The HUSH Project: Using codesign to reduce sleep disruptions for patients in hospital

Abstract Background Poor quality sleep in hospitals may be problematic for patients, negatively impacting their recovery and wellbeing. This project aimed to investigate the effectiveness of codesign in addressing key issues affecting sleep disruption in the healthcare setting. Methods Codesign with patients, staff and consumer representatives was conducted in an acute metropolitan tertiary public hospital in Sydney, Australia. Through a four‐stage process, a multimodal intervention to address and reduce the impact of sleep disruptions among hospital inpatients was created. Pre‐ and post‐intervention evaluation was used to determine changes in patient‐reported sleep disruption. Results ‘The HUSH Project’ (Help Us Support Healing) intervention resulted from the codesign process, which included the provision of HUSH Sleep Packs (with earplugs, eye masks and herbal tea), patient information resources, and ward‐based Sleep Champions. Survey data from 210 patients revealed a statistically significant decrease in patient‐reported noise disturbances for patients in shared rooms following the 4‐week intervention period of the HUSH program. Conclusion The HUSH Project demonstrated that a novel multimodal intervention may be valuable in reducing sleep disruption in hospitals. These findings also indicate the benefits of using codesign methodology to support improvement projects that seek to enhance patient experiences of care. Patient or Public Contribution This project utilised codesign methodology, which involved significant contributions from patients and consumer representatives, from research conceptualisation into intervention design, implementation and project evaluation.


| INTRODUCTION
Healthcare organizations strive to facilitate healing and recovery through care and treatment, yet various environmental factors in hospitals may have negative impacts on patient recovery and wellbeing. 1Patients frequently report significant challenges sleeping in the hospital setting, [2][3][4] which is often attributed to extrinsic factors, such as clinical interactions, ambient noise and artificial lighting. 5,68][9] One of the primary causes of sleep disturbance for patients is hospital noise. 41][12] Evidence from a systematic review of interventions to reduce sleep disturbances in hospitals suggests that multifaceted sleep interventions appear to be more effective than single interventions. 13However, a meta-analysis of the available literature revealed that no specific intervention demonstrated the most significant impact on noise reduction. 13The efficacy of earplugs remains inconclusive, 12 with research findings indicating that earplugs may be more effective in reducing background noise rather than peak noise levels. 13Overall, there is a lack of appropriately designed studies to evaluate the effectiveness of noise-reducing interventions in hospitals 13 ; therefore, more rigorous research is needed about improving sleep health for patients.
A systematic review and meta-analyses investigating the effectiveness of noise reduction interventions in hospital settings indicate that there is an opportunity to enhance the design of interventions to improve sleep in hospitals. 13For instance, while the majority of patients (86%) used earplugs and/or eye masks when they were provided during their hospital stay, 12 other components of multifaceted sleep interventions have demonstrated low utilisation by patients, such as 'Do not disturb' signs. 13The findings from a systematic review identified that the majority of sleep improvement projects were not designed with significant involvement from patients; 13 thus, additional efforts may be required to design interventions that better align with patient needs and preferences.
To do this, healthcare organizations may use existing participatory design methods, such as codesign.
Codesign involves actively engaging patients, healthcare providers and other stakeholders in the design and implementation of quality improvement initiatives. 14By including the perspectives and input of all stakeholders in the process, codesign is associated with a range of benefits, including enhanced user engagement and empowerment, improved communication and collaboration among healthcare providers, increased value creation and development of more effective and sustainable quality improvement initiatives. 15,16e aim of this project was to explore the effectiveness of codesign in developing an intervention that could reduce sleep disruptions within the hospital setting.

| METHODS
Stakeholders, including patients, consumer representatives and healthcare staff, participated in the project from its conceptualisation through to involvement in developing and implementing strategies aimed at minimising sleep disruptions.This study involved a two-step approach: codesigning the sleep intervention and then evaluating it.

