There is a growing awareness of sleep disorders among primary care providers (Simon, 2016), but this has not translated to widespread integration of sleep education into nursing curricula (Gellerstedt et al., 2019; Meaklim et al., 2020) despite numerous recommendations put forth over the years (Colten & Altevogt, 2006; King et al., 2021; Lee et al., 2004; Meaklim et al., 2020; Ramar et al., 2021; Redeker & McEnany, 2011; Ye & Smith, 2015). Some studies have addressed sleep education in nursing curricula (Colvin et al., 2014; Gellerstedt et al., 2019; King et al., 2021; McIntosh & MacMillan, 2009; Meaklim et al., 2020; Redeker & McEnany, 2011; Ye & Smith, 2015), but consistent with the prior decade of research, advanced practice nurses continue to report little (two hours) to no education about sleep and sleep disorders (Sawyer et al., 2022). Furthermore, a recent narrative review to evaluate sleep education provided across health care provider training programs included 16 published studies, only one of which focused on sleep in nursing curricula (Meaklim et al., 2020).
Master's-prepared nurse practitioners (NPs) comprise one of the fastest growing populations of the health care workforce in the United States, have high levels of advanced practice potential in primary care, and are poised to fill unmet primary care needs (Maier et al., 2016). Most NPs (88 percent) are primary care prepared in adult, family, or gerontology fields, indicating they are prepared to meet health needs for individuals across the life span (American Association of Nurse Practitioners, n.d.). Patients commonly present to primary care with sleep issues (Simon, 2016), but the literature demonstrates that NPs are not adequately prepared to handle sleep-related issues, as programs from which they emerge have little to no education about sleep (Meaklim et al., 2020).
Providing sleep education to NPs and other master's-prepared nurses tasked with assessing patients in primary care settings is critical. Nurses must effectively recognize presenting symptoms of poor and disordered sleep and the negative health implications. Having introductory education to sleep may increase the likelihood that sleep is considered during differential diagnosis processes, thereby assisting NPs in better understanding the root causes of presenting symptoms or health conditions. NPs are well positioned to address the increasing sleep health needs of the population, especially as shortages of sleep providers increase (Collen et al., 2020), but managing sleep health requires preparation with timely practice recommendations. Furthermore, educating NPs in sleep can expand the pipeline of sleep specialty practitioners by increasing awareness of practice opportunities. The aim of this study was to explore NP students' perceptions of a sleep e-learning program.
BACKGROUND
Sleep, diet, and exercise are the three pillars of well-being (Haapasalo et al., 2018). Identification and treatment of most health conditions takes place in primary care settings, urgent care/walk-in clinics, and emergency departments (Simon, 2016). As such, NPs are often first-line providers for patients with sleep complaints or complaints that may be directly related to disturbed or disordered sleep. Though conditions such as diabetes, obesity, cognitive decline, and negative mood are treated daily by health care providers, the impact that sleep may have on these conditions often goes unrecognized (Chattu et al., 2018).
Despite far-reaching health implications of poor sleep (Chattu et al., 2018), nurses in the United States receive little to no sleep education in undergraduate or graduate programs (Gellerstedt et al., 2019; Lee et al., 2004; McIntosh & MacMillan, 2009; Rogers & Valerio, 2011). This highlights the need for structured sleep education curricula, especially in graduate nursing programs where NPs are prepared and will necessarily address sleep health and disorders in everyday practice. Even among specialty NPs who practice in sleep centers, a 2012 survey study of NPs (n = 45) and physician assistants (n = 20) found that 84 percent of NPs reported that sleep-specific education was primarily received through "on-the-job" training, 9 percent through continuing education, 2 percent through formal education, and 9 percent from other sources (one NP selected three types of education; Colvin et al., 2014). A recent scoping review evaluating 22 studies found the most common educational approaches to educating primary care providers, including NPs, in the identification and management of sleep disorders included didactic (32 percent), active (18 percent), and blended (41 percent) approaches using technology-mediated (45 percent), face-to-face (27 percent), and multimodal (5 percent) delivery (King et al., 2021). By providing sleep curricular content, the practice of NPs in both specialty and primary care practices will be further enhanced to meet the health needs of the population.
