Kath Kearns and her SCPHN colleagues used the MacQueen bursary to help young people and families improve and better value their sleep.
If you are a health practitioner who identifies a health need in your area of practice and you have the desire to make a meaningful improvement to the care you or your team provide, the MacQueen bursary could make it happen.
This was the case for one school nurse (one of the authors, Kath Kearns) who was passionate about sleep and wanted to better equip the wider school nurse team to meet the growing problem of sleep difficulty.
During the autumn term of 2020, following the first Covid-19 lockdown, school nurses from the 0 to 19 team within Derbyshire Community Health Services NHS Foundation Trust resumed targeted face-to-face appointments. As a service it was overwhelmed by the number of young people and parents of primary-age children requesting support for sleep difficulties, which were having an impact on the whole family’s wellbeing. In addition, it became evident from the holistic assessments completed within these contacts that those who were regularly having both insufficient and poor-quality sleep were also experiencing difficulties with their emotional wellbeing. This is a common picture that is evidenced in other parts of the world (Top and Cam, 2021).
It appeared that the loss of routine in lockdown, when face-to-face lessons were replaced with recorded lessons and planned work had to be completed ad hoc, resulted in young people’s body clocks shifting significantly, with many spending most of the night awake and sleeping or having naps during the day.
Covid-19 had highlighted the vital importance of school nurses’ public health role – especially, it seemed, in supporting healthy sleep, which is now a significant and growing public health issue for our children and young people and their families.
The Implications of poor sleep
Allan Rechstaffen, a pioneer in the field of sleep research, once said: ‘If sleep doesn’t serve some vital function, then it is the biggest mistake evolution ever made.’
Four things are vital for life; oxygen, water, nutrition and sleep (Mental Health Foundation, 2020). We should value sleep because it is essential for the body’s growth, development and repair, metabolism, ability to fight infection, learning and memory, and the ability to regulate emotions. Policy-makers are now acknowledging the importance of sleep. The recent green paper Advancing our health: prevention in the 2020s recognised that a lack of attention has been given to sleep difficulties and their subsequent detrimental effects on health (Dorries, 2020). A review of current evidence has been requested.
NHS Digital (2021) reports that over a quarter of six- to 10-year-olds had had difficulties with their sleep on three or more nights out of the previous seven. These difficulties increase as children get older, with over a third (38.4%) of 11- to 16-year-olds and over half (57.1%) of 17- to 23-year-olds reporting sleep problems.
Across these three age groups, the sleep problems were significantly higher in those who had a probable mental health disorder (59.5%, 74.2% and 86.7% respectively). In addition, a large study (Brooks et al, 2020) involving 3398 young people in England found that over a quarter (27%) were not getting enough sleep to feel awake and concentrate on their schoolwork.
Older adolescents were significantly less likely to get sufficient quality sleep, with 42% of 15-year-olds reporting not having had enough sleep to be able to concentrate (Brooks et al, 2020). It could therefore be argued that the implication of poor sleep for young people is huge, with profound impacts on their academic outcomes and future employment possibilities, as well as their physical and mental health across their life span.
How did we respond to the challenge?
Initially, a sleep special interest group of Derbyshire school nurses was established, with members sharing a core belief that health promotion and early intervention in the area of sleep would make a significant impact on the whole family’s health and wellbeing. This created the driving force to look at opportunities that would enable the service to be better equipped to meet this growing public health need. One inspired school nurse, Kath Kearns, made a successful application to the individual MacQueen bursary. The bursary funded six places on the Sleep Charity’s sleep practitioner behavioural approach course in May 2021, resulting in significant improvements to the service we are now able to provide.
The qualified sleep practitioners are now able to educate the whole family on achieving optimal sleep, thereby bringing about changes to their quality of life and health going forward. However, we recognise that parents don’t always access support due to fear of being judged: they are concerned that any difficulties may be perceived as being due to poor parenting. We are mindful that parents’ own mental and physical health concerns or socioeconomic worries may also result in them failing to access help, which can lead to poor sleep habits becoming embedded. Overcoming these barriers by actively enquiring about the family or young person’s sleep at routine contacts, thus normalising these issues, reassures them that simple changes can be made to improve their overall health, both now and for the future.
