Hurley-Wallace et al.

BMC Psychology (2024) 12:788 BMC Psychology

https://doi.org/10.1186/s40359-024-02281-9

RESEARCH Open Access

An opportunity to sleep well in hospital:

development of a multi-level intervention
to improve inpatient sleep (ASLEEP) using
behaviour change theories
Anna Louise Hurley-Wallace1,2*, Wendy Bertram1,2, Emma Johnson2, Vikki Wylde1,2 and Katie Whale1,2

Abstract
Background Sleep is substantial issue for hospital inpatients and can negatively affect healing and recovery. There is
a good evidence-base for interventions which can improve sleep, however currently they are not being implemented
into NHS practice. To address the evidence-practice gap, we have conducted early-phase development for an
inpatient sleep intervention (ASLEEP); a multi-level intervention to improve inpatient sleep in UK hospital wards.
Methods We used an iterative development process incorporating Patient and Public Involvement and Engagement,
ward staff surveys and stakeholder consultations (orthopaedic and acute medicine), and theoretical mapping using
behaviour change theories. Development took place in four stages: identification of existing patient-level intervention
components to improve sleep in hospital; identification of environmental barriers and facilitators to sleep in hospital;
consultation with health professional stakeholders; and final theoretical mapping using the COM-B model and
Theoretical Domains Framework, also considering who holds ‘change power’ for each change construct.
Results We identified 18 variables contributing to inpatient sleep, which are malleable to change universally across
hospital wards. Central domains for change were identified as the ward environment context and resources; to reduce
noise from equipment (material resources), and social influence; to modulate staff and patient noise awareness and
behaviours (group norms). Change power mapping identified key stakeholders as patients, ward staff, procurement/
estates, and NHS management.
Conclusions Improving sleep in hospital requires a whole-systems approach which targets environmental
factors, staff behaviour, and patient behaviour. We have provided recommendations for a multi-level intervention,
highlighting core areas for change and essential stakeholders who must be involved to progress implementation.
The next stage of development will involve operationalising recommendations and piloting, including evaluating
mechanisms of change. It will be important to continue working with a broad range of stakeholders to bridge the
evidence-practice gap and support sustainable practice adoption.

*Correspondence:
Anna Louise Hurley-Wallace
[email protected]
Full list of author information is available at the end of the article

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
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Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 2 of 11

Keywords Inpatient Sleep, Orthopaedic inpatients, Acute Medicine, Hospital inpatients, Intervention development,
Behaviour Change, Sleep Behaviour

