Ep 15: Overcoming sleep problems and trouble sleeping

Posted April 11, 2023

Show notes:

In this episode, Nathan talks about sleep difficulties, problems, and insomnia and how to improve those for nurses and midwives.

In the previous episode, Nathan talked about some general tips and tools for improving sleep. Today’s episode focused on people struggling with sleep; this episode is part two of a series about sleep tips.

Here is a summary of key points from the episode:
  • Insomnia is the most common sleep disorder; it is a problem in initiating sleep in the first place or a problem with waking at night. 
  • Insomnia causes functional impairment where your sleeplessness or your perceived sleeplessness bothers you.
  • Sleep difficulties likely started from stress and worrying about something.
  • The leading cause of insomnia for people is stress in the short term. Irregular sleep-work-wake cycles also lead to insomnia. 
  • It is the things that we are doing unintentionally that are maintaining the problem. 
  • Sleep is a natural behavior. The problem is that we focus on sleep as something to be controlled, and the unintentional consequence is that it creates more anxiety.
Nathan shares several tips to improve sleep and break the cycle of insomnia.
  1. As you notice worries coming into your mind, acknowledge them as worries. Give your fears a name and change your attitude towards the concern. Try and disengage from thinking about how insufficient your sleep was and how it will affect the rest of your day.
  2. The other one is questioning the validity of your thoughts. Examining what your mind is saying as you go about the rest of your day is essential.
  3. Try and put yourself in the shoes of someone who is a good sleeper and apply that to your thinking.
  4. You have to start abandoning what you are doing to try and control sleep.
  5.  Try to reduce the extent to which you’re obsessively monitoring yourself internally. People with insomnia tend to focus negatively on their internal sensations.
  6. Sleep window- Set your bedtime and waketime and stick to it. Get out of bed when your alarm goes off, even if you feel you have not slept well. 
  7. Stimulus Control- Even going to bed creates that sense of worry and anxiety. You have to start retraining that association with the bed as somewhere calming and where you can fall asleep.
  8. Have a balance between having healthy sleep habits and what we call sleep hygiene and then using sleep hygiene-type behaviors to try and make ourselves sleep.
  9. Managing insomnia is emotions. Allow those sensations and emotions to be present, and open yourself up to them. Focus on breathing- breathing into your nose and out through your mouth.

Sleep has a massive impact on our physical and mental health. Share this episode with your colleagues and have more conversations about sleep. This way, we can help more people get adequate rest and improve their well-being.

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Nathan Illman  00:06

Hello, everyone, my name is Nathan and I’m here to bring you this episode of nurse wellbeing Michigan, where I’m going to be talking about sleep difficulties, sleep problems and insomnia, and how to improve those for nurses and midwives. So if you are someone who has been struggling with your sleep, you having lots of difficulty getting off to sleep, or perhaps you wake a lot in the night feeling fatigued and tired during the day, and sleep has just become a real problem or issue for you, then this is the episode for you. So I’m bringing you this information in these tips as part of my effort to improve preventative mental health for nurses and midwives. If you don’t already follow me, then you can find me elsewhere on Facebook and join my free Facebook group, it’s Nurse and Midwife Wellbeing Mission, you can find me on Instagram, it’s at underscore nurse wellbeing mission. And you can follow me on Twitter at nurse wellbeing. And on all of those channels, I share lots more tips and resources on how to improve well-being. So things like sleep, also how to manage stress, how to develop a better relationship with yourself, loads of helpful things. So let’s dive into the episode today. This is part two of a series I’m doing on sleep. So the last episode was some general tips and tools on how to improve and