led to higher follow-up rates and limited internal validity. Additionally, the PMHNP was a content expert for this project, which could have led to bias in recommending sleep diaries, following up, and prescribing medications. Finally, someone related to the project completed the chart review, which could have led to implicit bias. 23 Conclusions The results of this project provide preliminary evidence that disseminating the sleep management guidelines and education to current and future JJYS providers can improve the standardization and delivery of evidence-based sleep management in incarcerated youths. Given the small number of youths who received the sleep guidelines after 66 days, more time is needed to evaluate practice changes in sleep management. This project can be easily implemented in other JJYS facilities with modifications as necessary. To improve sustainability, all documents prepared as part of this project have been uploaded to the JJYS facility-wide Box, where facility documents are housed. The educational presentation and guidelines were disseminated to all JJYS providers across the Wasatch Front in Utah during the monthly provider meeting, and posters of the guidelines were placed in JJYS facilities. Clinical guidelines have been developed and used with success in various healthcare settings for the management of health problems. The PARIHS framework can facilitate the adoption and implementation of evidence-based guidelines. Guidelines serve as feasible and sustainable means of integrating evidence into practice, but it is crucial to monitor adherence to ensure that any implemented guidelines are being followed. This project’s sustainability is attributed to its ease of use, buy-in from JJYS providers, and applicability to the JJYS population. The project was highly encouraged and supported by JJYS staff members, enhancing its potential for future success. Future projects should assess providers’ knowledge of sleep disturbances and implement sleep screenings during nurse intake assessments. An additional project could examine the efficacy of adding supplements to the prepared education and sleep management 24 guidelines. Further, as sleep management recommendations evolve, updates to the education and guidelines may be necessary. 25 Acknowledgements There are so many individuals who have helped me achieve this great accomplishment, and it is hard to know where to start. I hope no one has to complete a doctoral degree alone but rather has an army of people supporting, encouraging, listening, and helping them and anxiously (yet patiently) waiting for them to cross the finish line. First, I want to thank those who have been my first call—my parents and my friend Curtis Le. My parents are my lifelong best friends and the best people I know. They never fail to answer a call and listen when I need support. They are my rocks, and I could not ask for more supportive and loving people. Curtis Le, “Curt,” you have been my best friend since I met you. Curt answers every call and text message and has been the most loyal friend I have ever met. Curt has visited me over ten times in the short 2.5 years I have lived in Salt Lake City. The number of times I have called him crying is too many to count, but his humor and friendly roasts always lift me up. Next, I want to thank those at the University of Portland—namely Casey Shillam, Brianna Rotter, and Kelly Lyp—who supported me while I obtained my bachelor’s degree in nursing and encouraged me to continue my education to get my doctorate in nursing. Your mentorship has been essential to me as a nurse and nurse practitioner student. I would like to extend a special acknowledgment to the providers and nurses who work with incarcerated youths, as their work is challenging, and I have seen them provide the utmost care to this population. I would also like to thank all those who helped with and participated in this project, especially the medical staff of Salt Lake Valley Youth Center and Decker Lake Youth Center, including Breck, Cara, Daniel, Heather, Russell, and Tom, who implemented