Background integrate evidence-based changes to improve sleep

Everyday approximately 115,000 people in the UK stay within NHS practice, research must identify barriers and
overnight in hospital [1]. Sleep disturbance in hospital facilitators to change, and work with NHS stakeholders
is a substantial problem with approximately 50–70% of to address issues.
inpatients reporting reduced sleep quality and duration For multi-level interventions which require engage-
[2]. The ward environment is a central barrier to good ment from various stakeholders (e.g., policymakers, staff,
sleep with noise, lighting, and nursing care highlighted as patients), behaviour change theories offer valuable insight
affecting sleep quality [3–5]. into how to enact successful, sustainable change within
Poor sleep can delay recovery and extend hospital stays complex systems. This study conducted the first stage of
by 1–8 days, with significant NHS cost implications [6]. work to bring together evidence-based approaches for
Shortening hospital stay is an NHS priority, with sleep improving inpatient sleep, into a new intervention pack-
deprivation highlighted as important [7]. A government age; the ASLEEP intervention. This included exploring
green paper further emphasised that guidance to improve patient views of sleep interventions, health professional
sleep in hospitals requires review and update [8]. How- views of the barriers and facilitators to inpatient sleep,
ever, no research has yet addressed this or implemented and organising evidence using theoretical mapping.
evidence-based changes.
Sleep directly impacts wound healing and immune Methods
function [9, 10]. Reduced sleep increases the risk of post- Ethical approval was given by the University of Bris-
surgical complications, including delirium [11, 12], and tol Faculty of Health Sciences Ethics Committee on
can lower memory function, energy, and strength [13]. 13/07/2022 (reference 10490). Informed consent to par-
Reduced sleep increases pain sensitivity by activating ticipate was obtained from all research participants in the
proinflammatory markers [14–16], where pre-operative study.
sleep disturbances are associated with increased post- This report follows the Good Reporting of A Mixed
operative pain severity [17]. Methods Study guidance [27] (Additional File 1), com-
Undergoing surgery is a common reason for staying prising four phases:
overnight in hospital. Total knee and hip replacements
are the second and third most common elective surgical 1. Understanding patient views of existing intervention
procedures in UK, with approximately 200,000 annually approaches (systematic review, Patient and Public
[18]. Most patients spend 1–3 nights in hospital after Involvement and Engagement [PPIE]).
surgery [19, 20]. Recovery programmes aim to reduce 2. Understanding ward sleep environments and
recovery time and length of stay by controlling pain and practices, including identification of targets for
supporting mobilisation [21]. Nonetheless, poor sleep change (staff survey, concept map, behaviour change
can be a barrier to timely recovery and discharge through theoretical mapping).
delayed healing, increased pain, and increased risk of 3. Stakeholder consultation (follow-up staff survey,
post-surgical complications [9, 11, 17, 22]. consultation with NHS staff ).
There is strong evidence that existing interventions can 4. Theoretical mapping of change factors (iterated
improve inpatient sleep. Patient-level interventions tar- theoretical map, identification of target variables and
geting noise, light, and patient anxiety have shown effec- malleability to change).
tiveness, based on meta-analysis results incorporating
data from 5375 patients [23]. Environment-focused inter- The methods and results for each phase are presented
ventions, such as reducing night-time care interruptions, together to aid understanding.
also show promise [3, 24].
Despite existing evidence, there is an evidence-practice Phase 1: Patient-level intervention approaches
gap in integrating sleep interventions into NHS practice. Objectives: To gain feedback from a PPIE group on the
Hospital contexts are challenging for the development acceptability of existing interventions for improving
of sleep interventions, as the physical and sociocultural inpatient sleep, how to implement them within the NHS,
environment, including existing policies, require con- and any potential barriers.
sideration [25]. Research indicates that ward staff are
supportive of improving sleep, but lack knowledge and
guidance for making changes [4, 26]. To successfully
Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 3 of 11

Methods approaches were physical sleep aids and relaxation

We previously conducted a systematic review and meta- because they could be easily provided and used individu-
analysis of trials of inpatient sleep interventions [23]. ally as desired.
Results were discussed with a PPIE group comprising The group additionally highlighted that worry and anx-
five patient-partners with recent experience of overnight iety about being in an unfamiliar environment as impor-
hospital stays. Three were recruited using an advert cir- tant. They suggested a leaflet could be sent to patients to
culated by People in Health (West of England). Two were help them prepare for their stay including what to expect
recruited through existing PPIE groups. on the ward, and a list of recommended items to enhance
PPIE group members had experience of orthopaedic comfort (e.g., earphones, pillow spray). For unplanned
surgery (total knee replacement n = 2, flat foot recon- stays, a leaflet could be given on admission with infor-
struction n = 1), gall bladder removal (n = 1) and gynaeco- mation and advice for what their family or friends could
logical surgery (n = 1). Length of stay ranged from 1 to 10 bring for them.
nights. Time since surgery at the point of the PPIE meet-
ing ranged from 1 to 8 months. Phase 2: Ward environment-level factors
The group met once for a 2-hour Zoom meeting in Objectives: To understand the sleep environment and
October 2022, facilitated by the research team (EJ, WB, sleep-related practices on NHS hospital wards, and iden-
KW). The aim of the meeting was to review the findings tify target areas for change.
of our previous meta-analysis of sleep interventions, and
explore acceptability and preferences for the sleep inter- Methods
vention approaches. The meta-analysis [23] identified six Orthopaedic ward staff from 19 UK hospitals were
interventions that were effective at improving inpatient invited to take part in a survey. This included tertiary
sleep: referral and general district sites treating urban, rural and
diverse demographic populations. Hospital sites were
•  Relaxation techniques. identified by the research team using existing contacts.
•  Physical sleep aids (ear plugs and eye mask). The survey was distributed online (JISC surveys) and on
•  Music. paper between 22 July 2022 and 18 March 2023.
•  Counselling. The survey was designed specifically for the study and
•  Massage and acupuncture. included four sections, comprising a mixture of open and
•  Environment changes (light, noise, observation, closed questions. These were: [1] ‘About your hospital’
monitoring). (ward environment and structure, shift patterns, pre-
scribing roles) [2], ‘Care after surgery’ (sleep-related care
The group were first asked about their experiences of routines and procedures) [3], ‘The ward environment
overnight stays in hospital and what helped or prevented and sleep’ (environment at night, set routines, night-time
them from sleeping. They were then shown a slide of the changes and current policies supporting sleep, available
six intervention areas and asked the following questions: sleep aids and medications, staff views on the importance
of patient sleep), and [4] ‘Improving inpatient sleep’ (bar-
•  What are the main barriers for a study on improving riers and facilitators, other factors not mentioned). Staff
sleep in hospital? demographic data was also collected.
•  Would anything stop you from taking part? Results were anonymised. Qualitative responses were
•  How could we test if these approaches work at: condensed into a concept map of ward environment-level
barriers and facilitators. Quantitative data summaries
–  Individual-level. (frequency counts) were conducted in Microsoft Excel.
–  Ward-level. Relevant theories from the health behaviour change lit-
–  Hospital-level. erature were then considered for theoretical mapping of
the results. This was done to help identify target areas for
•  How should we measure changes? change.