Studies indicate that primary care practitioners, inclusive of NPs, identify sleep disorders as important but feel less confident in the management and treatment of sleep disorders, such as obstructive sleep apnea (OSA; Chang et al., 2020; Mindell & Owens, 2003; Stansbury et al., 2022). Focus groups with 14 rural practitioners (five NPs) in West Virginia identified that providers feel OSA is an important disease to consider and had a reasonable knowledge of the condition; they desired more education regarding screening, diagnosis, and management to supplement lack of confidence in identifying and managing OSA and treatments such as positive airway pressure (Stansbury et al., 2022). This sentiment has been similarly echoed in studies of primary care physicians. Most physicians (90 percent to 94 percent) considered adult and pediatric OSA very/extremely important, but only 55 percent agreed/strongly agreed that they were confident about OSA diagnosis, management (25 percent), and treatment/management of continuous positive airway pressure (18 percent; Chang et al., 2020). Lack of confidence in managing sleep disorders was also observed in a study of pediatric NPs, with less than 13 percent feeling confident in evaluating or managing sleep disorders (Mindell & Owens, 2003).
If equipped with the knowledge and skills necessary to assess, intervene, and manage varied sleep disorders, NPs can conduct appropriate sleep screenings and make treatment recommendations or referrals to sleep specialists, as needed. To address the lack of available sleep education, our team developed a sleep e-learning program. We conducted a pre/post evaluation study to assess the impact, feasibility, and utility of implementing the asynchronous, case-based sleep education modules (Sawyer et al., 2022) and followed this evaluation with a qualitative descriptive study to explore NP students' perceptions of the program.
SLEEP E-LEARNING PROGRAM
Six asynchronous, online modules were offered to a cohort of primary care NP students undergoing the clinical sequence of their specialty tracks. The interactive modules addressed screening for sleep disorders to identify healthy sleep/sleep deprivation, insomnia, OSA, restless legs syndrome, narcolepsy, and circadian rhythm disorders (see Supplemental Content 1, available at http://links.lww.com/NEP/A444, and Supplemental Content 2, available at http://links.lww.com/NEP/A445, for details about the curriculum and example of the presentation to learners). Although the course was online and self-paced, completion of one module per week across the six-week course was recommended. Each module included pre- and post-quizzes, a clinical case that progressed through patient presentation and assessment, differential diagnosis, development of a treatment plan, selection of appropriate diagnostic studies, creating a plan for follow-up, and follow-up evaluation. Modules also included the availability of discussion boards for peer-to-peer engagement.
Participants were encouraged to ask questions; share additional resources, including timely publications of interest relative to the module topic; and discuss relevant clinical experiences. The discussion boards were monitored by a research team member, and responses to questions were posted one to two times per week by a board-certified sleep physician. Module completion was optional; two clinical hours were awarded per each completed module. Completion was defined as complete pre- and post-quiz, with post-quiz access only permitted after navigation through the module. At the end of the course, students were invited to participate in a focus group, irrespective of module completion status, to provide feedback on their experiences. One-hour focus group sessions were held on two dates to accommodate varied student schedules and were conducted virtually because of COVID-19.
METHOD
The Kirkpatrick model (Kirkpatrick & Kirkpatrick, 2005) served as the theoretical framework for the study to guide the evaluation of the sleep e-learning program. The model specifies four levels of evaluation outcomes: 1) reaction, the degree to which participants find training favorable, engaging, and relevant; 2) learning, the degree to which participants acquire intended knowledge, skills, attitude, confidence, and commitment based on their participation in training; 3) behavior, the degree to which participants apply what they learned when they are on the job; and 4) results, the degree to which targeted outcomes occur as a result of the training.
