Care process for breast cancer patients with sleep disturbances: a best practice implementation project.

Introduction
Sleep disturbances are a long-term debilitating symptom for breast cancer patients throughout the treatment trajectory and into survivorship.1 Over the past 20 years, the worldwide prevalence of sleep disturbances in breast cancer patients has been approximately 20%–70%, with a higher prevalence of poor sleep occurring in breast cancer survivors during treatment.2 Sleep disturbances encompass various overlapping symptoms, including insomnia, sleep-wake disturbances and short sleep, excessive daytime sleepiness, sleep difficulty, poor sleepers, and self-reported sleep dysfunction.1 Sleep disturbances can decrease quality of life, impair daily functioning, and cause emotional distress, which may decrease treatment adherence and be associated with increased breast cancer recurrence and mortality.3 The multifactorial and complex sleep disturbance mechanisms in breast cancer patients include cancer treatment (e.g., chemotherapy and hormonal treatment), immunity, circadian rhythm, behavioral factors, stress, fatigue, and depression.1,3
A better understanding of patient factors that cause poor sleep during and after treatment for breast cancer would allow tailored care to prevent disturbed sleep, thereby improving patients’ quality of life. Most guidelines recommend a two-step process for identifying sleep disturbances, starting with initial screening, followed by a comprehensive assessment for those who screen positive.1 Brief screening questions in the clinical setting may include “Are you having any problems with sleep?”1,4 The American Association of Sleep Medicine recommends a sleep disturbance assessment, which includes patient history, completion of a general medical/psychiatric questionnaire, an Epworth Sleepiness Scale (ESS), and a self-report sleep log.5 Sleep logs, including reports of sleep quality, napping, daytime impairment, medications, activities, time of evening meal, caffeine and/or alcohol consumption, and stress levels before bedtime, are recommended.4 Comprehensive assessment findings may help determine which patients would benefit from interventions to improve sleep, such as a multimodal sleep improvement strategy, thus providing selective strategies. The results of a meta-analysis suggest screening and treatment of pre-existing sleep disturbances may be beneficial for such patients.4
Although the prevalence of sleep disturbances is high in breast cancer patients, and there are numerous evidence-based recommendations for sleep care, the literature reports that health care providers rarely pay attention to patients’ sleep concerns, and discussions regarding sleep problems are often brief, even when sleep disturbances have been evaluated.6 A study reported that about 86.7% (n = 98) of nurses had never screened patients with cancer for any sleep problems, while 76.7% (n = 99) of the patients reported that they have never been assessed for sleep problems by the nursing staff during hospitalization.7 These results highlight the need for hospital measures to avoid and alleviate sleep disturbances in cancer patients.
In Taiwan, 1 in 120 women have breast cancer, and the incidence is rising.8 It is reported that 67% of breast cancer patients in Taiwan experience sleep disturbances.9 These prevalences were similar to world literature reports. In the ward where the present study was conducted, sleep disturbances are poorly documented and managed as part of routine clinical practice. Therefore, the Sleep Disturbance Care Process (SDCP) project was established to implement best practices for screening, comprehensive assessment, and management of sleep in breast cancer patients.

Objectives
This project aimed to improve nurses’ adherence to the SDCP for sleep disturbances in the general surgery ward of the Chang Gung Memorial Hospital in Kaohsiung, Taiwan.
The specific objectives were to:
1.Determine current compliance with the best practice recommendations for sleep care in breast cancer patients.

2.Identify barriers to delivering evidence-based sleep care and develop strategies to improve compliance.

3.Evaluate changes in compliance with the evidence-based sleep care recommendations after implementing strategies to address the identified barriers.

Methods
This project followed the seven-phase JBI Evidence Implementation Framework10 to implement best practices for sleep care in breast cancer patients. The JBI approach is grounded in an audit, feedback, and re-audit process. Audit criteria were developed and gaps and barriers were identified by using JBI's Getting Research into Practice (GRiP) approach; data were collected and compared using the JBI Practical Application of Clinical Evidence System (PACES). The seven phases of activity involved in this project are discussed below.

