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Worldview 2008: A global nursing perspective

Geoffry Phillips McEnany: Professor of sleep

by Jane Palmer

Clinicians and researchers are opening their eyes to the important role sleep plays in health and illness, says Geoffry Phillips McEnany, PhD, APRN, BC. Over the past decade, scientific knowledge about sleep and its application to clinical practice has grown rapidly. Research studies have shown that disturbed sleep can increase vulnerability to cardiovascular disease, diabetes, obesity and cancer, as well as contribute to daytime sleepiness, psychiatric and medical disorders, memory problems and other conditions.

Geoffry Phillips McEnany

Phillips McEnany, a professor of nursing at the University of Massachusetts Lowell, USA, has focused much of his research on sleep dysregulation in people diagnosed with psychiatric illnesses. His early clinical work sparked his interest in the care of people with psychiatric illness and the role that sleep played in the illnesses.

“As a clinical nurse specialist and previously as a staff nurse in psychiatric nursing, I realized that pretty much every individual I worked with in psychiatric nursing was a victim of some sleep dysregulation,” Phillips McEnany says. “I didn’t understand why that was, and as a nurse, I had not learned much in nursing school about sleep and its relationship to psychiatric illnesses.”

His doctoral and postdoctoral studies were directed at understanding sleep dysregulation in women diagnosed with major depression. His studies utilized polysomnography and core body temperature measures as markers of depression, and he researched the impact of interventions on sleep and biological rhythm dysregulation in depression.

He was fortunate to be studying at the University of California, San Francisco, where he was mentored in his doctoral and postdoctoral work by Kathryn A. Lee, RN, PhD, FAAN, an international nursing leader in sleep studies. Phillips McEnany cites the seminal work conducted by many nurse researchers over the last 30 years. These visionary nursing scientists have contributed significantly to scientific knowledge in the area of sleep in ways that have shaped the understanding of sleep-related phenomena.

Clinical role enhances teaching, research
At UMass Lowell, Phillips McEnany juggles several roles as a professor, researcher and advanced practice clinician. “I believe that being in practice is critical to effective teaching in our practice discipline," he says. "It enhances the quality of what I bring to the classroom and assures a fresh perspective on practice. As nurses, we understand and are engaged by clinical phenomena. The clinical work informs questions for research as well, but coordinating the three roles is challenging.”

His students and colleagues give Phillips McEnany high marks for his work.

“He is a phenomenal asset to our faculty,” says Karen Devereaux Melillo, PhD, APRN, BC, FAANP, professor and chair of the Department of Nursing at UMass Lowell. “He is a master teacher. He teaches both online and in face-to-face venues. His expertise in sleep dysregulation, chronobiology and psychopharmacology is wonderful. His evaluations by students are always outstanding. He’s willing to give of himself as a guest lecturer. I don’t know how he divides himself in the many ways that he does.

“He’s very, very thoughtful in meetings. All nursing faculty have meetings that can get a bit contentious, and he has a way of seeing the total picture. He’s an expert in group dynamics and utilizes that skill in his own practice role as an adult psych CNS, and to effectively deal with all of us,” Melillo says with a laugh. “It’s an honor and a privilege to have him on board.”

Discoveries in sleep research
In many ways, sleep-related science has been a sleeper in medicine and nursing, Phillips McEnany says. The rapid growth of scientific knowledge in the past few years is exciting, but much research remains to be done.

Geoffry Phillips McEnany talks with UMass faculty members (from left) Ainat Koren, Mary Ellen Doherty, Susan Houde and Mary Findeisen about sleep research.

From 1995-97, he studied nursing strategies for major depression in women as a postdoctoral fellow with the Agency for Healthcare Research and Quality. The research that he and Lee, his mentor, conducted led to publication of “Effects of light therapy on sleep, mood and temperature in women with nonseasonal major depression” (McEnany & Lee, 2005).

Previous research had shown the effectiveness of light therapy in treating seasonal affective disorder (SAD), a form of depression that occurs during seasons with less daylight. Phillips McEnany and Lee wondered if light therapy could also improve sleep, mood and energy among women with nonseasonal depression. Research participants included women who were either premenopausal or postmenopausal and were diagnosed with major depressive disorder, but not taking psychotropic drugs or hormone replacement therapy. Core body temperature was among variables that were monitored because of its critical role in sleep, and the relationship of sleep to symptom expression in depression.