the guidelines and showed their willingness to improve sleep care. 26 I want to thank Jennifer Clifton and Valois Feneziani, who served as my content experts and supported, edited, and counseled me through the creation of my entire project. Finally, I would like to extend a special appreciation to my project chair, Sara Hart. Sara, thank you for your ideas and support in planning and implementing this project and making it something I am proud of. Finally, I want to thank those at the University of Utah who have supported me along the way. Their gentle pushing, mentorship, and professional development have inspired me to go forth and do the same. I aspire to be a community leader at the forefront of my patient’s healthcare needs and hope to be a scholar, educator, and mentor, as all of them are. 27 References American Civil Liberties Union. (2020). America’s addiction to juvenile incarceration: State by state. https://www.aclu.org/issues/juvenile-justice/youth-incarceration/americas-addiction -juvenile-incarceration-state-state Berger, S., Culpepper, N., Hidalgo, J., McKee, J., & Wortzel, H. (2018). AAPL practice resource for prescribing in corrections. Journal of the American Academy of Psychiatry and the Law, 46(2), 2–50. https://jaapl.org/content/jaapl/46/2_Supplement/S2.full.pdf Binswanger, I. A., Redmond, N., Steiner, J. F., & Hicks, L. S. (2012). 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BMJ Open, 8(8). https://doi.org/1 0.1136/bmjopen-2018-022406 Division of Juvenile Justice Services. (2016). 2016 annual report. J. J. Services. https://jjys.utah.gov/wp-content/uploads/2017/07/FY2016-Annual-Report.pdf El-Amin, W., & Sufrin, C. (2020). Addressing racism in correctional health care. National Commission on Correctional Health Care. https://www.ncchc.org/addressing-racismincorrectional-health-care/ Elger, B. (2007). Insomnia in places of detention: a review of the most recent research findings. Medicine, Science, and the Law, 47(3), 191–199. https://doi.org/10.1258/rsmmsl.47.3. 191 Elger, B. (2008). Prisoners’ insomnia: to treat or not to treat? Medical decision-making in places of detention. Medicine, Science, and the Law, 48(4), 307–316. https://doi.org/10.1258/rs m msl.48.4.307 29 Faruqui, F., Khubchandani, J., Price, J. H., Bolyard, D., & Reddy, R. (2011). Sleep disorders in children: a national assessment of primary care pediatrician practices and perceptions. American Academy of Pediatrics, 128(3), 539-546. https://doi.org/10.1542/peds.20110344 Ghassemzadeh, S., Lew, V., & Podder, V. (2022). SOAP notes. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482263/ Intellectus Statistics [Online computer software]. (2022). Intellectus Statistics. https://analyze.intellectusstatistics.com/ Ireland, J., & Culpin, V. (2006). The relationship between sleeping problems and aggression, anger, and impulsivity in a population of juvenile and young offenders. Journal of Adolescent Health, 38(6), 649–655. https://doi.org/10.1016/j.jadohealth.2005.05.027 Ivanenko, A., Crabtree, V., Tauman, R., & Gozal, D. (2003). Melatonin in children and adolescents with insomnia: a retrospective study. Clinical Pediatrics, 42(1), 51–58. https://doi.org/10.1177/000992280304200108 Kansagra, S. (2020). Sleep disorders in adolescents. American Academy of Pediatrics, 145, 204– 209. https://doi.org/10.1542/peds.2019-2056I Kitson, A., & Harvey, G. (2016). Methods to succeed in effective knowledge translation in clinical practice. Journal of Nursing Scholarship, 48(3), 294–302. https://doi.org/https://d oi.org/10.1111/jnu.12206 Kratochvil, C., & Owens, J. (2009). Pharmacotherapy of pediatric insomnia. Journal of the American Academy of Child and Adolescent Psychiatry, 48(2), 99–107. https://doi.org/htt ps://doi.org/10.1097/CHI.0b013e3181930639 30 Levenson, J., London, S., Ekas, D., Woods, M., Vojtash, M., Mulvey, E., & Miller, E. (2022). Sleep among adolescents in juvenile detention. Sleep, 45(1), 218. https://doi.org/10.1093/ sleep/zsac079.488 Lewandowski, A., Toliver-Sokol, M., & Palermo, T. M. (2011). Evidence-based review of subjective pediatric