optimize sleep that are relevant for anyone really, today’s focus is much more of people who are really struggling with sleep. And perhaps it’s gone past the point of having the odd sleepless nights due to stress. And it’s become a bit more of a chronic problem. And indeed, what we might classify as insomnia. So this episode is going to be split into three sections. The first, I’m going to be introducing and talking a little bit of background about insomnia, what it is, its prevalence in nurses and midwives, and where it comes from what kind of initiates insomnia in the first place. In part two, I’m going to be focusing on what maintains sleep difficulties. And this is really key in understanding your own insomnia, or poor sleep is it there are lots of factors that influence the maintenance of the sleep problems, it’s a vicious cycle of sleep that involves thoughts, feelings, and behaviors. And I’m going to be deconstructing that a little bit. And I’m going to give you my own personal example of a period of insomnia that I experienced several years ago. In part three, I’m going to be diving into some tips and some evidence-based tools that you can try out for yourself at home, to improve your sleep to break that cycle of insomnia. And hopefully, this will all help you at least raise awareness of some of the things you might be doing that might be unintentionally contributing to that poor sleep, and give you an idea of what you can try out to improve things. So let’s move on to part one, let’s talk about insomnia and poor sleep in nurses and midwives. Now, insomnia is the most common sleep disorder, there is a diagnostic classification for insomnia that is used with psychiatrists and doctors, I’m not going to go into all the details of that. But really, the main way of looking at insomnia is that it is a problem with initiating sleep in the first place, or a problem with waking in the night. So being able to maintain sleep, it could be both of those things. So you could be someone who struggles to get off to sleep, and you wake up multiple times in the night, or you just have early awakening. And the third part is that it causes what we call functional impairment. So your sleeplessness or your perceived sleeplessness bothers you. It creates distress for you in some way the next day, and often will lead to things like anxiety, and feelings of low mood, and then that itself impact on your day-to-day work. So in your role, as a nurse or midwife, your lack of sleep is leading to distress, which then makes you feel like you’re performing poorly, or maybe actually is making you perform poorly, for example, making mistakes or maybe you’re just really reactive with your colleagues and not treating people in the kind of way that you would like to. So insomnia is very common in nurses and midwives much more common than in the general population. So there’s a number of research studies that have looked at this. There’s more literature on nurses there’s actually very little on midwife. wives. But we can assume that midwives go through very similar kind of conditions. As nurses, there’s the same kind of stresses the same kind of healthcare environments that nurses work in. And we know from the literature that really around 30%, of nurses and midwives struggle with some kind of sleep disorder, and particularly insomnia. Now, estimates vary between studies. But from what I’ve read from the literature, 30% is a pretty, pretty good round number to sort of focus on. Now in students that can be higher. Sometimes University kind of life is associated with increased stresses and pressures, as opposed to when you sort of go into the world of work. And perhaps you’re not taking exams and that sort of thing. So it’s really common. And if you’re a nurse or midwife listening to this, while you’ve probably been experiencing sleep, difficulties yourself, so you know that it’s been a problem for you. But it’s a real silent issue within our culture, most people don’t talk about their sleep, they are suffering in silence. And often, a lot of this is because we didn’t really want people to know, and he might be focused on yourself and the issues it’s causing you and not want to share that with other people. So they’re guaranteed to be other people that you work with who are struggling with similar issues. So what causes