| Part 1: Codesign of a sleep intervention
Codesign was used to design and implement an improvement initiative that aimed to reduce sleep disruptions in the hospital setting.To guide the codesign process, the 'Double Diamond' framework was utilized, which employs divergent and convergent thinking in a multiphased process (see Figure 1). 17The Double Diamond was developed by the UK Design Council in 2005 and has been used extensively in previous research on codesign. 18The four phases of the Double Diamond design framework include exploring problems and gathering insights ('Discover'), refining problems ('Define'), creating and exploring solutions ('Develop') and testing and evaluating the solution ('Deliver').

| Developing the solution
Following this, the Develop phase focussed on generating ideas for potential solutions through a collaborative effort involving multiple stakeholders.Staff, patients and consumer representatives were all involved in this process to maximize the level of engagement and feedback garnered.To support solution ideation, the codesign process was designed to be flexible and iterative, with interviews conducted with patients and staff members on the wards.For example, staff members proposed the use of headphones for televisions at night, which was later supported by the consumer representative group and trialled with patients.The final phase (Deliver) involved implementing "the HUSH Project" across the healthcare network in all inpatient wards.

| Staff engagement
Recommendations of the Design Council highlight the importance of strong leadership in fostering a culture of innovation. 18cordingly, the CEO provided executive sponsorship for the project across the healthcare network.In addition, the presence of Sleep Champions in each ward aided in the implementation.The communications and engagement plan for the project was codesigned by staff members; for example, providing herbal tea and HUSH branded pens for ward-based clinicians.The project's successful implementation was due to the early collaboration and codesign with hospital staff, particularly nurses, and their involvement ensured that the implementation aligned with the hospital's culture and clinical processes.

| Design
To evaluate the effectiveness of the sleep intervention, a pre-and post-intervention design was used in this study.

| Sample
The inclusion criteria were adult patients (>18 years old) admitted for over 48 h to the inpatient wards at an acute tertiary hospital in Sydney, Australia.Patients with acute psychosis and/or cognitive impairment who may require additional support to safely use the interventions (i.e., earplugs and eye masks) were excluded, as well as patients admitted to short-stay surgical wards (with length of stay less than 48 h).

| Setting
The study was conducted at a tertiary hospital in Australia, with data collected in seven inpatient wards.

| Analysis
Pre-and post-intervention results were analysed using the independent samples t test, with data analysed using SPSS (version 12).Following this, further analysis was conducted to compare the results for patients in shared and single rooms.For patients in shared rooms, there was a significant reduction in ratings of noise disturbances following HUSH implementation (M = 2.94, SD = 1.29) compared to those without HUSH (M = 3.4,SD = 1.27), t(136) = 2.07, p = .04.These results suggest that the HUSH intervention had a positive effect on reducing noise disruptions for patients in shared rooms.disruptions, yet it is essential to design sleep improvement initiatives with greater collaboration with patients and patient representatives. 13In response, this study utilised a codesign approach to facilitate the design process, which was guided by the Double Diamond framework.Employing divergent and convergent thinking helped mitigate risk and promptly identified potential issues, while prototyping contributed to refining the feasibility and design of interventions based on stakeholder feedback.

| Partnering with consumers for quality improvement
Codesign is a critical method in healthcare service planning and delivery that actively involves all stakeholders to address the specific needs and concerns of patients, including consumer representatives.
Although consumer representatives can provide valuable insights and perspectives, their involvement in improvement activities can be perceived as tokenistic and superficial. 20Codesign necessitates a partnership approach that eliminates power imbalances. 21

| Engaging clinicians in the codesign process
The Design Council recognizes the significance of engagement and relationship-building with all stakeholders. 22In the healthcare setting, clinician involvement is imperative.Despite this, ineffective codesign can occur due to conflicting priorities, inadequate information sharing between service providers and users, and overlooking of staff perspectives, which may lead to reduced clinician engagement. 16In the HUSH Project, it was important to be accommodating to staff needs and preferences.For instance, staff collaboration was often obtained via informal meetings on the wards, which minimised disruption to clinical processes and reduced barriers to their involvement.
Staff participation ensured that the solutions met the needs of both patients and healthcare providers.