Implementation planning

Phase 1: Identify the practice area to be changed
The project was implemented from October 2023 to February 2024 in a general surgery ward with 57 beds and 30 nursing staff in a medical center in southern Taiwan. A total of 152 breast cancer patients in this ward received chemotherapy during the third quarter of 2023. Of these, 29% (n = 44) were not screened for sleep issues, 21% (n = 23) experienced sleep problems, and none had undergone a sleep assessment. Among the nurses, 73% (n = 22) reported that they screened patients, but no patient-related sleep problems were documented in the nursing records and no sleep care was provided. Before this project started, we held an initial meeting to establish the project team and review the care process for sleep problems in breast cancer patients. The coordinating group, including nurse leaders (director, deputy director of the nursing department, and the nursing supervisor), a case manager, a physician, a head nurse, and two nurse specialists, were invited. Team roles included the project coordinator, coordination group, implementation group, and evaluation group. The roles and responsibilities of each team member were determined and assigned (Table 1).

Phase 2: Engage change agents
Before this project was implemented, sleep problems were screened using two questions: “Did the patient experience difficulty in sleeping, such as difficulty falling asleep, waking up easily or early?” and “Did the patient lose much sleep through worry?” These questions were asked as part of the initial nursing assessment in the Health Information System, which is the digitalized medical care system used in the hospital. Each patient was screened upon admission. However, no care plan followed this initial screening. Through project team meetings, a care process was established to provide suitable sleep care. The sleep specialist nurse provided professional knowledge, training, and advice on sleep disturbances and assisted in developing sleep management plans and procedures. Nurses and case managers need to be aware of the sleep care process for breast cancer patients. Physicians can diagnose and treat patients’ sleep disturbances and provide professional medical advice and pharmacological treatment plans. The case manager and head nurse were responsible for collecting data, while the nursing supervisor and the nursing deputy director identified barriers to compliance and implemented appropriate strategies.

Phase 3: Assess context and readiness to change
Two focus group meetings were conducted with key stakeholders to evaluate the ward's readiness for change, including the Deputy Director of Nursing, a breast cancer specialist physician, the head nurse of the unit, and two nurse specialists. Issues regarding the current sleep care process, nursing staff perspectives on sleep assessment and management, and the feasibility of implementation strategies, were identified. The focus group meetings indicated that the entire care team supported the idea of establishing a standardized sleep care process, which they considered essential for improving the quality of patient care. Moreover, the team identified that JBI's best practice recommendations11,12 for managing sleep disturbances in breast cancer patients provided a robust clinical framework for the project. However, it was also recognized that limited knowledge among nursing staff regarding sleep assessment and management may result in sleep disturbances being overlooked. Moreover, heavy workloads and staffing constraints may increase the time pressure for conducting comprehensive sleep assessments.
Nurse specialists designed a 12-item survey to elicit nurses’ perspectives on patient needs and the importance of sleep care. The results of this survey revealed that nurses in the ward all viewed sleep as an important problem, with a needs and importance average score above 4.2 to 4.5 on a five-point Likert scale. While challenges exist, the ward was generally prepared for change with the support of leadership, professional resources, and evidence-based guidelines.

Baseline assessment and implementation

Phase 4: Review practice against evidence-based audit criteria
A baseline audit was conducted in October 2023 to compare our current practices against best practices. Audit criteria (Table 2) were developed based on two JBI evidence summaries.11,12 The following evidence-based practices were chosen11,12:
1.Any health care professional may conduct sleep disturbance screening. (Grade B)

2.Sleep disturbance assessment should include a thorough clinical history, current symptoms, and current management strategies. (Grade A)

3.A validated screening tool, such as the Pittsburgh Sleep Quality Index (PSQI), the Patient-Reported Outcomes Measurement Information System (PROMIS), or the Epworth Sleepiness Scale (ESS), should be used. (Grade B). In our project, the Brief Fatigue Inventory – Taiwanese version (BFI-T)13 was used instead of the fatigue measure in the PROMIS because the BFI-T is also a validated instrument for cancer-related fatigue and has been extensively used in our hospital.14