sleep measures. Journal of Pediatric Psychology, 36(7), 780–793. https://doi.org/10.1093/jpepsy/jsq119 Lewien, C., Genuneit, J., Meigen, C., Kiess, W., & Poulain, T. (2021). Sleep-related difficulties in healthy children and adolescents. BMC Pediatrics, 21(1), 82. https://doi.org/10.1186/s 12887-021-02529-y Mindell, J., & Owens, J. (2015). A clinical guide to pediatric sleep: diagnosis and management of sleep problems (Third ed.). Wolters Kluwer. http://ebookcentral.proquest.com/lib/utah/ detail.action?docID=6897888 Morris, N., Holliday, J., & Binder, R. (2021). Litigation over sleep deprivation in U.S. jails and prisons. Psychiatric Services, 72(10), 1237–1239. https://doi.org/10.1176/appi.ps.202100 438 National Commission on Correctional Health Care. (2019). Adolescent sleep hygiene. National Commission on Correctional Health Care. https://www.ncchc.org/adol escent-sleephygiene Owens, J., Au, R., Carskadon, M., Millman, R., Wolfson, A., Braverman, P., Adelman, W., Breuner, C., Levine, D., Marcell, A., Murray, P., & O’Brien, R. (2014). Insufficient sleep in adolescents and young adults: an update on causes and consequences. American Academy of Pediatrics, 134(3), 921–932. https://doi.org/10.1542/peds.2014-1696 31 Razali, N. M., & Wah, Y. B. (2011). Power comparisons of Shapiro-Wilk, Kolmogorov Smirnov, Lilliefors, and Anderson-Darling tests. Journal of Statistical Modeling and Analytics, 2(1), 21–33. Sateia, M., Buysse, D., Krystal, A., Neubauer, D., & Heald, J. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal Clinical Sleep Medicine, 13(2), 307– 349. https://doi.org/10.5664/jcsm.6470 Singh, G., & Kenney, M. (2013). Rising prevalence and neighborhood, social, and behavioral determinants of sleep problems in US children and adolescents. Sleep Disorders, 2013. https://doi.org/10.1155/2013/394320 Stojanovski, S., Rasu, R., Balkrishnan, R., & Nahata, M. (2007). Trends in medication prescribing for pediatric sleep difficulties in US outpatient settings. Sleep, 30(8), 1013– 1017. https://doi.org/10.1093/sleep/30.8.1013 Tapia, I., & Wise, M. (2022). Assessment of sleep disorders in children. UpToDate. https://www.uptodate.com/contents/assessment-of-sleep-disorders-in-children?search=As sessment%20of%20sleep%20disorders%20in%20children%20&source=search_result&s electedTitle=1~150&usage_type=default&display_rank=1 Utah Department of Human Services. (2015). Non-emergency medical and dental services. https://public.powerdms.com/UTAHDHHS/documents/163774/07-01%20MedicalDental%20Services Utah State Legislature. (2022). 78A-6-103 Original jurisdiction of the juvenile court -magistrate functions -- findings —transfer of a case from another court. https://le.utah.go v/xcode/Title78A/Chapter6/78A-6-S103.html 32 Westfall, P., & Henning, K. (2013). Texts in statistical science: Understanding advanced statistical methods. Taylor & Francis. Yoon, S. (2020). Pro-equity policy framework for racial and ethnic disparities in Utah’s Juvenile Justice System 2020. Utah Commission On Criminal & Juvenile Justice. https://justice.utah.gov/wp-content/uploads/RED_Final-2.pdf 33 Tables and Figures Table 1 Pre-Implementation Team Interview Themes Themes • Sleep disturbances are prevalent among incarcerated youths, resulting from a range of etiologies. • Providers utilize a psychiatric mental health nurse practitioner for complex sleep and comorbid mental health conditions. • The current sleep management in JJYS facilities is inconsistent, and there needs to be standardization in how sleep is managed in the JJYS setting. • Sleep logs have been found to be ineffective in gathering information about the sleep patterns of incarcerated youths. • To effectively manage sleep across the JJYS facilities, providers need a guided, evidence-based approach that takes into account the unique JJYS setting. 