Results Results
The PPIE group supported improving inpatient sleep and Thirty-seven responses were received from three hos-
had all experienced sleep disruption. They saw benefit pitals. Participants included nurses (n = 20), healthcare
in all approaches, but felt that counselling and massage assistants (n = 8), nurse sisters (n = 4), trainee nurse asso-
may not be suitable for everyone, and possibly difficult ciates (n = 2), clinical nurse managers (n = 2) and a consul-
to access due to needing trained staff and a suitable loca- tant orthopaedic surgeon (n = 1).
tion for the massage treatments. The two most acceptable
Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 4 of 11

Wards had a mixture of open bays (4–5 patients/ up to sleep aids, one offered sleep aids to every patient. Pre-
12 patients) and individual rooms. A regular night shift scribing sleep medication was described as ‘not routine’.
pattern was noted from 7pm to 7.30am. Results indicated good knowledge of the impact of
Post-operative care routines depended on surgery sleep on patients’ recovery and wellbeing. Staff high-
type, patient condition, and time of return from theatre. lighted poor sleep as affecting patients’ pain levels
Night-time observations were guided by patients’ Early (n = 14), participation in care (n = 8), general wellbeing
Warning Score (EWS). Post-op day 1 observations were (n = 8), mental health (n = 7), recovery (n = 7), and mood
4-hourly, post-op day 2 onwards observations were every (n = 5).
4–6 h. Comments indicated that patients in bays are
often woken by other patients being attended to. Identification of barriers and facilitators to inpatient
There was a consensus on sleep times; lights dimmed sleep Survey questions 28 and 29 asked staff to identify
by 11pm, turned back up between 6am-7am, with low barriers and facilitators to good inpatient sleep. Qualita-
levels of noise encouraged at night. Nonetheless, there tive responses were visualised as concept map. (Fig. 1).
were mentions of loud call bells, banging doors, and poor
awareness of noise levels by colleagues. A small number Theoretical mapping using behaviour change theories
of responses indicated use of a call bell ‘night mode’ func- Environment-level variables identified in the concept
tion. Some staff stated their ward is ‘quiet and calm’ with map were mapped to behaviour change theories. Appli-
hot drinks provided in the evening to help patients settle. cation of theory is important for understanding what
Nineteen staff indicated there was a strategy or pol- changes are needed and how change can be achieved
icy in place to improve inpatient sleep. Most responses [28].
(n = 25) indicated sleep aids (eye masks and ear plugs) Theoretical mapping was undertaken using the COM-B
were available on request. One ward had discontinued model [34] and Theoretical Domains Framework (TDF)

Fig. 1 A concept map of ward environment-level barriers and facilitators impacting inpatient sleep
Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 5 of 11