4.A trained health care professional, sleep specialist, or primary care physician should conduct a sleep disturbance assessment. (Grade A)

5.Sleep disturbance management strategies should be multimodal and implemented according to the screening and assessment outcomes. (Grade A)

6.Sleep hygiene counseling and guidance should be provided, and may include environmental, behavioral, and cognitive strategies. (Grade B)

Because the hospital did not have sufficient resources for cognitive behavioral therapy for insomnia, and because the facilities were inadequate to provide suitable exercise and physical activity, we only used eight audit criteria.
The audit sample consisted of 30 nurses from the ward and the nursing records of all hospitalized patients who met the inclusion criteria during the third quarter of 2023 (n = 152). The nurses’ experience ranged from 2 to 20 years. The inclusion criteria for the target patients were (1) female patients aged 18 to 75 years, (2) diagnosed with stage I to IV breast cancer, and (3) undergoing or having completed chemotherapy. Breast cancer patients in this ward received one to six cycles of chemotherapy.
The baseline audit identified gaps in the current practice. The Nursing Record Audit Form (Appendix I) was designed to evaluate the current status of the sleep care procedures regarding the screening, assessment, and management provided by nurses to breast cancer patients.
In addition, we designed a questionnaire to review the needs and opinions of nurses while providing sleep care for breast cancer patients with sleep disturbances. This questionnaire was designed according to the audit criteria, which includes three aspects (screening, assessment, and management of sleep care) regarding nurses’ needs for training on sleep care.

Phase 5: Implement changes to practice using GRiP
Following the baseline audit, the project team met to analyze the baseline audit results and identify the reasons for non-compliance with best practice recommendations. A GRiP analysis was conducted to address the barriers to best practice and identify strategies, resources, and expected outcomes.
The key barriers identified were a lack of procedures to screen, assess, and manage breast cancer sleep quality, as well as a lack of sleep hygiene information for patients. Therefore, we developed standardized procedures, the SDCP, with the deputy director of the nursing department, nurse specialist, nurses, case manager, and physicians for conducting sleep screening, assessment, management, and to integrate this into existing nursing workflows (Figure 1). The SDCP process is based on the concept of a shared care program15 that emphasizes interdisciplinary teamwork. The process commences with breast cancer chemotherapy patients being screened for sleep disturbances by nurses upon admission within an 8-hour timeframe. Next, patients who screened positive are referred to a case manager, and their physician is notified. The case manager conducts a comprehensive sleep assessment, including (1) the Comprehensive Assessment of Risk Factors Checklist (CARFC), with current symptoms, clinical history, current treatment, and sleep-related lifestyle behaviors; (2) the Pittsburgh Sleep Quality Index (PSQI); (3) the Epworth Sleepiness Scale (ESS); and (4) the Brief Fatigue Inventory-Taiwan Form (BFI-T). Nurses then deliver individualized multimodal sleep disturbance management interventions or initiate interdisciplinary sleep care based on the results of the comprehensive sleep assessment. The project team also produced a health education video entitled “Care for Breast Cancer Patients Who Experience Sleep Disturbances at Kaohsiung Chang Gung Memorial Hospital.” This video was routinely shown to breast cancer patients with sleep disturbances when admitted to hospital. This project was carried out over 3 months, from November 2023 to February 2024.

Impact evaluation and sustainability

Phase 6: Re-assess practice using a follow-up audit
A follow-up audit was conducted to measure changes in practice. This audit used the same sample size, audit criteria, and data collection strategies as the baseline audit. The evaluation group monitored staff adherence to recommended practices during the audit, which took place from February to March 2024.