34 Table 2 Chart Review Checklist: Checkbox’s for chart review: • • • • • • • One of the following completed: sleep log, sleep diary, or RN sleep sick call questionnaire Documentation of the social worker being notified Evidence of sleep education: sleep hygiene, napping, sleep behaviors, relaxation, meditation, etc. Medication prescribed at the dose on the guideline for the reason indicated on the guidelines SOAP note with medical decision making (MDM) Assess for comorbid condition Follow-up visit with NP or PMHNP PreImplementation One of the following completed: sleep log, sleep diary, or RN sleep sick call questionnaire Documentation of the social worker being notified Evidence of sleep education: sleep hygiene, napping, sleep behaviors, relaxation, meditation, etc. Medication prescribed at the dose on the guideline for the reason indicated on the guideline SOAP note with MDM Assess for comorbid condition Follow-up visit with NP or PMHNP Postimplementation 35 Table 3 Post-Implementation Team Interview Themes Themes • Providers prefer a shorter sleep diary. • Incorporating more visuals could improve the effectiveness of the sleep hygiene handout • The educational presentation reinforced sleep knowledge and helped providers implement the sleep guidelines • The guidelines are easy to follow, facilitate decision-making. They are effective, feasible, and specific to the juvenile corrections environment • The non-pharmacological section of the guidelines ensures consistent interventions for all youths 36 Table 4 Chart Review Results PreImplementation Postimplementation One of the following completed: sleep log, sleep diary, or RN sleep sick call questionnaire 7 12 Documentation of the social worker being notified 1 2 Evidence of sleep education: sleep hygiene, napping, sleep behaviors, relaxation, meditation, etc. 4 5 Medication prescribed at the dose on the guideline for the reason indicated on the guideline 6 7 SOAP note with MDM 4 6 Assess for comorbid condition 2 5 Follow-up visit with NP or PMHNP 10 7 Total 34 44 *Note: 4 wrong medication doses noted pre-implementation 37 Table 5 Two-Tailed Paired Samples t-Test for the Difference Between the Pre-Implementation and PostImplementation Means Pre-Implementation Post-Implementation M SD M SD t p 4.86 3.08 6.29 3.04 -1.55 .172 Note: N = 7. Degrees of Freedom for the t-statistic = 6. d represents Cohen's d. d 0.59 38 Figure 1 The Means Pre-Implementation and Post-Implementation with 95.00% CI Error Bars 39 Appendix A Doctoral Project Pre-Implementation Team Interview Questions 40 Appendix B Sleep Guidelines 41 Appendix C Sleep Hygiene Handout 42 Appendix D RN Sleep Sick Call Questionnaire 43 Appendix E Sleep Diary 44 11/9/22 Appendix F Educational Presentation Slides WHAT IS SLEEP? • • EDUCATION AND GUIDELINES FOR MANAGING SLEEP DISTURBANCES IN INCARCERATED YOUTH • ELIZABETH JACOBS, RN, BSN, DNP STUDENT UNIVERSITY OF UTAH COLLEGE OF NURSING IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DOCTOR OF NURSING PRACTICE • Sleep Cycles: – NREM and REM alternate throughout the night in cycles of about 90 to 110 minutes – Three distinct states: Wake, NREM sleep, and REM – Distinct features of electroencephalographic (EEG) patterns, eye movements, and muscle tone NREM: relatively low brain activity • Stage 1: sleep–wake transition – 30 seconds to 5 minutes • Stage 2: the initiation of “true” sleep – 5 to 25 minutes • Stage 3: “deep”, slow-wave sleep (SWS), or delta sleep, – 30 to 45 minutes REM sleep: Desynchronized cortical activity and the highest brain metabolic rate – vital cognitive functions – occurs about 70 to 100 minutes after sleep onset, and lasts for about 5 minutes Rest is not sleep Figure 1: Sleep Cycles In Children And Adults © U N IV ER SITY O F U TA H H EA LTH , 2018 1 © U N IV ER SITY O F U TA H H EA LTH , 2018 2 SLEEP IN ADOLESCENTS • • • • • • PROBLEM Hours of sleep: – As age increases, sleep duration declines Circadian factors: – Around puberty onset, adolescents develop an approximately 2-hour physiologically based phase delay Sleep drive: – “Accumulate” their sleep drive more slowly during periods of prolonged wakefulness compared to younger children Sleep needs: – Optimal sleep 8.5 to 9.5 hours per night Sleep also changes as a function of age: – Decline in the average 24-hour sleep duration – Decrease in the proportion of REM