[29]. These theories were chosen as they provide a com- •  What timepoint(s) are best for sleep packs to be
prehensive list of environmental constructs and over- given to participants (pre-op, admission, both)?
arching domains or areas that require change. Variables •  Any other physical or procedural issues identifiable?
affecting inpatient sleep were initially conceptualised as
COM-B physical and social opportunity factors, which Stakeholders were additionally asked about key contacts
were then mapped to TDF domains; environmental con- or other job roles that should be included in consultation.
text and resources, and social influence (Table 1). Initial stakeholder meetings identified that the key vari-
ables affecting sleep were universal across wards, thus
Phase 3: Stakeholder consultation intervention development could be expanded to other
Objectives: To consult staff stakeholders on variables wards and patient groups in addition to orthopaedics to
identified in Phase 3, understand feasibility of ward envi- provide maximum patient benefit. Following this, respi-
ronment changes, and identify barriers to change. ratory and acute medicine staff were invited for consulta-
tion, and to participate in the follow-up survey.
Methods
Two approaches were used to gain stakeholder views: (i) Staff follow-up survey The follow-up survey was dis-
stakeholder meetings with NHS staff, and (ii) follow-up tributed online or on paper between 6 May 2023 and 17
ward staff survey. August 2023. Eight staff from the Phase 2 survey who con-
sented to be contacted were emailed an online survey link.
Stakeholder meetings Consultations were carried out The paper version of the survey was distributed to ortho-
with Consultants (orthopaedics, respiratory), Senior paedic and acute medicine wards at one South West NHS
Ward Nurses (orthopaedics, respiratory, acute medicine), site, using opportunity sampling (the researcher delivered
a Ward Matron, and Ward Administrator. The consulta- paper questionnaires directly to the ward receptions). No
tions were facilitated by one researcher, KW. One meet- contact details were collected. Surveys were anonymous.
ing took place using videoconference (orthopaedic con- The survey presented variables identified in phase 2
sultant), all other meetings took place face-to-face at the (see Table 1), which were split into two categories: envi-
hospital site. Stakeholders were provided with a summary ronment and equipment (e.g. doors, lighting, call bells,
of findings from the first staff survey and the variables bins), and other noise (e.g. talking, clinical care, ward
identified from the theoretical mapping. Discussion ques- radio, patient devices). For each variable, staff were asked
tions were: if they would change this in an ideal world (yes/no), and
the ease of change (easy/ possible/ too difficult), with
•  What variables would you want to change in an ideal open-ended responses on each category (‘What makes
world? this change easy/ difficult?’ and ‘What support is needed
•  What can be feasibly changed within the ward to make this change?’). Two open-ended questions asked
environment (physical structure procedural/ care staff whether they would feel comfortable asking patients
delivery change)? to turn off devices or use headphones, and for any other
barriers.
Blank responses to the ‘ideal change’ and ‘easy to
change’ questions were coded as ‘no’ or ‘too difficult’ for
Table 1 Theoretical mapping of variables affecting sleep
data entry. Analyses were conducted in Microsoft Excel.
COM-B TDF domain Variable
component
Results
Physical Environmental Lighting
opportunity context and Doors
Stakeholder consultation Stakeholders were highly
resources Bins
supportive of work to improve inpatient sleep and rec-
Call bells ognised this as an important issue. Views on the causes
Medical equipment of poor sleep matched the results from Phase 2. Discus-
Care routines sion of care routines and night-time observations reiter-
Shift patterns ated use of the EWS. It was noted that if patients were
Critical medical and hospital- stable it could be possible to reduce overnight observa-
wide incidents tions between the hours of 12am-6am, however changes
Social opportunity Social influence Staff talking (social awareness) to the recommendations would require review to ensure
Staff talking (patient care) clinical safety. To address staff talking, noise monitors that
Staff/ ward radio
Patients talking
Patients’ TV or devices
Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 6 of 11