Nathan Illman  06:27

insomnia, so when someone has difficulty getting off to sleep at night, or they have trouble with waking up in the middle of the night, and then they have those difficulties the next day? Well, what causes this? Well, it’s really important to consider that insomnia is a condition that can be classified according to its chronicity, how long it lasts. So in the short term, we all will experience stressful events or stressful periods of life, that lead to kind of short episodes of insomnia. Whether it is a breakup in a relationship, perhaps it’s the stress of moving home, it might be your job is under threat, there could be a particularly stressful period at work or something really challenging is going on, maybe you’ve lost a few key members of staff, and the amount of work that is expected of you is really high. So someone might develop insomnia in the short term kind of acute insomnia, because of a reasonably short episode of increased stress in their life. So this is actually the main cause of insomnia for people is stress in the short term. But then what happens is that can persist into the long term, it might not even be that the person’s day-to-day life or their world is as stressful as it once was. But the initial stressful episode has led to a range of thoughts, feelings, and behaviors around sleep, that maintain that poor sleep. And as I alluded to, at the beginning, create a vicious cycle of poor sleep. So one of the things that leads to insomnia is irregular, sleep, work wake cycles. So that can be from shift work. So it’s known that people who are shift workers have higher rates of insomnia. And there is also something called shift work sleep disorder. So as well as there being stresses that can lead to insomnia and sleep difficulties, the irregularity of the sleep-wake cycle that is imposed upon someone who is doing night shifts, can lead to insomnia. And it will be for the same kind of reasons that it’s maintained, as I’ll be going into shortly, but it’s just to let you know that if you are someone who works night shift, and you’re experiencing sleep difficulties, there is a much higher proportion of people in this category that have insomnia. And it is because it just makes sleep quite difficult and can create anxiety around sleep when you’re not able to get adequate sleep, which is understandable given that if you’re working night shift, you’re trying to sleep when your body wants to be awake basically during the day. So if you’re listening to this, it’s likely that your sleep difficulties started from stress and worry about something. But what I’m going to be outlining and hopefully highlighting in this episode, is how actually it’s things that we’re doing unintentionally that are maintaining that problem. So let’s talk about that. What is it that maintains sleep difficulties, whether it’s getting off to sleep at night, waking early, or waking multiple times throughout the night or a combination of both of those So what I’m about to share with you is really the underpinning of the most evidence-based treatment for insomnia. And that is cognitive behavioral therapy for insomnia or CBT. I. And this approach looks at the influence that thoughts feelings, and behaviors have on our sleep and the role they have in maintaining sleep difficulties. And what I’m going to do is I’m going to share with you my own personal experience of insomnia, and hopefully, into weave those different elements to illustrate to you how an initial problem with a period of stress for me led to unhelpful associations with sleep and anxiety around being in the bed and sleeping, that created this cycle that led to further poor sleep and further distress. For me, before I go into that, something that’s really key in understanding about all this is that sleep is a behavior, it’s a natural thing that we all do. And unfortunately, what happens is, some of these things that we’re going to be talking about, lead to us creating an unhelpful association with sleep. So sleep becomes associated with anxiety and worry. And in fact, being in your bed itself, becomes associated with anxiety and worry. And if you remember from the last episode, I explained how having a low level of arousal, being calm and relaxed, is crucial to fall asleep. So really, the key problem here is that things are happening that lead to a high level of arousal, being on alert, feeling anxious and stressed. And that makes sleep basically impossible, because one of the key conditions necessary for sleep is not present. So let me go into my own story a little bit. So this was several years back, I was working in a stressful job in a learning disability service, and a very high level of responsibility. I had very high-risk clients, I had a number of other psychologists that I was supervising, I had a personal disposition to kind of put pressure on myself at the time and take a lot of responsibility for things. I wasn’t being particularly kind on myself at the time. This was before I develop lots of self-compassion skills. And I had a tendency to worry and overthink things. Now, this all came to a head, I had a particularly difficult set of circumstances at work. And I developed initially distress related sleep problems. So prior to this, I’d slept better to kind of normal sleep, or I guess you could call it sleeping between seven and eight hours per night, then what happened was this, this period happened, and I would be okay falling off to sleep at night. But then I would wake up at about 3 am in the morning, and would not be able to get back to sleep, I would wake up in the middle of the night, and my mind would immediately be thinking about work-related issues. So I’d be worrying essentially. Now, I mentioned before that we’re going to be focusing on thoughts, feelings and behaviors. So I’m lying in bed. This is a behavior. I’m lying there thinking about my work and worrying. So there’s the thoughts, and that’s creating a feeling or emotion, a sense of anxiety, and dread, and overwhelm. So of course, you’re lying now, you’re feeling this, and then you can’t get to sleep. Then what happens is that fuels further anxious thoughts, you start worrying about how am I going to perform tomorrow, I’ve got this big thing I need to do, and I’m not asleep, then you start to do other behaviors like checking the clock. So constantly checking what the time is in the hope that you have fallen asleep. And then that starts to make you worry more and more and more. So this happened in the kind of short term, but unfortunately, it only got worse. So then what happened was during the day, I started to focus on how tired I felt. I would spend a lot of time focusing on the feeling of tiredness and fatigue. And that would make me worry about how I’m going to perform with my day-to-day activities. I started to think, oh, maybe I shouldn’t go out my friend this evening. Because maybe I’ll end up coming back too late, I won’t be able to sleep. And then that’s going to affect this sleep problem I have. So there was some avoidance of activities or at least considering avoiding things trying to organize my day in a way that manage this tiredness because I was constantly focused on the being tired. And this led me to be in my head quite a bit and I will And B is focused on things that I needed to be focused on. So the problems I was having at night, also spilled out into the day. So there’s a high degree of worry and distress about the sleep issues, then. And that’s what we know about insomnia is that there is this nighttime issue of the not being able to sleep or getting off to sleep, which leads to anxiety, and worry, and some other behaviors and things that interfere with sleep. And then that spills out into the day and creates further distress, we start dwelling on the previous night’s sleep or lack thereof, and that creates anxiety about yourself and your performance, and makes you worry about sleep at night. So it’s almost like you just can’t let go of sleep, sleep becomes this thing that you are hyper-focused on. Now the problem with this is that sleep is a totally natural behavior is something that we evolved to do over millions of years. It’s something that other animals do. And they aren’t able to have the kind of thought processes processes that we do.


