Knowledge about sleep and sleep disorders is becoming increasingly important for health care professionals at individual, family, and community levels of practice. Nurses are in a highly visible and pivotal position to evaluate and intervene to promote sleep for patients. Furthermore, as potential shift-workers in health care settings, nurses need a more comprehensive understanding of sleep and circadian rhythms to manage their own health risks. The future nursing workforce must be educated to increase the understanding of healthy sleep practices, adverse health consequences of impaired sleep, and common sleep disorders. Unfortunately, education about sleep and sleep disorders has not been part of the established undergraduate nursing curricula.
Importance of Sleep Education
Sleep is a fundamental human need for survival, health, and well-being (Rechtschaffen, 1998). Lack of education for nurses about the importance of sleep, consequences of impaired sleep, strategies for sleep promotion, and care for common sleep disorders may directly lead to clinical practices that neglect restorative sleep in hospitals and in other health care settings (Ye, Keane, Hutton Johnson, & Dykes, 2013). Furthermore, sleep deprivation and disrupted body rhythms caused by shift work leads to major physiological and psychological effects on nurses’ health, potentially undermining their ability to provide a high standard of care and jeopardizing the safety of the patients (Muecke, 2005). Improving nurses’ knowledge about sleep and circadian rhythms should be the first step in managing their own health risks and improving patient safety in their practice.
However, as yet, there is no established curriculum for sleep in nursing education. As a result, most nurses start their clinical practice without any instruction or training related to sleep and sleep disorders. A nursing curriculum task force of the Association of Professional Sleep Societies, including a group of nursing experts in sleep research and clinical practice, was formed to begin exploring this issue and published its recommendations in 2004 (Lee et al., 2004). That task force emphasized the need for nursing curricula to further educational efforts for the next generation of nurse clinicians and researchers interested in sleep, regardless of the type of patient population (Lee et al., 2004). Since then, some nursing programs dedicated to sleep education have been developed. For example, the University of Pennsylvania School of Nursing started the first online post-master’s certificate program in 2009, which teaches nurses about the theoretical concepts of sleep medicine and how to apply them to practice and research. Also, the University of Massachusetts Lowell offered a graduate online certificate program on sleep and chronobiology that was initially designed to meet the learning needs of psychiatric nurses. Although those courses are an excellent start to arm nurses with scientific knowledge about sleep, they are primarily designed as continuing education for nurses in advanced practice or at the graduate level. Also, the solely online format may limit the interactive learning experience, which is the preferred approach in health care education. In addition, enrollment in this type of course may be prohibited by its expense, time constraints, and enrollment caps, thus limiting its impact among a larger audience. A great need exists to develop and emphasize sleep and sleep disorders in undergraduate nursing education, with the goal of educating nurses who are new to the workforce as health care professionals.
The goal of the current study was to develop a sleep education program for college nursing students and determine its effect on students’ knowledge related to sleep and sleep disorders. Instead of being a stand-alone course, the goal was to develop a succinct education program that could be easily integrated into the established undergraduate nursing curriculum.
Introduction of the Program
A team composed of faculty members with expertise in sleep and sleep disorders, simulation curriculum development, and undergraduate education developed the program. The principal investigator (L.Y.) surveyed a group of experienced clinical nurses from various specialty areas, asking, “What do you wish you had known about sleep when you were a new nurse?” Based on the nurses’ replies, the following five topics were identified as the most important to be covered in the sleep education program: basics about sleep and circadian rhythm; benefits of sleep and consequences of sleep deprivation; sleep across life span in various populations; shift work, fatigue, and healthy sleep tips; and care for common sleep disorders.
The sleep education program includes three sequential components: a lecture related to sleep and sleep disorders in the traditional classroom setting (2 hours), Web-based virtual guided self-learning (approximately 6 hours), and simulation-based discussion in an interactive classroom setting (2 hours). This multiphase design, using innovative and engaging teaching methods, has accommodated a variety of learning styles, offering opportunities for students to expand and apply their learning into practice.