Carol Picard A nursing treasure Geoff is a great scholar and clinical expert. His knowledge in sleep dysregulation and psychopharmacology is truly of the first order. But that is not what sets him apart in my mind. It is his ability to take this knowledge and, in the finest way, convey it to others, be they patients, students or practicing nurses. I had the pleasure of working with Geoff, and students would tell me he was the best teacher they had ever encountered, either in an online or classroom venue. People I have referred to his practice have also spoken about his knowledge and compassion as he helped them sort out their clinical problems. He sends a little “spiritual vitamin” (my term) to people he knows each morning called “Daily Dharma for Spirit Sangha.” It’s a little quote and a picture—something to reflect on as you start your day, and often from the Buddhist tradition. It is just another of the creative ways in which he provides compassionate care. For example, a couple of days ago the quote was from Pema Chödrön, a Buddhist nun: “If we learn to open our hearts, anyone, including the people who drive us crazy, can be our teacher.” I consider Geoff a “living nursing treasure.” —Carol Picard is past president of the Honor Society of Nursing, Sigma Theta Tau International.

“Temperature is on a circadian rhythm,” Phillips McEnany explains. “The warmer daytime temperatures correspond with being awake and alert, and the cooler nighttime temperatures are requisite for sound sleep. A lot of people get sleepy during the middle of the afternoon, and this too corresponds with a normal dip in the circadian rhythm of temperature. Physiologically, anything that significantly alters core temperature will effect wakefulness or sleep, and this is absolutely normal. However, in illnesses like depression, the dysregulation in core temperature is associated with symptom manifestation.”

Core body temperature has special relevance for women. In the normal menstrual cycle, temperature rises at ovulation and remains up until the menstrual period begins, he says. Higher core temperature corresponds with more arousal in sleep; thus, sleep quality may be reduced during that portion of the menstrual cycle. “The works of nursing scientists such as Drs. Joan Shaver, Kathryn Lee, Martha Lentz, Nancy Woods and others have made great contributions in the area of sleep and women’s health,” Phillips McEnany notes.

“Sleep and mood are very, very tightly connected,” he says. “I sometimes use the analogy with students or patients that sleep dysregulation is to psychiatric disease as chest pain is to cardiac disease. It’s an indication of a core dysregulation in underlying physiology.” With this perspective, patients are able to see that sleep disturbances in psychiatric illnesses have significant roots in disturbed physiology related to the disease. Coupled with knowledge about behavioral influences on sleep, patients begin to see that sleep disturbances constitute a part of the disease process and also can alter the clinical outcomes of treatment.

Treating sleep disorders
Phillips McEnany maintains an adult psychiatric nursing practice in Boston. Patients referred to him by other clinicians often have sleep disorders in combination with depression, bipolar illness, schizophrenia or other major psychiatric illnesses.
 
“I see a lot of people with undiagnosed obstructive sleep apnea, restless legs syndrome or other sleep disorders who are also being treated for psychiatric illnesses,” he says. ”Sometimes primary sleep disorders are mistakenly diagnosed as psychiatric illnesses. Insomnias, excessive daytime sleepiness, episodes of disturbed behavior associated with sleep, obstructive sleep apnea and a variety of other sleep-related conditions share symptom constellations with many of the psychiatric illnesses. In those who are diagnosed with psychiatric illnesses, the potential for missing a sleep disorder may be great. As clinicians, we may not have received the type of training that would allow for this type of symptom-based discrimination. Our learning needs related to sleep assessment and intervention are great.”

As an advanced practice nurse in Massachusetts, Phillips McEnany has prescriptive authority across different classes of drugs. He has become well-versed in psychopharmacologic strategies in treating psychiatric illnesses, often in the presence of comorbid sleep disorders. Practice guidelines from the American Academy of Sleep Medicine specify which treatments have the greatest evidence base for sleep dysregulation, he says. Drugs used to treat sleep disturbances include benzodiazepine receptor agonists, such as triazolam (Halcion), eszopiclone (Lunesta), zolpidem (Ambien) and others. Conversely, there is the issue of excessive daytime sleepiness, which may be treated with wakefulness-promoting agents such as modafinil (Provigil) and others. These drug treatments must be coupled with behavioral interventions to assure the best clinical outcome.