Nathan Illman  16:14

So what the problem is, is that we develop a focus on sleep as something to be controlled. And the unintentional consequence of this is that it creates more anxiety about the process of sleep. And of course, what this means is that your brain starts to interpret and associate being in bed, and the act of falling asleep as a threat. Basically, in very simple terms, it sees it as something threatening and anxiety provoking. Basically, your limbic system, your kind of extremely old evolutionary system designed to help protect you kicks in stress response gets activated. And it means you can’t sleep because you have a higher level of arousal. So if you are experiencing sleep problems, and it sounds to you, like you might have insomnia, then it’s very likely that what has happened is over time, you’ve unintentionally created a negative association with sleep, it’s become something to be feared, it creates anxiety, or at least being in your bed creates anxiety and other unpleasant emotions, which are just not conducive to sleep. So just have a sort of mental check over whether you do any of these things. During the day, are you trying to alter or control your behavior in different ways to ensure you have good sleep at night. So for example, it might be that you’ve started to restrict or avoid certain activities, because you’re thinking about whether or not they are going to affect or impact your sleep. You see, good sleepers or normal sleepers. Yes, of course, they will try and have be sensible with the kinds of activities that they’re doing, they’re not going to be going out going to nightclubs every night of the week. If you’re trying to hold down a job, you might not go out on a massive drinking binge on a Tuesday night because you know that that is going to affect your sleep and, and your work the next day. But normal sleepers aren’t restricting their activities, and telling themselves I can’t do things like exercise, I can’t go out with my friends in the evening, because it probably means I’ll be too stimulated and I won’t be able to sleep. So have you started rearranging or reorganizing your life in a way that is designed to control sleep? Have you started recently or over time, incorporating lots of rituals into your day or perhaps maybe just in your evening period, in order to make sure you fall asleep at a certain time? It might be pills and potions and things you do might be that you have to have a bath with certain essential oils in order to get you to sleep. So it does it feel like there is some rigidity and fixation and perhaps obsessiveness, about the things that you do in a certain order or a certain way to help you get to sleep. And this is very common with people with long-standing insomnia, because the annoyance and frustration with not being able to sleep leads to desperately trying to find the one thing that will help you get that perfect sleep. Unfortunately, sleep is kind of messy. Even in good sleepers. They relatively regularly have what we might call a bad night of sleep. So it’s impossible to have have perfect sleep. Other things that you might be doing during the day are, as I mentioned before, like what happened to me, You’re spending a great deal of time monitoring your own behavior monitoring your own tiredness levels. You might be thinking negatively about the previous night’s sleep, focusing on that, how am I going to function today? And then worrying about what will happen that night? Am I going to be sleeping tonight? Oh, no. If I don’t sleep tonight, that means I won’t be able to do this thing tomorrow. I really catastrophizing. Then at nighttime. When you go to bed? Are you lying in bed worrying? Do you even feel anxious about the thought of entering the bed? When you’re in bed? What are the kinds of things that you’re thinking about? It’s almost like your mind just switches on and kicks into gear when you go to sleep? And then during the night, what are you doing? Is there any other behavior that is kind of designed to try and monitor sleep or control sleep in some way? Are you checking the clock? Are you taking more medication or doing something else to desperately try and fall asleep, or perhaps you’re just lying in bed, almost trying to force yourself to sleep. So these are all things that may be unhelpful. So let’s move on to thinking about what we can do to improve this, then we might have identified some of the issues here that are contributing to this unhelpful, vicious cycle that is making your brain see sleep, and your bed as a kind of threat or something to be anxious about.