sleep – Decrease in arousals – Shift to a later bedtime and sleep onset time – Irregularity of sleep–wake patterns Nature vs Nurture: – Sleep habits can be learned behaviors may be modified by genetic factors and developmental changes © U N IV ER SITY O F U TA H In Utah JJYS, the most prevalent mental health diagnosis was a sleep disorder, with 37% having the diagnosis and 33% of Youth being prescribed a sleep aid • Sleep disturbances can negatively effects cognitive, behavioral, emotional, and physical health • Poor sleep can lead to: o Risk-taking behavior § Associated with other health-risk behaviors including such as substance use, alcohol use, poor nutrition, and decreased physical activity o Neurobehavior consequences: § Negative impact on mood, vigilance, reaction time, attention, memory, behavioral control, and motivation o Poor mental health outcomes: § Increased risk of depression, anxiety, and other mood disorders H EA LTH , 2018 3 © U N IV ER SITY O F U TA H H EA LTH , 2018 © U N IV ER SITY O F U TA H H EA LTH , 2018 4 GOAL CAUSES OF INSUFFICIENT SLEET • • • • • • Difficulty initiating sleep Difficulty maintaining sleep PTSD Medical and Psychological Comorbidities Puberty Environment Figure 2: Treatment Goals. (WASO= Wake After Sleep Onset; SOL= Sleep Onset Latency; TST= Total Sleep Time) Figure 3: Causes Of Insufficient Sleep © U N IV ER SITY 5 O F U TA H H EA LTH , 2018 6 1 11/9/22 45 EFFECTS OF CHRONIC SLEEP LOSS CIRCADIAN RHYTHM SLEEP –WAKE DISORDERS • “Mismatch” between the individual’s intrinsic sleep–wake schedule and environmental • Onset: typically during adolescence • Signs and symptoms: – Sleep onset difficulties – Oversleeping/daytime sleepiness – Evening preference DDX: insomnia, mental health issue, substance use • Figure 4: Effects Of Sleep Loss © U N IV ER SITY O F U TA H H EA LTH , 2018 7 © U N IV ER SITY O F U TA H H EA LTH , 2018 8 NIGHTMARES/PTSD SLEEP ONSET/MAINTENANCE DIFFICULTIES • • • • • • • Subjective significant difficulty initiating and/or maintaining sleep defined as greater than 20 to 30 minutes. Can be short term or long term – Short term: acute and often related to stress or event (incarceration?) – Long term (at least 3x a week for 3 months) Normally excessive worry about sleep and exaggerated concern Risk factors: – Sleep habits, poor sleep hygiene, underlying medical and psychiatric conditions, acute stress, lower socioeconomic status Signs and symptoms: – Muscle tension, mood disturbances, alcohol, marijuana or drug use, poor school performance, daytime sleepiness. DDX: OSA, Psychiatric disorder, poor sleep hygiene © U N IV ER SITY O F U TA H • • • • Nightmares are frightening dreams, occurring during REM sleep resulting in an awakening from sleep Usually involve fear, anxiety, anger, sadness, embarrassment, or disgust and typically involve immanent physical harm to the patient Signs and symptoms – Somatic complaints-stomach aches, headaches, anxiety, daytime behavior problems DDX: – Mood disturbances, fatigue, daytime sleepiness, anxiety, abuse Education: § Coping skills § Reduce stressors § Ensure adequate sleep, as insufficient sleep contributes to increased nightmare frequency. § Relaxation strategies H EA LTH , 2018 9 © U N IV ER SITY O F U TA H H EA LTH , 2018 © U N IV ER SITY O F U TA H H EA LTH , 2018 10 GUIDELINE APPROACH FOR INITIAL SLEEP COMPLAINT • Youth reporting a sleep disturbance. o Step 1: The RN will: • Start the youth on a 2 week sleep diary. o See appendix A • Fill out the RN Sick Call for Sleep disturbances o See appendix B • Notify the Provider and Social Worker • Give the youth the sleep hygiene handout. o See appendix C o Step 2: Acute Care visit with a Provider: 30 minutes • Prior to visit: Review RN sick call note, sleep diary, and MAR. • Visit: Subjective, Objective, Assessment, and Plan. © U N IV ER SITY 11 O F U TA H H EA LTH , 2018 12 2 11/9/22 46 SLEEP DIARY SLEEP HYGIENE HANDOUT © U N IV ER SITY O F U TA H H EA LTH , 2018 13 © U N IV ER SITY O F U TA H H EA LTH , 2018 14 NURSE QUESTIONNAIRE VISIT: SUBJECTIVE Subjective: • CC: Sleep onset, sleep