provide visual signals of noise levels e.g., SoundEar II [30] hearing, thus increasing the volume of talking during
were suggested to improve awareness. interactions. Social staff talking and patient devices were
most frequently marked as easy to change, with com-
In addition to universal ward variables, care aspects ments indicating that simple reminders and providing
affecting specific patients groups were discussed e.g., headphones could resolve the issues.
oxygen masks for respiratory patients, foot/calf pumps Support needed to implement changes included all
in orthopaedics. To address this, it was suggested that staff being ‘proactive’ and ‘cooperative’, with recommen-
‘bolt-on’ modules could be used to augment the core dation for a change management strategy. Three respon-
recommendations. dents suggested staff education would be beneficial.
Twenty-nine staff reported they would be comfortable
Ward staff follow-up survey Thirty-eight staff com- approaching patients to turn off devices or use head-
pleted the survey (two online, 36 paper). Respondents phones (‘yes’=25, ‘comfortable to approach’=4). Three
were from acute medicine wards (acute care of the elderly; participants indicated they would not be comfortable
n = 17, sub-acute care/respiratory; n = 18), and orthopae- to approach patients, by responding ‘no’ or ‘not always’.
dic wards (n = 3). Alternative approaches to address patient device use
The ‘ideal change’ results are presented in Fig. 2. Staff were offered, for example asking patients to ‘turn [the
agreed that equipment and the structural environment volume] down, but not off.’ Respondents noted that using
(e.g., doors and lighting) should ideally be changed, and headphones presents difficulties for hearing impaired
staff social talking should be reduced. Comments indi- patients.
cated that some colleagues are ‘unaware’ of their volume. Additional barriers to sleep were highlighted as room
General equipment was viewed as easy to change, temperature (n = 2), patient transfers (n = 3), send-
with several suggestions of soft close bin lids. Equip- ing patients for tests (CT, X-ray etc.) (n = 4), confused
ment reported as ‘ideally would change but too difficult’ patients being noisy (n = 5), uncomfortable mattresses
included clinical monitoring equipment and call bells (n = 1), and late administration of medications (n = 1).
(Fig. 3). Responses indicated that some staff were con-
cerned about patient safety if the volume was lowered, Phase 4: Mapping change factors to improve inpatient
and alerts went ‘unnoticed.’ sleep
Noise from clinical care conversations was reported Objectives: To integrate phase 3 results with the theoreti-
as too difficult to change. Responses emphasised that cal mapping, identify variables malleable to change, and
patients could be confused, uncooperative, and hard of identify ‘change power’ for each construct.

Fig. 2 Staff responses to ‘In an ideal world, would you change…?’ for all sleep-related ward environment variables
Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 7 of 11

Fig. 3 Staff responses to ‘How easy is … to change?’ for all sleep-related ward environment variables

Methods for change relating to ‘capability’ and ‘motivation’, which

Phase 3 results were added to the theoretical mapping more broadly cover the psychological and motivational
table. A column was added to reflect the malleability of processes underpinning why procedures and protocols
each variable and identify which variables could be tar- that impact night-time noise levels are not aways adhered
geted for change within the NHS. A ‘change power’ col- to.
umn was added to identify the stakeholders needed to Based on these findings, the ASLEEP intervention rec-
implement changes. For example, new ward equipment ommendations are:
requires support from NHS management and estates/
procurement. 1. Environment and equipment:
•  L
 ighting dimmed at night.
Results
•  Ward equipment to be modified or replaced with
Final theoretical mapping is presented in Table 2.
low noise options (e.g., soft close bins).
Twenty-one variables impacting inpatient sleep were
•  Medical equipment used with night mode if
identified, mapping to five COM-B areas and 10 TDF
available (e.g., call bells).
constructs, with 18 variables malleable or partially mal-
leable for change.
2. Staff awareness and behaviour:
Proposed ASLEEP intervention
•  S
 taff noise reduction (non-clinical conversations).
We identified 18 variables impacting inpatient sleep
•  No electronic device noise between 11pm-6am.
which can be targeted. Considering all stakeholder input
(e.g., ward radio).
throughout the development process, we interpret that
the core domains for change relate to the ‘opportunity’
to sleep well in the hospital environment. Specifically, 3. Patient awareness and behaviour:
ward environment context and resources; to reduce noise
•  P
 rovide patient sleep packs, including sleep aids,
from equipment (material resources), and social influ-
relaxation resources and information leaflets.
ence; to modulate staff and patient noise awareness and
•  Patient noise reduction and a ‘quiet time’ policy
behaviours (group norms), should be a priority within
between 11pm-6am.
the intervention. Table 2 additionally proposes domains
Table 2 Final theoretical mapping of variables impacting inpatient sleep. New variables are indicated with *
COM-B component TDF domain TDF construct Change power Variable Mallea-
Hurley-Wallace et al. BMC Psychology

ble for
change
Physical opportunity Environmental context and Material resources - Management & Lighting Yes
resources leadership Doors Yes
- Estates/ procurement Bins Yes
Call bells Yes
(2024) 12:788