Nathan Illman  21:46

And let’s think about some techniques to break that cycle. Before I go into that, just a couple of quick reminders. One is that if you’re someone who works, night shifts, and then day shift, or maybe just night shift, and you’re wanting something a bit more specific for you, then listen for the next episode of the podcast because I’ll be covering how this stuff relates to shiftwork in more detail. However, I am confident that what I’m about to share with you will still be helpful if you’re struggling with your sleep, and you feel like you do have insomnia. The other is, if you are enjoying what I’m sharing with you, you’ve enjoyed last episode, and you’re already finding this helpful, then check out the other resources that I have a nurse while being mission.com. And if you want to bring this kind of practical, hands-on stuff to your team, the nurses and midwives that you work with, you’d like to see them get better sleep and perform better and have overall better well-being. And you can find out our website about ways you can work with me. All right, let’s dive into thoughts, behaviors and emotions and how you can modify these things, and work with them more constructively to improve and break that cycle of insomnia. So let’s start with thoughts. And to begin with, I’m going to start with nighttime thoughts. So one of the main issues that we see with people who’ve got insomnia they’re struggling with their thoughts at night is that word, they’re struggling with their thoughts at night. So the relationship we have to our thinking, can determine the extent to which we have more unhelpful or stressful, anxious thoughts. So you may be someone who finds that you’re lying in bed at night, and you are desperately trying to sleep. When you notice worries about not being able to sleep, you are trying to push those away, you’re saying to yourself, I just don’t want to have these worries, I don’t want this. You’re trying to suppress them, you’re investing energy and effort into that, because you’re trying to clear your mind because you know that if my mind is just clear, then I will be able to sleep. Now I’m guessing if you’re listening to this, if you’ve listened up until this point, you may have found that that strategy, unfortunately, doesn’t really work in the long term. We know there’s something called thought suppression. And the effect of thought suppression can be an unintentional or paradoxical effect in that we actually have more of the same kind of thoughts. And if those thoughts worrisome thoughts about sleep itself, or what you’ve got to do the next day, for example, then that creates even more anxiety and the problem persists. So what do we do instead? Well, we have to flip this thing on its head and is thinking something completely different and change the way you relate to those thoughts. So instead of getting all caught up in those thoughts, what I’m going to invite you to try out out, is to see if you can actually just make space for them being there, you’ve spent a long time perhaps battling them every night, when you go to bed, whether it’s at the beginning of the night or during the night, is not been successful in the long term. Or maybe you have the odd night of good sleep. But generally, your sleep is not particularly great. And these thoughts keep coming back. So if we keep doing the same thing we’ve always done, we’re gonna keep getting the same results. So it’s now time to try something different. And I’m going to invite you to actually just be open to a completely allow those thoughts to be there. And actually, to welcome them. So as you notice those worries coming into your mind, I want you to acknowledge them as worries, see, if you can, for a moment step out of that thoughts that you’re having. When you notice that you are having the same kinds of worries about not being able to sleep or your performance the next day, for example, or how you’re going to come across to other people, see if you can just give that worry a name. So almost in a kind of friendly way, you know, kind of curiosity and friendly way saying, Ah, okay, I’m noticing the performance worry, again, I’m noticing the work worry. Again, each time you do that, what happens is you are stepping out of the worry itself. And you’re giving yourself the opportunity to not get caught up in it and not persist with that cycle of what the worry does is it just contributes to this sense of danger and threat in your brain, sort of metaphorically. And that’s what leads to the increase in that sort of stress response in the body. So that is my recommendation at night, giving the worries a name lying there, you expect them to come welcome into your mind, change your attitude towards the worry. So whereas in the past it is, I’m guessing likely have been one of resistance, not wanting them wanting to clear your mind in order to sleep, try out, abandoning that, and actually doing the opposite saying, Okay, right, these worries are going to come. Regardless of what I do, I’m just going to allow them to be there. And I’m going to acknowledge them and give them a name and just see what happens. And I guarantee if you practice this, and you change that relationship to your thinking, then it will dramatically help especially with the distress you have in the middle of the night. Because when we are a bit more detached from our thinking, we’re not wrestling with it, we’re not battling with it, we’re not contributing to that cycle of anxiety and frustration, as well. Now, when it gets to the daytime, suddenly, that’s really important to begin with off the bat in the morning is that we do that same process. So it’s funny because as I’m recording this, I actually had a bad night’s sleep last night, I really unusually had a bad nightmare in the middle of the night, and then woke up and couldn’t get back to sleep and was up at like 4:30 am. And to begin with my mind kicked in with things like, ah, today’s gonna be really hard. I had a workshop I was delivering, ironically, on sleep this afternoon. And my mind was saying to me are you going to be able to be engaging Are you going to be able to, you know, always kind of worries. And what I did was I use a technique I just shared with you and acknowledged them, got myself out of bed and got on with the day. And each time anything like that showed up, I just acknowledged, okay, that’s a worry in my mind, and allow that thought to pass and carried on with what I needed to do. So there is this really crucial thing that’s important for insomnia. In the morning, when your mind is trying to almost kind of attach you to the previous night’s sleep, it wants to dwell on it, it wants to remind you of how bad that sleep was and what effect it’s going to have. On the rest of your day. It’s really important to try and disengage from that process of thinking, and just remind yourself what you need to do and get on with doing it. So if you can focus your attention on the outside world externally. So that’s essentially using a mindfulness technique of noticing a particular worry or judgment about yourself or about the sleep and and allowing it to pass. So not buying into it. The other thing you can do as well. And a combination of these is really helpful is actually questioning the validity of some of those thoughts. So it’s very typical in people with insomnia that their mind will convince them of this story. If you cannot perform at all, perhaps you just won’t be able to do your job, I can’t, I won’t be able to function. And you can get stuck in this kind of story. See if you can catch that and name it, as we’ve just been saying, you know, this is the performance story or performance worry, for example, and ask yourself, Is it really true that I won’t be able to do my job today? Have there been other times where I’ve actually not slept that well, but I’ve still, for example, had a really nice day, I’ve actually done a good piece of work, and maybe you’ve been given some feedback about it. So our minds tend to focus on the negatives. And when you’re tired as well, we know that that’s what tends to happen even more. So it’s really important to sometimes actually question what your mind is saying, as you go about the rest of your day. Of course, if you have got long-standing insomnia, it’s likely that you’re going to have a lot of sleep-related thoughts during the day. So I’m going to invite you to practice again, every time any sleep-related thoughts show up for you, that will probably come in the form of some kind of worry, Oh, should I do this because it might affect my sleep, or am I going to be able to sleep tomorrow, or maybe work so on mentioned something that you’re going to be doing later in the week, and you’re immediately thinking or worrying?