| LIMITATIONS
The limitations of this study include its limited scope, as it was conducted in a single hospital (in Sydney, Australia), and the survey was only available in English.Additionally, the evaluation was conducted immediately after project implementation, which may not provide a comprehensive understanding of the effectiveness of the sleep intervention over time.The factors influencing sleep are multifaceted and may take time to be fully implemented in an organization.Additionally, sleep improvement also involves a change in culture, which takes time to be fully integrated into the healthcare setting.Also, there is scope for a more extensive partnership with patients and stakeholders, including more diversity with consumer representation and involvement.

| CONCLUSION
In conclusion, the HUSH Project demonstrated the value of codesign in healthcare service planning and delivery to create an intervention that tackled the issues of importance to the project stakeholders.The results of the HUSH Project indicated a statistically significant reduction in noise disturbances for patients in shared rooms.These findings highlight the complex nature of sleep in hospitals and the need for further research to identify effective ways to mitigate sleep disruptions in hospitals.Overall, codesign is a promising approach for improving healthcare services, and healthcare organizations should consider its implementation to enhance patient experience and service quality.

2. 1 . 1 |
Intervention designTo progress the improvement project, a subcommittee comprising five consumer representatives from the hospital's consumer network was established.These representatives voluntarily offered to participate and were recruited from the hospital consumer network based on their interests and experience.To facilitate their participation, fortnightly online meetings were conducted, facilitated by the lead researcher (C.A.).The consumer representatives played a critical role in the project and provided ongoing support throughout its different phases, including assessment, design, implementation and evaluation.Additionally, staff contributions were obtained through informal meetings with the Nursing Unit Managers of each ward, which allowed for flexibility and minimized disruption to clinical workflows.2.1.2| Understanding the problemIn the Discover phase, various data sources were examined, including patient experience survey data and patient complaints/ grievances.In addition, new information was gathered from various stakeholders, with the researcher (C.A.) conducting interviews with both patients and staff on the wards.Next, in the Define phase, the researcher and consumer representatives carefully analysed the data and prioritized the issue of night-time noise on the wards, which was particularly problematic in shared patient rooms.

2. 2 |
Part 2: Evaluation Survey materials: Patient evaluation of sleep disruption was assessed using the publicly available 'Sleep Disruption in Hospitals' survey, which was developed by the Sleep Health Foundation. 19The survey consisted of 12 questions, with the evaluation of eight potential factors causing sleep disruption, such as noise, light, and clinical interventions.Patients rated their responses about the level of disruption to sleep for each factor using a 5-point Likert scale (ranging from 'not at all disruptive' to 'very disruptive').

F
I G U R E 1 The Double Diamond model of design (adapted from Design Council, 2005).ADAMS ET AL. | 3 of 7 2.2.4 | Procedure The study duration was 8 weeks, with 4 weeks of baseline measurement (preintervention) followed by 4 weeks of intervention and evaluation.The nursing staff provided patients with a participant information sheet about the research project.During the intervention period, patients also received a HUSH Sleep Pack on admission to the ward.After two nights in the hospital, patients were sent a text message containing a link to the survey.If patients did not have a mobile phone, nursing staff provided a paper-based survey.Their participation was voluntary and anonymous.

3 | RESULTS 3 . 1 |
Part 1: Developing the intervention The codesign methodology facilitated the development of 'the HUSH Project', which was created in collaboration with patients, consumer representatives and staff members to reduce sleep disruption in hospitals.This project also aligned with best-practice recommendations for sleep in hospitals, outlined in the Sleep Health Foundation's 'Code of Practice'. 19The intervention included giving patients resources to improve their sleep in the hospital, including 'HUSH Sleep Packs', on admission to the ward.The HUSH Sleep Packs contained earplugs, eye masks, noncaffeinated drink options (herbal tea and hot chocolate sachets) and patient information about improving sleep in the hospital (see Figure2).Also, hospital-wide changes were implemented, including 'Quiet Times' from 10:00 PM to 6:00 AM, providing 8 h of minimised noise and interruptions.Other sleep interventions included the development of a HUSH website (which was easily accessible via QR codes on the HUSH brochure) and provided access to guided meditation, white noise (rain sounds) and relaxing music.

