Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation

Stephanie Armstrong; Julie Pattinson; Aloysius Niroshan Siriwardena; Simon D Kyle; Peter Bower; Ly-Mee Yu; Yaling Yang; Emma Ogburn; Nargis Begum; Leonie Maurer; Barbara Robinson; Caroline Gardner; Victoria Lee; Dimitri Gavriloff; Colin A Espie; Paul Aveyard

doi:10.3399/BJGP.2023.0162

Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation

Br J Gen Pract. 2023 Dec 28;74(738):e34-e40. doi: 10.3399/BJGP.2023.0162. Print 2024 Jan.

Authors

Stephanie Armstrong¹, Julie Pattinson¹, Aloysius Niroshan Siriwardena¹, Simon D Kyle², Peter Bower³, Ly-Mee Yu⁴, Yaling Yang⁴, Emma Ogburn⁴, Nargis Begum⁴, Leonie Maurer⁵, Barbara Robinson⁴, Caroline Gardner⁶, Victoria Lee⁶, Dimitri Gavriloff², Colin A Espie², Paul Aveyard⁴

Affiliations

¹ Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.
² Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
³ National Institute for Health and Care Research School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK.
⁴ Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
⁵ Mementor DE GmbH, Leipzig, Germany.
⁶ Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK.

Abstract

Background: Sleep restriction therapy (SRT) is a behavioural therapy for insomnia.

Aim: To conduct a process evaluation of a randomised controlled trial comparing SRT delivered by primary care nurses plus a sleep hygiene booklet with the sleep hygiene booklet only for adults with insomnia disorder.

Design and setting: A mixed-methods process evaluation in a general practice setting.

Method: Semi-structured interviews were conducted in a purposive sample of patients receiving SRT, the practice nurses who delivered the therapy, and also GPs or practice managers at the participating practices. Qualitative data were explored using framework analysis, and integrated with nurse comments and quantitative data, including baseline Insomnia Severity Index score and serial sleep efficiency outcomes to investigate the relationships between these.

Results: In total, 16 patients, 13 nurses, six practice managers, and one GP were interviewed. Patients had no previous experience of behavioural therapy, needed flexible appointment times, and preferred face-to-face consultations; nurses felt prepared to deliver SRT, accommodating patient concerns, tailoring therapy, and negotiating sleep timings despite treatment complexity and delays between training and intervention delivery. How the intervention produced change was explored, including patient and nurse interactions and patient responses to SRT. Difficulties maintaining SRT, negative attitudes towards treatment, and low self-efficacy were highlighted. Contextual factors, including freeing GP time, time constraints, and conflicting priorities for nurses, with suggestions for alternative delivery options, were raised. Participants who found SRT a positive process showed improvements in sleep efficiency, whereas those who struggled did not.

Conclusion: SRT was successfully delivered by practice nurses and was generally well received by patients, despite some difficulties delivering and applying the intervention in practice.

Keywords: cognitive behavior therapy; general practice; insomnia disorder; nursing primary care; programme evaluation.

Publication types

Randomized Controlled Trial

MeSH terms

Adult
Family Practice
Humans
Primary Health Care
Sleep
Sleep Hygiene / physiology
Sleep Initiation and Maintenance Disorders* / therapy
Treatment Outcome