Nathan Illman  31:29

Am I going to get enough sleep in order to do that presentation at ward round or something, you know, that you’ve got to do. So each time you notice a sleep-related thought, acknowledging it and just saying to yourself, Okay, that’s another sleep-related thought. And seeing if you could just hold that in your awareness, give it a name, and disengage from it. Even if your mind is particularly sticky, and really wants you to think about it, it’s placing a lot of emphasis on it, do not be tempted to buy into that story. Imagine your mind as a kind of pushy salesperson, they’re trying to sell you this story of poor sleep, they’re trying to sell you the worry about what how your sleep loss will affect your work or your family life. And just as a salesperson might be doing this, you don’t have to listen to what they’re saying or to buy what they’re trying to tell you. So try to approach your mind with this kind of always play for attitude, it can be really helpful. And this is especially the case, when your mind is trying to get you to shift your behavior in order to try and control sleep in some way. So underlying this maintenance of insomnia is essentially the need, or what’s developed, is it a flight, you feel like you need to try and control sleep, even though it’s actually this natural process. So if your mind starts saying to you things like, Ah, my friends asked me to go out with them tonight, but I better not go out. Because if I go out, I’m going to be too stimulated. And I won’t be able to sleep. Or for example, if in the past you had done some kind of movement or exercise after your shift, you might not be that late into the evening. And actually, that was a really, really big part in contributing to your well-being. But now your mind is saying, I can’t exercise because I’d be too stimulated, that’s going to affect my sleep. Notice your mind trying to control your life in different ways by adding things in to it might be trying to tell you to, you need to take this supplement, or do this behavior, this ritual in order to sleep, be more aware of sleep-related thoughts. What can be really helpful is to just imagine that you are a good sleeper, someone who sleeps well, and almost put your mind in their shoes, and try to think of it from their mindset. A good sleeper or someone who sleeps well is not thinking about sleep. If they have sleep-related thoughts, they’re probably just acknowledging them, then getting on with their day. So I might want to improve their sleep, they might be doing certain things to try and optimize their sleep. They’re certainly not thinking about them obsessively. And they don’t have this underlying element of trying to control their sleep. So they’re letting thoughts go about sleep. They’re being flexible with their socializing and other activities they do. They’re just accepting that sometimes they might go out a bit later, doing something and that maybe they’ll affect their sleep, but also maybe not to try and put yourself in the shoes of someone who is who could sleep and apply that to your own thinking. So let’s move on to behavior. Technically thinking is a behavior. So I’ve already covered some behavior with the law. Last section. But there’s definitely more to add here. In terms of breaking this, this cycle of poor sleep, and or insomnia. The first relates back to something I was just saying about rituals and routines. So what we know from kind of treatment of insomnia is that if you raise awareness of all the things you are doing, that are designed to try and control your sleep, or make sure you fall asleep, by removing or reducing those from your life, it helps to undermine this belief that I need to control sleep. And in order to repair that negative association you have between sleep and anxiety, is absolutely crucial to undermine this belief that sleep is something to control. Because as long as that persists, your brain is going to continue associating it with this anxiety. So look at your behavior, what you’re doing in the evenings. Are you eating certain things or not eating certain things? Are you taking sleeping medication? Are you taking melatonin? Are you doing or taking anything else, maybe you have some weird and wacky routines and rituals some people do. And this is just something that has built up over time, because people are desperately trying to get better sleep. Now, of course, I am not saying that there are certain things that one should always abandon if you’re trying to optimize sleep. So for example, there is research that shows that taking certain supplements or certain compounds can help to improve your sleep quality. And certain dietary things you can do. What we want to be doing here is just being discerning. So if you are listening to this, and thinking of making these changes, you think you’ve got insomnia is about the function of that behavior for you. So again, a good normal sleeper might be taking supplements, or avoiding sugar and trying to eat a lighter meal or something before he goes to bed. Not really, because they’re trying to control sleep, because they ultimately they believe that they’re going to sleep, that sleep is just this natural thing. But they’re just thinking, I kind of want to improve my sleep quality. There’s a kind of lightness and flexibility to those behaviors. Whereas if you’re someone with insomnia, particularly long-standing insomnia, it’s very likely that you feel you need to or you have to do these things to get to sleep. And if you don’t do them, then there is a kind of fear around it. So good sleeper won’t have that if they forget to take their magnesium or zinc supplement, or whatever it is, one evening, they’re not going to panic about it, because they just have this natural trust and sleeping. So that can be you. But you have to start abandoning all of these things that you’re doing, to try and control sleep. Another behavior that is really important to consider is the way in which you monitor your own internal sensations, and tiredness and fatigue. So what can happen in insomnia is, because it’s unpleasant, obviously, feeling tired the next day, we have this natural thing where our attention shifts between our emotions and sensations and thoughts internally, and things going on