The model of the study enabled students to build on foundational knowledge delivered in the traditional in-classroom lecture. The more extensive-guided, self-learning progressed the learning of the five major topics. Educational effectiveness of online instruction has been documented. For example, a supplementary Internet-based sleep learning module demonstrated its potential to enhance sleep literacy in college psychology students (Quan, Anderson, & Hodge, 2013). Common course management systems, such as Canvas and Blackboard Vista™, can be used as the platform for this guided online learning. For each of the five topics covered in the program, the principal investigator developed PowerPoint® slides and included required reading from a section of the book Sleep Disorders and Sleep Promotion in Nursing Practice (Redeker & McEnany, 2011). Suggested readings are listed for students to gain extended knowledge, with links to Web sites with useful and reliable information (e.g., http://www.sleepfoundation.org; http://www.sleepnet.com/; http://healthysleep.med.harvard.edu/portal/).
Following the guided online self-learning, the simulation-based discussion provides an interactive teaching and learning opportunity for students to apply their newly acquired knowledge and skills into practice. Simulation-based education in nursing has been identified as an influential mechanism to improve patient care and has demonstrated its ability to generate an active learner response and a significant learning experience (Brewer, 2011; Nehring, Ellis, & Lashley, 2001; Robertson et al., 2010). Video clips were produced that depict sleep- and sleep disorder–related scenarios that are commonly experienced by nurses in various practice settings. These true-to-life vignettes (1 to 5 minutes each) can be shown to and discussed among students in small groups in an interactive classroom setting, followed by faculty-led debriefing sessions to enhance the discussion.
A total of 20 vignettes have been posted on http://www.sleepeducationprogram.com, a Web site dedicated to this program. Seven menu items are available: sleep in the acute care setting, sleep in the critical care setting, sleep and new parents, sleep in the older adult, sleep and fatigue, identifying sleep disorders, and sleep and the college student. Each menu item presents a list of at least two video clips. Examples of the scenarios for the simulation-based discussion include:
- Scenario 1: A new nurse is sleep deprived and complains to a colleague about her fatigue. Discussions are focused on the impact of shift work and sleep deprivation on health and safety, fatigue management, and healthy sleep tips.
- Scenario 2: A nurse is working with a patient who has been diagnosed with obstructive sleep apnea and about to begin continuous positive airway pressure treatment at home. Discussions are focused on obstructive sleep apnea and its therapeutic management, health care for patients with continuous positive airway pressure treatment, and treatment adherence.
- Scenario 3: A 65-year-old female talks about her sleep experience when she was hospitalized in the intensive care unit. Discussions are focused on the importance of sleep and healing, sleep in older adults, sleep and intensive care unit delirium, and sleep-disturbing factors during hospitalization.
Program Implementation and Testing
This sleep education program was implemented in spring 2013 by integrating it into an undergraduate core course offered to every senior-level nursing student. The time line was an in-classroom lecture in the beginning of the semester, a guided online (using Blackboard Vista) virtual self-learning during the semester, and an interactive simulation-based discussion in the classroom at the end of the semester. The total time commitment for each student was approximately 10 hours. The book Sleep Disorders and Sleep Promotion in Nursing Practice (Redeker & McEnany, 2011) was offered to students as a reference.
The knowledge related to sleep and sleep disorders was tested with a quiz developed by the principal investigator, including questions related to the five key topics covered in the sleep education program. The quiz was pilot tested on more than 30 students who had taken the same course in the previous semester, and the psychometrics were carefully considered before it was ready for use. The final version of the quiz included 12 multiple choice questions. Two additional questions were added to examine the self-rated level of knowledge related to sleep and sleep disorders (on a scale from 0 to 10, with 0 being completely not knowledgeable and 10 being very knowledgeable), and the student’s belief in the importance of education about sleep and sleep disorders for college nursing students. The same questions were delivered to the students before and after the education program. In addition, students were asked how much previous training they had received about sleep and sleep disorders, and they were asked for feedback and suggestions at the end of the program. The students completed the baseline testing prior to the in-classroom lecture, and the posttest after the interactive simulation-based discussion.