In recent years, use of off-label drugs (drugs the U.S. Food and Drug Administration has not approved for sleep dysregulation) has increased. Antidepressant, anticonvulsant, antihistamine or antipsychotic medications have all been prescribed to treat sleep-related problems, but these drugs may carry significant levels of risk.
 
Many patients use herbal remedies to help them sleep. “Having an understanding of herbals is critical, because they are biochemically active substances, and there is potential for interactions with prescription or non-prescription drugs,” Phillips McEnany says.  He recommends that students and nursing colleagues buy a copy of the PDR for Herbal Medicines (Kush et al., 2007). In this reference book, certain herbals are designated as approved by Commission E, which means there is an evidence base to support use of that herbal for a particular condition.

Sleep hygiene 1. Use your bed for sleep and sex only, not for reading, writing, eating or watching TV. 2. Establish a regular bedtime routine, and keep a regular sleep-wake schedule, even on weekends and holidays. 3. Avoid naps, particularly in the late afternoon or evening. 4. Create a sleep-promoting environment that is quiet, dark, cool and comfortable. 5. Avoid caffeine, nicotine and alcohol late in the day. 6. Don’t perform strenuous exercise late in the day. 7. Don’t eat or drink too much before bedtime. 8. Don’t go to bed unless you are sleepy. If you’re not asleep after 20 minutes, get out of bed and do something that is relaxing. Sources: American Academy of Sleep Medicine, 2007; National Sleep Foundation, 2007.

Medications, however, are just one way clinicians treat patients with sleep disorders. Part of the nurse’s role, traditionally, has been teaching patients and clarifying which strategies are healthier and more effective, Phillips McEnany notes. “In the absence of understanding what to do with sleep dysregulation, a clinician might write a prescription for a sleep medication. Last year, there were around 8 million prescriptions written for sleep medicines in the United States, and that doesn’t include the off-label medications that have been prescribed. The nonpharmacologic treatments for sleep disturbances need to be included in any care plan or treatment plan, and as is the case with sleep medications, there is a growing evidence base for the use of nonpharmacologic interventions for sleep.

Treating patients without drugs
Cognitive behavioral therapy for insomnia (CBT-I) is one nondrug intervention that has great potential for helping patients with sleep problems, he says. CBT-I seeks to influence how a person perceives a situation, how those perceptions shape thinking, how that thinking shapes feelings, and how the feelings are expressed in behavior.

Phillips McEnany cites this example: “If my perception is ‘I’m not going to sleep tonight,’ then the subsequent thoughts are likely to be negativistic: ‘If I don’t sleep, how am I going to take care of my kids?’ ‘How am I going to function at work?’ ‘What am I going to do if I don’t get to sleep?’ Those thoughts create anxiety. That anxiety is activating, so the person lies in bed, tossing and turning and getting more and more anxious." The best predictor of a bad night’s sleep is anticipation of a bad night’s sleep, and CBT-I aims to correct these patterns to enhance healthy sleep patterns.

In cognitive behavioral therapy, the clinician helps the patient recognize distortions in perception and the cascading impact of those perceptions on emotional states. The goal of CBT is to teach patients to become more aware of their thoughts, moods and behaviors, and then to challenge and alter dysfunctional patterns.

The need for skillful application of nonpharmacologic therapy in practice is great, but few clinicians are qualified to use strategies such as cognitive behavioral therapy to treat patients with sleep disturbances, Phillips McEnany says. Without adequate behavioral treatment of insomnia, patients may become dependent on sleep medications. Along with this dependence comes the fear that insomnia will recur without the medication.

Catching up with sleep
Rapid advancements in evidence-based knowledge about sleep underscore the need to provide more education for nurses. One educational opportunity will soon be available to members of the Honor Society of Nursing, Sigma Theta Tau International. Phillips McEnany recently received a $135,000 grant from Sepracor to fund a 12-module online course, “Sleep and Chronobiology for  Nurses: A Program of Clinically Focused Education.” UMass Lowell is partnering with the honor society and the American Psychiatric Nurses Association to make the course available to nurses. While this course was initially designed to meet the learning needs of psychiatric nurses, its content is appropriate for any nurse.