in the external world. Over time, one of the maintaining things that goes on with insomnia is people start to focus a lot on how they’re feeling. They’re focusing entirely on the feeling of tiredness or fatigue. And then that can create further thoughts on I’m so tired off, this is so terrible. And that creates these difficult and unpleasant emotions like anxiety, or anger, frustration, or even low mood or even depression at its worse. So what can we do about this? Well, it’s about trying to reduce the extent to which you’re obsessively monitoring yourself internally. Again, coming at this from the perspective of someone who is a pretty good sleeper, if they’ve had a bad night and this is a great example, I had a bad night. Like I said, whilst I feel tired doing this, I felt have felt a background level of tiredness and fatigue all day. I’ve simply noticed that but then come back to what I was doing what was important to me. Because what we tend to find is that if we’re focusing on the fatigue and the tiredness, that saps our energy, so people with insomnia tend to focus negatively on their own internal sensations, and then start thinking I’m tired and fatigued. Okay, well, maybe I need to conserve my energy. And that leads to avoidance of activities that leads to being disengaged from things like work. But actually what we know is energy is something we generate, we create it fine purposely being energetic as I’m delivering this as I’m talking to the camera and recording this, and it’s making me feel energized, right. But I’m not focused internally, I’m just focused externally. So that’s something for you to go and try is to notice when you’re focusing on the internal sensations. And perhaps again, you can just name those if you do happen to that, okay, I’m noticing tiredness or noticing fatigue, and then shifting your attention externally. The next thing that is really important are sleep routines. And suddenly, that’s called a sleep window. Now, I mentioned in the last episode, the importance of creating a positive, structured, regular routine for sleep. So this involves having a regular bedtime and wake time, and kind of sticking to this because your brain expects to go to sleep at a certain time, expects to wake up at a certain time, our brain and bodies love these kinds of rhythms. And essentially, we developed this positive association between bed and sleep. Many people with insomnia have very irregular routines. So because of having sleepless nights, many people with insomnia on their days off, for example, will think I need to catch up on sleep, they’ll sleep in long that day, the next night, they might not go to bed too late. And then of course, this has has this impact of chopping and changing the sleep routine. And sometimes putting naps, long naps in the day, which then reduce that sleep pressure and make it probably impossible to go to sleep, or the kind of bedtime that you would like to go to sleep, what’s really important is coming back to creating a solid routine. So setting yourself a realistic bedtime and wake time and giving yourself what’s called a sleep window. So for example, if you want to aim to sleep that say seven and a half hours a night, you need to be up for work, you need to get to work for 6:37am, say, and then you think, okay, I want to work back, I need an hour to get ready. So I need to be up at 530 I want seven and a half hours sleep, okay, so I need to go to bed at 10 pm. So setting yourself an alarm for the bedtime, and for the wait time and trying to stick to that. So in the most evidence-based research back treatment for insomnia, the technique is used in which people are given us this kind of sleep window. And it’s tailored individually to people depending on their circumstances. But it basically involves kind of shortening your sleep window, forcing you to go to bed a little bit later. So waiting until you are really tired, sleeping and getting up at your set wake time in the morning. And then staying awake the whole of the rest of the day. Bringing your bedtime a little bit earlier and a little bit earlier a little bit earlier. Because what this does is it gradually gets your body used to having to fall asleep, right because that sleep pressure increases. Now of course, this is quite an individualized thing as I mentioned. But if you’re listening to this, and you want to give this kind of thing ago, I’d really recommend doing what I just said to begin with, which is around setting your scope back to a regular routine. So setting that bedtime and wake time and sticking to it getting out of bed in the morning at the time your alarm goes off, even if you feel you haven’t slept well. And then try to stay awake the whole of the next day. And not napping, and making yourself so tired that you will fall asleep the following night and then sticking to this. And when it comes to your days off doing the same thing, or there abouts. Because if we then start to try and catch up on sleep at the weekends, for example, it can create this continued with this vicious cycle. Now another behavioral technique that I’m going to talk to you about is something that’s called stimulus control. So one of the problems people have is that they start to associate being in bed with worrying and anxiety to even the thought of going to bed creates that sense of worry and anxiety for you. It just feels really unpleasant. So the more time that we spend lying in bed awake worrying, the more your brain starts to associate. The bed is a place to worry about a place that is basically unsafe for you because your brain is interpreting it as some kind of threat or danger. So it’s really important to break that cycle. How do we break that cycle? You have to start retraining that association with the Add as somebody that is calming, and somebody that you are able to fall asleep. So what’s recommended is that when you are lying in bed and you feel like you’ve been there for about 15 or 20 minutes, just worrying or thinking about things is that you get yourself up out of bed, you go to a different room, ideally, you have a calming activity already set up for you that you put there before you went to sleep. Because it’s hard to do this in the middle of the night harder generate the kind of motivation to