Medical equipment Partially

Organisational culture and - Management & Care routines Partially
climate leadership Shift patterns No
Patient tests and transfers* No
Salient events /critical - Management & Critical medical and hospital-wide incidents No
incidents leadership
- Ward staff
Social opportunity Social influence Group norms - Ward staff Staff talking (social awareness) Yes
- Patients Staff talking (patient care) Yes
Staff/ward radio Yes
Patients talking Yes
Patients’ TV or devices Yes
Psychological capability Knowledge Procedural knowledge - Ward staff Staff knowledge of night-time protocols* Yes
(knowing what to do) - Patients Patients’ knowledge of night-time protocols* Yes
Knowledge of task - Patients Patients’ knowledge of ward environment (what to expect) * Yes
environment
Automatic motivation Reinforcement Consequents - Patients Patient awareness of consequences (social or physical) of not following Yes
night-time protocols*
Page 8 of 11
Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 9 of 11

Consultations identified that ‘bolt-on’ recommendations known to increase pain, reduce strength, and adversely
for specific patient groups could be used to augment the affect respiratory function [33].
universal recommendations. This could include sleep aids This development work took a combined theory- and
suitable for use with specialist equipment e.g., neck pil- systems-based research perspective [28], which has been
lows for patients using oxygen masks. useful for breaking down a complex issue into areas of
change that are targetable within an intervention. This
Discussion breakdown has been equally useful for presenting target
This early-phase intervention development work has areas for change to stakeholders throughout consulta-
benefitted from a combined theory- and systems-based tions. The TDF [29] has been important in understand-
research perspective [28], which helped break down the ing and explaining environmental factors to stakeholders,
complex issue of inpatient sleep into areas of change and and we have mapped the TDF to the COM-B [29, 34] to
specific variables that are targetable within an NHS con- present a holistic view of how inpatient sleep can be tack-
text. This study supports that a whole-systems approach led through organisational, group, and individual behav-
is needed to implement evidence-based approaches to iour change.
improving inpatient sleep [31]. The next step in ASLEEP development is operation-
Insights from NHS patient and staff stakeholders iden- alisation into a useable toolkit, and pilot testing in
tified key target areas for change at patient, ward, and NHS orthopaedic and acute hospital ward settings to
hospital-level, which must be addressed synchronously. ensure the intervention is acceptable and sustainable.
We have identified that reducing noise levels is pivotal To enhance potential for real-world implementation,
to giving patients the opportunity sleep well. To achieve further stakeholder work using knowledge mobilisation
this, several material resource variables require change, approaches is recommended [35]. This involves seek-
including equipment and ward structure (e.g. doors), as ing consultation from broader stakeholders that hold
well as staff and patient group norms that contribute to power to enact change. At a hospital-level, this study has
noise levels, such as talking and device use. This reflects identified domestic staff, estates, procurement and NHS
findings from previous studies, which all highlight noise management as important. Additionally, this broader
as a central issue [3, 4]. stakeholder group should include policymakers and com-
A major challenge this work has identified is bridging missioners. Whilst there is little practical guidance on
the gap between research evidence on sleep in hospitals how to onboard high-level stakeholders [36], they can
and real-world implementation [32]. Medical Research provide valuable insight on how best to operationalise
Council (MRC) guidance highlights the importance of intervention recommendations, and help develop a sus-
working with a range of stakeholders throughout inter- tainable practice adoption plan.
vention development, including those whose personal or At intervention piloting stage, a process evaluation will
professional interests are affected, to enhance potential be needed to understand mechanisms of change or ‘how’
for real-world implementation [28]. In addition to con- the intervention works, as well as any other contextual or
ducting consultation with patient and staff stakeholders, moderating factors that have not yet been identified [28,
this study sought to bridge the evidence-practice gap by 37]. Some variables identified within the current study
considering the wider hospital context and identifying represent moderators, such as hospital-wide bed short-
other stakeholders who hold ‘change power’. By adding age. These factors are marked as not malleable to change,
change power to the theoretical map, we identified that however, should be considered as moderators when con-
the people who hold responsibility for factors impacting ducting a process evaluation.
sleep in hospitals differs between constructs, with addi- In summary, the current work has identified an exten-
tional stakeholders identified as domestic staff, estates sive list of target variables that are malleable to change in
and procurement, and NHS management. Further work an NHS context, through sequential integration of stake-
to develop ASLEEP will actively seek to involve these holder input and iterative organisation of findings using
broader stakeholders in consultations. behaviour change theories. These targets for change pro-
Stakeholder consultation undertaken in this study also vide a foundation to operationalise and refine ASLEEP
highlighted that ASLEEP could benefit patient groups as a toolkit that can be flexibly used to improve inpatient
beyond orthopaedics, as the domains and constructs sleep in UK hospital wards.
impacting inpatient sleep are universal across wards.
Good sleep is essential to wound healing, reduces the Strengths and limitations
risk of post-surgical complications [9, 12], and can reduce This work used behaviour change theories to inform
pain [14]. Whilst pertinent to orthopaedic surgical recov- early-stage intervention development, and is strength-
ery [21], patients in acute wards can equally benefit from ened by the range of stakeholders involved. Findings
improved sleep. Poor sleep in acute hospital settings is help bridge the gap between sleep research and hospital
Hurley-Wallace et al. BMC Psychology (2024) 12:788 Page 10 of 11