Phase 7: Sustainability considerations
During this stage, our team validated that the SDCP was an effective process for screening, assessing, and managing sleep disturbances. However, conducting a comprehensive sleep assessment for breast cancer patients consumes a significant amount of time. Moreover, we used paper tools to do the assessments within a digitalized medical care system. It was not convenient and mandatory to provide this care. Therefore, using AI for a thorough assessment instead of manual, paper-based evaluation would be better suited to a busy clinical setting. This would represent a sustainable solution for the project.

Data analysis
Changes in compliance were measured using descriptive statistics embedded in PACES in the form of percentage changes from baseline to follow-up.

Results

Baseline audit
In the baseline audit, we checked the medical records of breast cancer patients (n = 152) who received chemotherapy in the ward during the third quarter of 2023. Of these, 71% (n = 108) were screened for sleep issues, 21% (n = 23) experienced sleep problems, and none had undergone a sleep assessment. No patient-related sleep problems were documented in the nursing records, and no sleep care was provided. Among the nurses, 27% (n = 8) reported that they did not screen patients.
Criterion 1, which involves using a screening tool for sleep disturbances, was already integrated into the existing digitalized admission service. However, despite its availability, around one-third of nurses did not adhere to this policy. Compliance for Criteria 2–8 was 0%. Because policies and procedures had not been established at our hospital, care for sleep disturbances in terms of assessment and management was not adequately provided.

GRiP strategies
After analyzing the results of the baseline audit, five barriers to improving compliance with best practices were identified (Table 3).
Barrier 1 was the lack of a policy and procedures to screen, assess, and manage sleep in breast cancer patients. All implementation group members participated in developing the SDCP process (Figure 1) and disseminating information about the SDCP.
Barrier 2 was nurses’ lack of awareness of sleep disturbances associated with breast cancer. To address this barrier, strategies included providing information on prevalence and management, surveying staff opinions, conducting training sessions during ward meetings, explaining the project's aim to nurses, and encouraging their participation.
According to the survey results on the demand for nursing in-service education, 47%–84% of nursing staff believed training should be provided on sleep disturbances. Additionally, the need for sleep assessment (72%) and management (76%) was higher than that for screening (50%). It is worth mentioning that there was a high demand for education and training among clinical nurses for “Providing patients with health education information on comorbidities affecting sleep” and “Providing patients with health education information on the impact of chemotherapy medications on sleep,” which attained the highest score of 84.2%.
Barrier 3 was the nurses’ lack of knowledge regarding the comprehensive assessment of sleep disturbances. To address this barrier, the nurse specialist conducted a training course for one case manager and one nurse, which included the use of the PSQI, BFI-T, ESS, and the checklist for the comprehensive assessment of risk factors. Assessment experiences were discussed and referenced to revise the assessment tools and care process.
Barrier 4 related to the ward not having tools for assessing sleep disturbances and risk factors. The strategy to resolve this issue was to obtain the relevant assessment tools from the evidence-based literature. In addition, the head nurse and case manager shared their experiences and suggestions for revising the assessment tools.
Barrier 5 was the lack of interdisciplinary collaboration to implement optimal sleep management for breast cancer patients. To address this issue, we established a multidisciplinary team with defined roles, reviewed the care process to ensure it was workable, and involved the case managers in the treatment assessment. We also created educational videos for health staff.

Follow-up audit
In the follow-up audit, we checked the records of 54 patients who were admitted to the ward from February to March 2024. Of these, 91% (n = 49) were screened. Nurses reported adherence to Criterion 1 on sleep screening, which increased from 73% to 90% (n = 27). The nursing records of 15 patients who screened positive for sleep disturbances were evaluated. The nurses’ and case manager's compliance rate improved from 0% to 100% for Criteria 2–6 and from 0% to 83% for Criterion 8. Criterion 7 was not applicable since the 15 patients did not need medical investigations or diagnosis, and only personalized sleep hygiene counseling was required for their sleep problems. Figure 2 presents the percentage of compliance in the baseline and follow-up audits.