maintenance, PTSD, etc. • HPI: See figure to right • PMH: o Emphasis on medical and mental comorbidities. § See appendix D for Medical Comorbidities and appendix E for Psychological comorbidities. • FH: • SH: o Emphasis on substance use o Nicotine: Increases SOL o ETOH: decreases SOL but impairs continuity o Illicit Drugs: Consider if marijuana was used for sleep outside the facility o Cultural considerations o See Socioeconomic and Cultural Considerations below. • Allergies: • Medications: o MAR review § See appendix F for medications affecting sleep. • ROS: Figure 7: Sleep History Guide (Sateia et al., 2017) © U N IV ER SITY O F U TA H H EA LTH , 2018 15 © U N IV ER SITY U TA H H EA LTH , 2018 16 VISIT: OBJECTIVE • • • VISIT: ASSESSMENT Differential Diagnosis – Differentiation between a sleep disorder and other medical or mental health conditions that may present with similar symptoms – See Appendix G for a list of differentials. – See appendix H for differentiation sleepiness versus fatigue. • FitBit • Additional Considerations • “What is the amount of sleep that this child needs to feel well-rested?” • Cultural considerations – See Socioeconomic and Cultural Considerations below. • Additional Screenings: • BEARS Screening – See appendix I • A physical examination should be conducted on adolescents being evaluated for sleep complaints. Medical Decision Making (MDM) must be used to guide the physical examination based on the patient’s symptoms and reports. The physical examination may be unremarkable in youth with sleep complaints. © U N IV ER SITY 17 O F O F U TA H H EA LTH , 2018 © U N IV ER SITY O F U TA H H EA LTH , 2018 18 3 11/9/22 47 FITBIT (ACTIGRAPHY) • • VISIT: ASSESSMENT Sample documentation: The patient is a 17-year-old male who presents with sleep complaints of difficulty falling asleep. The patient reports sleep disturbances that started seven days ago following the patient arriving at DLYC. The patient reports it takes 2 hours to fall asleep and is concerned about lack of sleep. The sleep diary was completed and showed an estimated bedtime of 11 pm and a wake-up time of around 7:30 am. Due to this, the patient is getting 8.5 hours of sleep. The social worker has worked with the youth on relaxation techniques, sleep hygiene, and CBT. Differentials include circadian rhythm disorders, PTSD, depression, anxiety, situational insomnia, and OSA. There are no red flag symptoms, including injury to self during sleep, gasping/choking upon wakening, reports of stopping breathing while sleeping, weight loss, or SI. The patient denies depression, nightmares, or anxiety. Depression and anxiety will continue to be assessed for. Situational insomnia is likely due to the new environment, stress of Incarceration, and new routine. The patient will likely be in detention for over a month. Due to this, Melatonin 1mg will be started in addition to extensive education on behavior therapies of relaxation, sleep hygiene, routine setting, and coping strategies. RN gave the patient a handout for sleep hygiene. If the patient continues to have sleep onset difficulties, Melatonin can be increased to 3mg, and/or a PMHNP consult will be placed. The patient will have continued follow-up for efficacy, duration of therapy, side effects, and discontinuation considerations. A repeat sleep diary will be completed in 3 months if the youth is still in the facility. The patient agreed with the goals and plan of treatment. The patient is aware of the sick call box and agrees to notify medical of any concerns. Why? – Differential Diagnosis, – Documentation on sleep duration – Education for the youth – Comparing to sleep diary. – Shows approximate sleep wake patterns Use: – Decker Lake Youth Center: • If referring to PMHNP OR per provider » Instructions: gather 3 nights of data – Salt Lake Valley Youth Center • AS NEEDED: – if PMHNP orders or per provider – If used: gather 3 nights of data. • Duration: – Repeat in 3 months. © U N IV ER SITY O F U TA H H EA LTH , 2018 19 © U N IV ER SITY U TA H H EA LTH , 2018 20 VISIT: PLAN o Combination Therapy: Pharmacological and