The first nine modules provide a foundation for understanding normal sleep, chronobiology, sleep in women, sleep disorders, and comorbidities with medical and psychiatric illnesses, along with fundamental information on both nonpharmacologic as well as medication-based interventions. Modules 10-12, intended for advanced practice nurses, examine topics such as cognitive behavioral therapy for insomnia, advanced pharmacology, and use of clinical instrumentation such as psychometric measures and actigraphy.

The online course is based on curriculum recommendations developed by a nursing task force of the Association of Professional Sleep Societies. The group’s position paper, “Sleep and Chronobiology: Recommendations for Nursing Education,” was published in Nursing Outlook (Lee et al., 2004). Registration for members of the American Psychiatric Nurses Association is now open at http://www.apna.org.

Sigma Theta Tau International members will be able to access the course by May 1 at www.nursingsociety.org. The course is offered to members of the nursing honor society at no cost, and participants who have successfully completed the course will be awarded 36 continuing education contact hours. The course has been accredited through the Maryland Nurses Association, which is an accredited provider of continuing education by the American Nurses Credentialing Center.

Two other resources that Phillips McEnany suggests for nurses are the National Sleep Foundation, www.sleepfoundation.org, and the American Academy for Sleep Medicine (AASM), www.aasmnet.org. He refers clinicians to clinical practice guidelines of the AASM for information on topics such as evaluating insomnia, using behavioral and pharmacologic interventions, assessing obstructive sleep apnea, and treating restless leg syndrome. Patients may find helpful information on the public education Web site from the American Academy of Sleep Medicine at www.sleepeducation.com.

His nursing roots
Phillips McEnany grew up in Massachusetts in a family with six children. Initially, he planned to be a language teacher, but after two years in college, he decided to take time off to reconsider his career choice. During that time, he worked as an emergency room technician. His sister Karen inspired him to pursue nursing. “She has been a nurse for about 35 years now and remains active in practice in the care of elders,” he says. “She is a living example of the art and science of nursing: skillful, informed, compassionate and caring."

Once in the diploma nursing program at Massachusetts General Hospital, Phillips McEnany was convinced that he had made the right career choice. During clinical rotations, he was particularly fascinated by psychiatric nursing. At that time, explanations for disorders such as schizophrenia or bipolar illness were mainly psychodynamic or interpersonal, he says. But, the idea that such illnesses were biologically based was beginning to gain ground. Huge advances in knowledge have been made in this area of science in the last 30 years.

After completing the diploma program, he moved to California and received his BSN from the University of San Francisco. He earned his MSN and his PhD from the University of California, San Francisco, and returned to Massachusetts in 1999 after living in the San Francisco Bay Area for 20 years. He recently was promoted to full professor with tenure at UMass Lowell.

“It continues to be an incredibly wonderful professional life,” Phillips McEnany says. “New England is beautiful, and it’s nice being back with my roots.” RNL

References and Resources:

American Academy of Sleep Medicine. (2007). Sleep hygiene: The healthy habits of good sleep. Retrieved February 14, 2008, from http://www.sleepeducation.com/Hygiene.aspx

Kush, R.D., Bleicher, P., Raymond, S., Kubich, W. Marks, R., & Tardiff, B. (2007). PDR for Herbal Medicines (4th ed.). Medical Economics.

Lee, K.A., Landis, C., Chasens, E.R., Dowling, G., Merritt, S., Parker, K.P., et al. (2004). Sleep and chronobiology: Recommendations for nursing education. Nursing Outlook, 52(3), 126-133.

McEnany, G.W. (2005). Beyond pharmacotherapy: The art of patient care. Advanced Studies in Nursing, 3(2), 54-58.

McEnany, G., & Lee, K. (2005). Effects of light therapy on sleep, mood, and temperature in women with nonseasonal depression. Issues in Mental Health Nursing, 26, 781-794.

National Sleep Foundation. (2007). Good sleep practices you can use in managing your insomnia. Retrieved February 14, 2008, from http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2421129/
k.251A/Cant_Sleep_Learn_about_Insomnia.htm

Phillips McEnany, G.W. (2006). No time to slumber: Addressing the paradigm shift in the science of sleep within psychiatric nursing. Editorial. Journal of the American Psychiatric Nurses Association, 12(5), 253-256.