Discussion
Sleep is a vital function affecting the quality of life of all people. Sleep disturbances are common in breast cancer patients undergoing chemotherapy. There is some evidence in the literature on the practice of sleep care. However, health professionals often pay limited attention to this area.6 The complexity and multifactorial aspects of sleep function make it difficult to manage the quality of sleep. Quality improvement in sleep care depends on the health professionals’ knowledge and experience. This project successfully improved compliance with best practice recommendations for sleep care in clinical practice. The main strategy was to develop and implement the SDCP, which included screening, comprehensive assessment, and management of sleep, in line with the best evidence.
The baseline audit in this project revealed a gap between the hospital's existing care practices and best practices. Five strategies were implemented to address the identified barriers to best practice. First, we established a care process for sleep disturbances in breast cancer patients, including screening, assessment, and management. The baseline audit findings revealed that the hospital solely conducted sleep screening, without incorporating any associated assessment and management protocol. Despite the presence of a mandatory screening tool for sleep disturbance as part of the admission process, almost one-third of nurses reported not complying with this protocol. This discrepancy underscores a disparity between the hospital's existing screening process and clinical practices. The absence of organizational sleep policies and protocols, along with co-workers’ attitudes, negatively affected nurses’ motivation to implement sleep care.16 Therefore, our team suggested creating a standardized, generalizable implementation process. Standard procedures would ensure that the health care providers, caregivers, workflow, technology, and interventional protocols17 were all carefully considered in the implementation project. Holding meetings to go through the care process in our clinical setting and gaining consensus from all involved staff were the key success factors in the project. The specific tasks for interdisciplinary team members were described at each step in the SDCP to ensure a standardized and replicable implementation process.
The second strategy was to increase nurses’ awareness of sleep disturbances in breast cancer patients through educational interventions. Lack of sleep knowledge is an issue for nurses, preventing them from delivering evidence-based interventions that promote sleep.18 There is a definitive need to have nurses trained in sleep assessment and management. Nurses in our ward had the basic knowledge of sleep care from their usual training and clinical experiences. To ensure that our educational intervention would be effective, we first investigated the nurses’ needs regarding sleep care in breast cancer patients. We also created an educational video for the nurses to review and use in daily care. These strategies contributed to the success of this project. Nurses play a crucial role in the holistic care of patients, and addressing sleep disturbances is essential for improving overall patient outcomes and quality of life. Therefore, incorporating sleep education into nursing curricula and continuous professional development programs, as well as having resources available, can empower nurses to provide effective care for sleep-related issues in clinical practice.
The third strategy was training health care professionals on sleep disturbance assessment. One case manager and one nurse received training on comprehensive sleep assessment. This training focused on several elements, including clinical history, current symptoms, medical and psychiatric comorbidities, quantity/timing of substance use (including caffeine), sleep assessment tools, etc. A national survey of cancer centers in the US found that the screening rate for sleep disorders was low, and few clinicians were well-prepared to conduct a proper sleep evaluation.19 The results of this survey suggested that developing patient education materials (80%) and offering in-service providers focused on the evaluation and treatment of sleep disorders (72%) were helpful in improving confidence in the assessment and treatment of sleep disorders. The case manager and nurse in our project were the in-service providers.19 A sleep management video was also available for them to learn and use. Once the case manager identified the factors affecting a patient's sleep, the case manager and nurses were able to provide a tailored intervention for the patient.
The fourth strategy in this project was developing comprehensive assessment tools, including the risk factor checklist (CASFC), along with the PSQI, BFI-T, and ESS. Sleep disturbances in cancer patients should be assessed using a comprehensive, reliable, and valid instrument, and evidence-based interventions should be provided according to the patient's needs.7 In assessing sleep disturbance, it is important to identify factors that affect sleep because of the multifactorial and complex sleep disturbance mechanisms in breast cancer patients. Many possible causes of insomnia in breast cancer patients have been identified, but no assessment tools are available for nurses to use.6 Therefore, we developed comprehensive assessment tools that include clinical history, current symptoms, current sleep management strategies, sleep quality, daytime sleepiness, fatigue, and chemotherapy regimens for breast cancer. The format of the risk factor checklist (CASFC) clearly distinguished between the normal or potential causes of sleep disturbances. After completing all the questions, the potential causes emerged, significantly reducing assessment time. In the follow-up audit, 15 patients with sleep disturbances received comprehensive sleep assessment and tailored optimal sleep management. The comprehensive assessment tools allowed health care providers to gather detailed information about the patient's sleep patterns, symptoms, and treatment plans, enabling nurses to provide tailored interventions effectively.
The fifth success strategy was an interdisciplinary collaboration to implement optimal sleep management for patients. Interdisciplinary team collaboration is crucial for delivering optimal sleep care.16,19,20 Our team, including nurses, case managers, physicians, nurse specialists, and the nursing deputy director, set up the roles of each discipline. The team then went through the SDCP to make sure the process of sleep care, including screening, referral, assessment, notification, and management, was workable. After receiving appropriate training, the case manager was able to conduct a comprehensive sleep assessment, differentiate the patient's need for pharmacological or non-pharmacological treatment based on the assessment results, and report back to nurses for management. Nurses were able to provide care to patients through non-pharmacological interventions or by asking physicians for pharmacological treatment. Creating an educational video material (Kaohsiung Chang Gung Memorial Sleep Disturbance Care, YouTube) for health staff and patients was also helpful in providing sleep care.
A key success factor in this project was the establishment of an interdisciplinary team. However, because of the lack of specialists in cognitive behavioral therapy (CBT) in our hospital, the recommendation of “referral to a CBT specialist”12 was omitted from our audit criteria, even though CBT is the first line recommended treatment for insomnia in breast cancer patients.6 A study in breast cancer patients showed that internet-based CBT (iCBT) with or without clinician guidance produced positive results in treating insomnia and menopause symptoms.21,22 How to apply iCBT for breast cancer patients should be considered and integrated into the care process. The efficacy and effectiveness of the iCBT in our setting should be further tested.
This project aimed to establish a SDCP and increase nurses’ knowledge of sleep disturbance care for breast cancer patients. Therefore, patient outcomes were not measured. This project was conducted in a limited timeframe with a limited sample. One notable problem was that conducting a comprehensive sleep assessment for patients was time-consuming due to the complexity of the sleep function. In the context of a busy clinical environment, this could hinder the long-term sustainability of the SDCP. A future direction for this project could be to develop digitalized or AI-based tools for rapid assessment and sustain the SDCP over time.