Non-Pharmacological § Medications • See Medication Section § Cognitive and Behavior Therapies • Stimulus control, Relation training, CBT, Sleep restriction, Sleep hygiene o See Appendix K for more Behavior Therapies o Goal Setting o Education § Sleep habits, sleep hygiene, bedtime routine • See Education Section o Referrals § Consider PMHNP referral o Follow Up in 3 months, sooner if needed: § In 3 months: • Repeat 2-week sleep diary • DLYC: o 3 nights of FitBit Data if working with PMHNP or per provider © U N IV ER SITY O F U TA H SOCIOECONOMIC, CULTURAL CONSIDERATIONS, AND BIAS • • • • • Racial and ethnic disparities in the U.S. Juvenile justice system – Link to Utah’s pro-equity policy framework Confirm the preferred language of the patient Diversion, abuse of medications, and “medication seeking – Never assume “med seeking” • Complete a thorough assessment, sleep log, FitBit as needed, and RN Sick Call Sleep Questionnaire • Ensure youth is working with Social Worker and participating in behavior therapies JJYS providers must be aware of existing disparities and potential for subconscious bias Goal: give equitable, appropriate, and standardized care for all youth H EA LTH , 2018 21 © U N IV ER SITY O F U TA H H EA LTH , 2018 O F U TA H H EA LTH , 2018 22 SOCIOECONOMIC, CULTURAL CONSIDERATIONS, AND BIAS • • • MEDICATIONS • Family and cultural considerations: – Cultural influences on sleep behaviors • Variability in sleep amounts and sleep behaviors • Family values regarding health priorities • Nonjudgmental when discussing sleep hygiene – Racial/ethnic differences • Increased sleep onset disturbances in Hispanic and black youth – Environmental variables • Physical environment • Family composition • Lifestyle issues • Cultural issues and family values sleep behaviors and habits – Napping Medications: – Cultural and societal variables, such as acceptance of psychotropics and acceptance of alternative therapies. Lower socioeconomic status: increased sleep onset/ sleep maintenance disturbances © U N IV ER SITY 23 O F O F U TA H • • • H EA LTH , 2018 Medications must be used in conjunction with behavior therapies – Diagnostically driven: • Type and severity of the sleep problem • Duration • Frequency • Previous failed attempts at conventional behavioral therapy Initiation of a medication should be accompanied with an “exit strategy.” Never use Benzodiazepines or Opioids for sleep disturbances. Currently no FDA approved medications for sleep in the pediatric population © U N IV ER SITY 24 4 11/9/22 48 MEDICATIONS • MEDICATIONS The choice of pharmacologic agent should be directed by: • Symptom pattern • Treatment goal • Past treatment responses • Patient preference • Cost • Availability of other treatments • Comorbid conditions • Contraindications • Concurrent medication interaction • Side effects Considerations for prescribing: – Patient variables: age, comorbidities – Provider and practice setting variables: Time youth will be in the facility – Cultural and societal variables – Concerns about efficacy, tolerance, side effects, and rebound insomnia – Concerns about safety and effects on sleep architecture. Sleep and Wake-Promoting Neurotransmitters © U N IV ER SITY O F U TA H H EA LTH , 2018 25 O F U TA H H EA LTH , 2018 © U N IV ER SITY O F U TA H H EA LTH , 2018 26 MEDICATIONS Drug Dosing Use EDUCATION M echanism of Half-life Action Hydroxyzine Starting:25m Sleep onset H1 subtype g to 50mg. receptor Max dose: agonist; first 50 mg. generations M elatonin Starting Circadian 6-24 hours dose: 1mg. Titrate up to 3mg, then 5 rhythm on minutes. disorder or suprachiasmati Returns sleep onset c nucleus; to cross bloodbrain barrier mg if not improving. Max dose: 5 Trazadone Main effects weak hypnotic 30-50 Time to peak plasm concentratio n Rapid absorption and onset of action; 2-4 hours. Sleep onset inhibits binding 5-9 hours dose: 50mg. Refer to PMHNP or sleep maintenan ce of serotonin and blocks histamine receptors Side Effects Drug-drug interactions daytime drowsiness, anticholinergi c effects, and ETOH/CNS depressants paradoxical excitation. 