Nathan Illman  45:32

the most obvious one is reading a book, some sort of book that is not going to stimulate you too much. You certainly don’t want to be watching some kind of horrific horror movie on TV, too, in the morning when doing this. But listening to some kind of calming music might be another one. And you want to sit in a chair ideally, and do a calming activity until you start to fall sleepy. So it’s something basically to distract yourself from worry and anxiety, you start to feel calm. And when you feel sleepy, then going back to bed, and waiting until you fall asleep. Now, if the same thing happens, is really tough and difficult, but you get yourself out of bed and do the same thing again, the more you do this, when you eventually go to sleep in your bed, you’re essentially telling your brain, okay, the bed is a safe place to fall asleep. And the more and more you do this, you can retrain that association. And it becomes possible to fall asleep easier in bed. So give that a go. If it’s something that you haven’t already tried, at least just be mindful of the fact that the more time you spend worrying in bed, the more negative association has been created between sleep, and kind of anxiety and worry. So the final thing to say about behavior is really just around having healthy sleep habits and routines. And this just goes back to all of the things I mentioned in that first episode. So again, you know, it’s really important to factor in the importance of things like not drinking caffeine, for example, and the fact that getting morning light is helpful for sleep. As I mentioned a few times in this episode already, you know, we want to be incorporating those things into our day. But we need to be mindful of if we’re doing that quite rigidly and we’re doing it as another means to try and control sleep. So there’s a balance between having healthy sleep habits and what we call sleep hygiene. And then using sleep hygiene-type behaviors as a way to to really try and make ourselves sleep to force ourselves to sleep. So the final aspect of this tips for managing insomnia is emotions. So the role that emotions play and how to kind of manage that and respond to them differently. So it’s very common at night for people to be lying in bed awake, having these difficult thoughts, difficult worries, and to be feeling anxious and frustrated and angry about the situation. And then what happens is, you start to get annoyed at how you’re feeling as well, there is this kind of cycle where emotions are being layered on top of each other, you start to feel restless, and then you’re anxious about feeling restless, and fidgety. And, as we said, this all contributes to that kind of wanting to force yourself to sleep to kind of just, I don’t want to feel these things, I just want to be relaxed. And as you know, that doesn’t really help. So why I’m going to suggest to you is again, you try something very similar to the technique I mentioned about thoughts is that instead you just allow those sensations and emotions to be present. Open yourself up to them. Focus on your breathing, breathing into your nose and out through your mouth. saying to yourself, I’m not going to try and control how I feel here. I’m going to be open to and just allow anything to be present. If anxiety shows up to just acknowledge and notice it say to yourself, I’m feeling or I’m noticing that I’m feeling some anxiety here. Or I’m noticing restlessness and see if you can just hold that in your awareness. Maybe even turn your attention towards it. Where are you noticing the restlessness. See if you can befriend the sensations be bold and courageous and turn towards the things that normally you would get frustrated about and kind of not want those aspects, those feelings in your body that feel difficult. So if you can actually open up to them and make space for them. And what we know is that when people do this, the act of lying there and falling asleep becomes easier because you’re just open to anything and this is paradoxical effect that if we fight less with the act of going to sleep, become something that we’re less trying to control. And when we’re not trying to control sleep, we fall asleep because it is natural. So we have reached the end of this episode. I guess there’s just a few things to finish off. In summary, insomnia is very common in nurses and midwives is something that is not spoken about enough. And hopefully, this is raising awareness of it should just by me sharing this podcast, go and talk to your colleagues have more conversations about sleep, please, because that is the way that we’re going to highlight this serious issue and we’re going to be able to help more people get adequate rest be able to perform better, but ultimately to improve their well-being. As I mentioned before, you know, sleep has a massive impact on our physical and mental health. Now, I am anticipating that people may get in touch and say, What about things like sleep and trauma, for example. And I will do future episodes on different aspects of sleep because it is a really big topic, in particular the role of post-traumatic stress disorder and sleep and for example, how to manage nightmares that you’re having, so I will focus on them in the future. And as I’ve said in this episode, already, the next episode we’ll be looking at shift work and how to optimize sleep patterns around shift work. So if you’ve been listening to this, or watching this and enjoyed it, and you’ve enjoyed maybe some of the other episodes that you’ve listened to, if you’re not already following me, then come along, come and join my community. You can find me on nurse wellbeing mission.com You can find my free Facebook group if you just search for nurse and midwife well-being mission. You can follow me on Instagram it’s at underscore nurse while being mission. Where else Twitter at nurse or Helbig. You can see a consistent theme here. Can you come along, join my community, find some of my other resources and check out the other ways that you can work with me as well. Providing different ways to better prepare nurses and midwives for emotionally challenging work. It’s been an absolute pleasure delivering this today and talking through a topic that I’m very passionate about. You will hear from me very soon. Bye for now.