Conclusion
We recognize that addressing sleep disturbances may not be a priority during busy clinical care. However, based on its high prevalence, the association with adverse outcomes, as well as the social and economic costs, we maintain that sleep care for breast cancer patients is important and needed. The use of the JBI Evidence Implementation Framework provided an easy-to-follow guideline for conducting this project and improving compliance with best practices. To ensure the sustainability of best practices, the next step would be the use of AI system rather than manual evaluation to conduct thorough assessment. This will be developed and implemented in the near future to accommodate the busy clinical setting of our hospital.

Ethics
This project did not require approval from the Institutional Review Board, as it was not considered research on human subjects but a quality improvement project. All the data collected for this project were de-identified by the information department in the hospital.

Availability of data and materials
Data, assessment tools, and video resources used in this study are available upon request from the authors.

Author contributions
CFL and CWC: Conceptualization, data retrieval and analysis, and manuscript draft. MCC and SCW: Execute and collaborate on the SDCP. YFL, SCL, and MWW: Providing resources and support during the implementation of the project. WCL: Theoretical guidance, project planning, and article revision. All authors approved the final version.

Acknowledgments
The authors wish to acknowledge the nurses’ cooperation and support from the Chang Gung Memorial Hospital in Kaohsiung, Taiwan, and the Sunyu Tech Co. to produce the educational video on breast cancer patients with sleep disturbances. Special thanks to Chu-Feng Tsai and Pei-Fan Mu and their team from the JBI Taiwan Holistic Care Evidence Implementation Center for their guidance and mentoring.

Supplementary Material

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Supplementary Material

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