The university’s institutional review board approved the study to test the education program. Although all students enrolled in this course in spring 2013 were invited and given access to the sleep education program, participation in this study was voluntary, and only data from students who gave signed consent were collected. The quiz results and any feedback related to the program were not counted as part of the students’ course performance. Each participant used the last four digits of their phone number as the study identification number, and no personal identification data were collected in this study. The effect of the education program on students’ knowledge related to sleep and sleep disorders was tested by the paired t test.
Fifty-seven students (all female seniors) participated in this study. At baseline, the majority of the students believed that the education of sleep and sleep disorders for college nursing students was extremely important (43.9%) or fairly important (49.1%). When asked about the training or education about sleep and sleep disorders they had received, 29.8% of the students reported no education at all, 52.6% reported that they read randomly or watched a video, and 17.5% reported that they had attended a lecture or talk. In terms of the estimated total number of hours of training and education, 43.9% of the students reported none and 54.4% reported 1 to 5 hours. The self-rated level of knowledge related to sleep and sleep disorders was 3.9 ± 1.9, ranging from 0 to 7. Due to the conflicts in clinical schedules, only 40 participants completed interactive simulation-based discussion in the classroom and the posttest. Among them, all believed the education of sleep and sleep disorders was extremely important (80%) or fairly important (20%) to college nursing students. Significant improvement was observed in the quiz performance after the education program, compared with the scores at baseline (the percentage of correct answers: 68.8 ± 9.8 versus 48.4 ± 11.8, respectively; p < 0.001). The self-rated level of knowledge of sleep and sleep disorders was also significantly increased, compared with the level at baseline (5.7 ± 1.5 versus 3.9 ±1.9, respectively; p < 0.001). Overall, the sleep education program was well received, with great feedback from the participants. Some students suggested starting the sleep education earlier during the undergraduate study.
Discussion and Implementation for Nursing Education
This innovative sleep education program for college nursing students has demonstrated effectiveness in improving knowledge related to sleep and sleep disorders. The immediate improvement of knowledge is likely to have an enduring impact, laying a foundation for better health care of patients in various health care settings, particularly for those with sleep disturbance or sleep disorders. In addition, nurses about to enter the workforce can become more knowledgeable about managing their own health risks related to sleep deprivation and shift work. This education program may also stimulate the interest of college students in sleep and sleep disorders, encouraging the pursuit of graduate education and the conduct of scholarly work, which contributes to knowledge development about sleep and sleep disorders.
One major advantage of this sleep education program is its succinct format, which makes it feasible to be translated into the established undergraduate nursing curriculum. On the basis of the students’ feedback, instead of putting the three components into one course, as the authors did for the purpose of testing the program, delivering the content over different semesters is recommended. For example, students can receive the in-classroom lecture earlier during the sophomore or junior year, which can be easily integrated into one lecture course, and then complete the online learning in the following semester. The interactive simulation-based discussion can be conducted during the senior year, when the students have completed theory and clinical courses, such as pathophysiology, pharmacology, adult health, child health, and psychomental health, and have been exposed to the professional role of a clinical nurse. The authors expect that this plan is feasible and will provide adequate time for students to consolidate and apply their knowledge related to sleep and sleep disorders. The sleep education program has been launched with this plan, and its effectiveness will be further evaluated after the first cohort of students completes the program.
More rigorous tools to evaluate student knowledge on sleep and sleep disorders are needed as part of future systematic evaluation. The Web site, http://www.sleepeducationprogram.com, has been made available to the public for educational purposes, and the authors will continue to refine it and validate the vignettes. It is hoped that this innovative and engaging sleep education program will inspire continued effort from other nursing schools to meet the urgent need to educate the future nursing workforce about sleep and sleep disorders.
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