3. 2 |
Part 2: Evaluating the intervention The Sleep Disturbances in Hospital survey was used to evaluate The HUSH intervention, with a total of 210 survey responses collected from seven inpatient wards, as shown in Table 1.Overall, 34% of respondents stayed in single rooms (N = 72), while 66% of respondents stayed in shared rooms (N = 138).Of these, the Sleep Disturbances in Hospital survey was completed by 114 patients before the HUSH intervention (i.e., no HUSH) and 96 patients following the HUSH implementation (i.e., with HUSH).A reliability analysis was conducted on factors causing sleep disruption using the Sleep Disruption in Hospitals survey.Cronbach's alpha (α) showed that the Sleep Disruption in Hospitals survey reached acceptable reliability, α = .847.Using the data from the Sleep Disruption in Hospitals survey, an independent two-sample t test was performed to compare the sleep disruption in patients without and with the HUSH intervention, see Table2.Overall, the results of the group comparisons were mixed.While the mean rating for some of the disturbances decreased (such as noise and acute medical conditions), these results were not statistically significant (p > .05).F I G U R E 2 HUSH Sleep Packs and hospital signage.
The HUSH Project aimed to design and investigate the effectiveness of an intervention to reduce sleep disruptions in hospitals.As sleep is influenced by a range of complex factors, the HUSH Project created and applied a multimodal intervention to deliver comprehensive and holistic support for patients.Pre-and post-intervention evaluations were conducted using the Sleep Disruption in Hospitals survey to measure the impact of interventions to reduce sleep disturbances in a ward setting.While overall results were mixed, the analysis indicated a statistically significant reduction in noise levels for patients in shared rooms.In this cohort, the average patient rating for noise disruption (using the Sleep Disruption in Hospital survey) improved from 'somewhat disruptive' to 'a little disruptive' within 4 weeks of program implementation.As a result of the HUSH Project, the hospital became the first healthcare facility in Australia to receive accreditation from the Sleep Health Foundation's 'Code of Practice for Sleep Care in Hospitals'.

4. 1 |
Using the codesign framework in healthcare A systematic review of sleep interventions concluded that multifaceted interventions may be effective to improve reducing sleep Accordingly, the HUSH Project aimed to establish meaningful partnerships with consumer representatives by involving them in all aspects of project design and implementation, such as developing training materials, facilitating staff training sessions, supporting policy development and creating patient communications.The project also addressed patients' physical and emotional needs, and improved communication diversity, including creating an animated video about sleep health in hospitals for culturally and linguistically diverse patient groups and those with low health literacy.
For instance, staff feedback influenced the development of visually appealing pull-up banners, specifically designed to enhance the ward environment, and the provision of disposable headphones to address noise issues from TVs in shared rooms.Also, staff feedback was necessary when setting designated times for 'Quiet Time' to avoid potential conflicts with clinical workflows.The HUSH Project highlighted the importance of integrating feedback from diverse stakeholders to cater to their varied needs.For example, the selection of herbal tea for the HUSH packs was altered based on pharmacist feedback about potential medication interactions.As such, effective communication and collaboration between clinical and nonclinical stakeholders was vital to ensure interventions were both person-centred and medically appropriate.
Demographics of Sleep Disturbances in Hospital survey respondents.Results of Sleep Disruption in Hospitals survey.
To further increase the generalizability of the findings, studies could be conducted in different hospital settings, such as private hospitals with single rooms, which would provide additional insights into how the interventions may be best adapted and implemented in different healthcare environments.Future research may also involve a longer evaluation period, such as 6-12 months, to gain a more comprehensive understanding of the effectiveness of the sleep intervention over time.Also, a larger sample size may permit further analysis, such as the influence of variables such as age, sex and length of stay on patient-reported sleep measures.Additionally, further research could be conducted to identify which components of the HUSH interventions were most effective in reducing sleep disruptions for patients in hospitals.