Sleep education
The special interest group has grown and as a team we have developed in-house sleep training that is specific to our role as school nurses. This has been delivered to all school nurses in Derbyshire. The training initially focuses on sleep education, including the circadian rhythm and sleep cycles, and the causes of sleep difficulties, including understanding the impact of sensory difficulties. Second, it looks at the practical issues of completing sleep assessments: the use of sleep diaries for the child or young person, suggesting appropriate strategies to implement, and how to measure the outcomes of sleep support. Finally, our training supports school nurses to educate parents and young people about the stages of sleep, sleep cycles and the development of a sleep plan. Working in partnership with parents and young people towards developing a sleep programme that they are willing to consistently put into practice enables them to realise the holistic health value of behavioural change.
The sleep practitioners are now able to educate the whole family on achieving optimal sleep, thereby bringing about changes to their quality of life
In conjunction with the training, two pathways were developed: primary-aged child sleep process and teen sleep process. These pathways provide a clear process for all nurses to follow when a referral for sleep support is accepted, ensuring an equitable service is delivered across the county. It was acknowledged that these contacts with young people and parents, which include the recording of assessments, writing sleep programmes and recording outcomes, would place a greater demand on practitioners’ time. This prompted changes to our electronic recording system, making documentation less onerous and allowing data on outcome measures to be easily accessed, evidencing the value of our interventions for commissioners.
As the need for sleep support grew, the service found that there were often cases where we were supporting the whole family, including parents and pre-school children. We are therefore now strengthening our partnership with our health visitor sleep practitioner colleagues to develop the training and pathways across the 0 to 19 service, strengthening the sleep support that can be given across the life span.
The Mental Health Foundation (2020) acknowledges that sleep education for young people and adults is essential. Findings from a survey completed by Year 7 pupils across Derbyshire in 2021, which highlighted sleep as a health need for this cohort of children, enabled us to evidence this need across Derbyshire. As a result, we are delivering health promotion sessions to a cohort of Year 6 pupils on a rolling programme over the next three years. These sessions have given us the opportunity to raise awareness at an early age around the importance of sleep, and the effect poor sleep has on children’s functioning in class, their relationships in the playground and at home, and the potential long-term impacts on their physical health. These interactive sessions enable the Year 6 pupils to examine their current sleep habits and explore changes they can make to their bedroom environment, as well as their daytime and night-time routines.
A further sleep session aimed at young people in secondary schools has also been developed. This uses a variety of approaches to explore the importance of sleep, circadian rhythm and the changes that happen during puberty that can impact on sleep. The young people get the opportunity to explore what can disrupt their sleep, and reflect on their own sleep with the use of the Sleep Charity’s ‘sleep survey’ (Sleep Charity, 2020a). Finally, they look at simple changes they can make to their daytime and night-time routine and bedroom environment, and set themselves their own ‘sleep challenge’ to put into action (Sleep Charity, 2020b).
The Mental Health Foundation (2020) identifies the need for research on the effectiveness of sleep education in schools and suggests working jointly with young people to come up with a ‘practical sleep toolkit’. Therefore, by using local data from previous cohorts, the service can be assured that we are developing programmes that are bespoke to current health needs.
Challenges ahead
There are significant challenges in meeting the needs of children and young people with neurodivergence where sleep difficulties are more complex, as they will require a closer and longer programme of support. As a service, we are committed to better equipping ourselves to meet these demands by working in partnership with a multi-agency team that includes the Sleep Charity and allied health professionals.