and distributed the ward staff survey. AHW produced the follow-up staff
practice by highlighting the variety of people and pro- survey and analysed all data regarding factors impacting inpatient sleep, from
cesses that are necessary to ignite change at multiple both surveys. AHW produced theoretical maps and wrote the first draft of the
system levels, with the mutual goal of improving inpa- manuscript. KW and VW provided supervision and oversight of the research
and analyses. All authors read and approved the final manuscript.
tient sleep. A further strength is the flexible approach to
development. As a result of initial stakeholder consulta- Funding
tion, this research was quickly adapted during Phase 4 to This study was funded by the National Institute for Health and Care Research
Bristol Biomedical Research Centre. The views expressed are those of the
include input from acute care clinicians. Rapid, adaptive authors and not necessarily those of the NIHR or the Department of Health
approaches are supported by the intervention develop- and Social Care.
ment literature [38], with emphasis on centrality of stake-
Data availability
holder input throughout development. A limitation of Data are available on request. Participants were asked on the consent form if
rapidly adapting is that clinician role details were not col- they were willing for their information to be shared anonymously to support
lected from acute care staff. Nonetheless, this broadened other research in the future. Anonymised data will be stored on the University
of Bristol Research Data Storage Facility (https://data.bris.ac.uk) and will be
the potential reach of the intervention in practice. shared via the University of Bristol Research Data Repository.

Conclusion Declarations
We have provided recommendations for ASLEEP, a
multi-level intervention to tackle the complex issue of Ethics approval and consent to participate
Ethical approval was given by the University of Bristol Faculty of Health
poor sleep experienced by hospital inpatients. These Sciences Ethics Committee on 13/07/2022 (reference 10490). Informed
intervention recommendations could benefit patients consent to participate was obtained from all research participants in the study.
across hospital wards, including orthopaedic and acute
Consent for publication
care. Improving sleep in hospital requires a whole-sys- Not applicable.
tems approach which targets environmental factors, staff
behaviour, and patient behaviour. This work has provided Competing interests
The authors declare no competing interests.
an applied example of how behaviour change theories
can be used in early-stage intervention development to Author details
1
breakdown complex healthcare issues. Theoretical map- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and
Weston NHS Foundation Trust and University of Bristol, Bristol, UK
ping has helped identify core areas for change and key 2
Musculoskeletal Research Unit, Bristol Medical School, University of
stakeholders who should be engaged to progress imple- Bristol, Bristol, UK
mentation, including patients, hospital staff, and NHS
Received: 13 June 2024 / Accepted: 10 December 2024
management. The next stage of development will involve
operationalising recommendations and piloting, includ-
ing evaluating mechanisms of change. It will be impor-
tant to continue working with stakeholders, and broader
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