30-60 Vivid dreams, Largely minutes abdominal pain, confusion, unknown, NSAIDS, ETOH, Benzodiazepines dizziness, and headache , may interfere with normal melanin 30-100 Dizziness, production Other SSRI’s due minutes headaches, tiredness, dry mouth, to increased risk of serotonin syndrome, nausea. CYP3A4 metabolizer © U N IV ER SITY O F • • • hours. baseline levels in 4-8 mg Starting before increasing U TA H • H EA LTH , 2018 27 Patient education should be included in every visit for sleep. Sleep Hygiene – Appendix C Napping – Strategic/Planned naps – Less than 30 minutes can improve wakefulness – Over 30 minutes=not recommended. – Appendix F Sleep Habits – Organized and consistent sleep-wake pattern • Consistent bedtime – Regular and consistent bedtime routine involving the same three to four activities. Should be calming and relaxing. • Shower, brush teeth, read • Reduce cognitive and emotional stimulation before bedtime • Limit activities that promote wakefulness in bed 28 APPENDIX A: SLEEP DIARY APPENDIX B: RN SICK CALL SLEEP QUESTIONNAIRE © U N IV ER SITY 29 © U N IV ER SITY O F U TA H H EA LTH , 2018 © U N IV ER SITY O F U TA H H EA LTH , 2018 30 5 11/9/22 49 APPENDIX D: MEDICAL COMORBIDITIES APPENDIX C: SLEEP HYGIENE HANDOUT Pain • • Obesity • Allergies • • Atopic • dermatitis • Asthma • • GERD • Headach • e • © U N IV ER SITY O F U TA H H EA LTH , 2018 31 Decreased sleep duration, reduced SWS, reduced subjective sleep quality and sleep efficiency Asthma symptoms often worsen at night as a result of physiologic changes. Secondary chronic cough. Heartburn, and other respiratory symptoms. Sleep-onset, sleep maintenance and reduced sleep duration. May disrupt sleep architecture, including reduced total sleep time, prolonged sleeponset latency, increased arousals, and reduced SWS and REM sleep. © U N IV ER SITY O F U TA H H EA LTH , 2018 32 APPENDIX D: MEDICAL COMORBIDITIES CONT © U N IV ER SITY O F U TA H APPENDIX E: PSYCHOLOGICAL COMORBIDITIES H EA LTH , 2018 33 © U N IV ER SITY O F U TA H H EA LTH , 2018 O F U TA H H EA LTH , 2018 34 APPENDIX F: MEDICATIONS AFFECTING SLEEP © U N IV ER SITY 35 Acute and chronic pain have physical and psychological effects on sleep. May cause sleep-onset delay, nightwalking, fragmented and restless sleep, frequent arousals, daytime sleepiness, and fatigue. Even adaptive behaviors, such as protection of the injured area by positioning and increased attention to movements during sleep, may further impact on sleep quality. Increased risk of sleep problems, particularly sleep-disordered breathing and daytime sleepiness; Chronic allergy-mediated rhinitis with nasal congestion, postnasal drip, and nocturnal cough, as well as pruritus associated with dermatologic manifestations of atopy are associated with difficulties initiating sleep and particularly with frequent arousals and disrupted sleep. Use of sedating antihistamines to control allergic symptoms during also disrupt regular sleep–wake patterns, and decongestants such as pseudoephedrine have been associated with insomnia. Difficulty falling asleep, sleep disruption, night awakenings, decreased sleep duration, and resulting daytime sleepiness as a result of pruritus. Aggressive treat and prevention measures for the underlying skin condition. O F U TA H APPENDIX G: DIFFERENTIAL DIAGNOSIS H EA LTH , 2018 © U N IV ER SITY 36 6 11/9/22 50 APPENDIX H: DIFFERENTIATING SLEEPINESS VERSUS FATIGUE © U N IV ER SITY O F U TA H APPENDIX I: BEARS SCREENING H EA LTH , 2018 37 © U N IV ER SITY O F U TA H H EA LTH , 2018 © U N IV ER SITY O F U TA H H EA LTH , 2018 38 APPENDIX J: NAPPING APPENDIX K: BEHAVIOR THERAPIES © U N IV ER SITY O F U TA H H EA LTH , 2018 39 40 REFERENCES © U N IV ER SITY O F U TA H H EA LTH , 2018 41 7 51 Appendix G Doctoral Project Post-Implementation Team Interview Questions 52 Appendix H Refined Sleep Hygiene Handout in English and Spanish 53 Appendix I Refined RN Sleep Sick Call Questionnaire 54 Appendix J Refined Sleep Diary 55 Appendix K University of Utah Institutional Review Board Exemption 56 Appendix L Refined Sleep Guidelines