Recent global economic challenges leading to a cost of living crisis leaves families facing the challenge of sleep poverty
Recent global economic challenges leading to a cost of living crisis for the nation not only results in families having to decide whether to prioritise eating or heating, but also leaves them facing the challenge of sleep poverty. Eighty-nine per cent of adults say that their cost of living has increased, with more than a third cutting back spending on food and other essentials (Office for National Statistics, 2022). It is widely accepted that adults worrying about the family’s finances experience poor sleep and, as a consequence, the goal of ‘good sleep’ will be increasingly out of reach for some families (Mental Health Foundation, 2020).
In addition, The Sleep Charity (2021) identifies hunger as a possible reason for sleep difficulties in children – something that could become a reality for an increasing number of families. Additional challenges are brought about by overcrowding as families aim to reduce the areas of heating in the home: teenagers share bedrooms with much younger siblings, and parents share beds with children or use blow-up mattresses rather than beds. For families on low incomes, there are increasing concerns around deteriorating housing conditions and not being able to afford the basics to support their children’s sleep, such as curtains, blinds, mattresses and adequate bedclothes, or being unable to include a regular bath time in bedtime routines. As school nurses, we will need to use our knowledge of organisations in our local communities that can help support families to provide the basic resources they need to address these wider issues that impact on sleep.
The funding received from the MacQueen bursary has enabled an evidence-based response to this significant public health need by increasing the number of trained sleep practitioners in the school nurse service. Providing this public health response to the sleep needs identified in our communities has been an enriching opportunity for us all as practitioners, but in particular for the lead, Kath, who has been able to realise her vision to improve sleep education across the workforce. We envisage that through our health promotion work we can continue to normalise sleep conversations and further increase the value that families place on sleep. This will enable them to make positive changes. Without the financial support, we would not have been able to facilitate change with the momentum that we have, and we are excited about our future work in this area.
Emma Heath, Laura Macauley and Amanda Trute are specialist community public health nurses (SCPHNs); Kath Kearns and Anna Mee are practice educators and SCPHNs, all at 0 to 19 Children’s Community Services, Derbyshire Community Health Services NHS Foundation Trust.
References
Brooks F, Klemera E, Chester K et al. (2020) World Health Organisation collaborative cross national study: findings from the 2018 HBSC study for England. Health Behaviour in School-aged Children England. See: https://hbscengland.org/wp-content/uploads/2020/01/HBSC-England-National-Report-2020.pdf (accessed 14 November 2022).
Dorries N. (2020) Evidence review on sleep and health. Department of Health and Social Security. See: https://ukhsa.blog.gov.uk/wp-content/uploads/sites/33/2020/08/Sleep-and-Health-review-commission.pdf (accessed 14 November 2022).
Mental Health Foundation. (2020) Taking sleep seriously. See: mentalhealth.org.uk/explore-mental-health/publications/taking-sleep-seriously (accessed 14 November 2022).
NHS Digital. (2021) Mental health of children and young people in England 2021 – wave 2 follow up to the 2017 survey. See: digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2021-follow-up-to-the-2017-survey (accessed 14 November 2022).
ONS. (2022) What actions are people taking because of the cost of living?. See: ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/expenditure/articles/whatactionsarepeopletakingbecauseoftherisingcostofliving/2022-08-05 (accessed 14 November 2022).
Sleep Charity. (2021) Diet and sleep. See: https://thesleepcharity.org.uk/wp-content/uploads/TSC-Advice-Sheets_Diet-Sleep_Col.pdf (accessed 16 November 2022).
Sleep Charity. (2020a) Sleep champion workshop. See: thesleepcharity.org.uk/our-courses/sleep-champion-workshop/ (accessed 14 November 2022).
Sleep Charity. (2020b) Sleep practitioner course. See: thesleepcharity.org.uk/our-courses/sleep-practitioner-course/ (accessed 14 November 2022).
Top FU, Cam HH. (2022) Sleep disturbances in school-aged children 6-12 years during the COVID-19 pandemic in Turkey. Journal of Pediatric Nursing 63: 125-30.
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