The research proposal affiliated with this work was reviewed by the site institutional review board and deemed exempt. The aim of this qualitative descriptive study was to explore NP students' perceptions of their experiences with engaging in a sleep e-learning program by addressing three research questions: 1) What are NP students' perceptions and attitudes toward a novel, asynchronous case-based sleep e-learning program; 2) Does NP student knowledge of sleep and sleep disorders change with exposure to the sleep education; and 3) Do NP students identify practical value for sleep education?
Study information was presented to students by researchers during one synchronous introductory session and again upon accessing the asynchronous course. A study information page was presented, informing students that participation was optional and data were being collected as part of a research study. Progression to the baseline survey by students was considered to indicate consent. For the focus groups, participants were verbally informed that the session would be recorded and they should exit if this was not agreeable. The videoconferencing platform prompted participants to agree to the recording. Only the audio recording was transcribed so that identities were protected.
Procedure
In May 2020, students in a cohort of primary care NP students (N = 67) in a single academic institution's master's degree in primary care nursing program were invited to participate in one of two one-hour, online focus group sessions. Students were in the first or second clinical semester of the NP program. A focus group interview guide was developed to elicit perceptions of: a) features of the modules, including the case-based learning approach, pre- and post-quizzes, and online barriers experienced; b) content of the modules, including the level and intensity of information presented and preferred additional topics; and c) students' perceptions about and experience with sleep education for NPs, including previous exposure to sleep education, perceived relevance to practice, and intention to apply learned skills.
Examples of focus group interview questions include: "What do you think of the case-based learning approach that you experienced with the modules?"; "Do you think this sleep education will make a difference in your care of patients? In what way?"; and "Thinking back to your undergraduate/graduate nursing education (before this program), what sleep content did you receive?" Two moderators attended both sessions and utilized the same interview guide for both groups. Field notes were taken during the sessions. Sessions were recorded and transcribed verbatim.
Data Analysis
Transcripts were uploaded to NVivo Version 12 (QSR International Pty Ltd., 2018), which was used to store and manage the data. Two authors with qualitative research experience independently coded the data. They developed an a priori codebook based on the Kirkpatrick model (Kirkpatrick & Kirkpatrick, 2005) and immersed themselves in the transcripts to become familiar with the data. They independently applied directed content analysis (Hsieh & Shannon, 2005) using the codebook and corresponding definitions. There was greater than 95 percent agreement between coders. Codes were summarized and independently examined for themes. The full team of authors held meetings to discuss the data, categories/codes that emerged under the model constructs, and reconciled differing insights. The full team agreed to the final coding scheme and themes.
Principles for assessing trustworthiness of the qualitative inquiry relied on the four traditional criteria: credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Credibility was addressed using investigator triangulation, transferability through transparent reporting of methods, dependability through peer scrutiny and reflexive auditing, and confirmability through providing rational for theoretical, methodological, and analytical choices. These principles were met at each phase of analysis through the guidance provided by Nowell et al. (2017) and dissemination through adhering to the standards for reporting qualitative research checklist (O'Brien et al., 2014).
RESULTS
The 67 students in the course were predominately female (88 percent) and <35 years old (81 percent). Demographics of focus group participants were determined to be not different from the larger sample. Students were undergoing the clinical portion of their NP specialty track program, representing specialties of adult gerontology, family, women's health and midwifery, and psychiatric NP programs; 24 students participated in the optional focus groups. Focus group data analysis revealed two main themes: 1) perceptions of course design and 2) perceptions of course content. Subthemes are described below and summarized in Figure 1.
Perceptions of Course Design
Students provided feedback on course design, delivery, and format. In terms of design, students found case-based scenarios and quizzes to be beneficial toward their learning. For delivery and format, students appreciated the asynchronous offering and found the format and modules to be user-friendly. Subthemes of students' perceptions follow.
COURSE DELIVERY AND FORMATTING
Overall, the course was perceived positively, even by individuals who claimed to not be "a virtual learner, usually." Compared to other online course experiences, students expressed it was "the best organized[horizontal ellipsis]it made it feel like the least virtual[horizontal ellipsis]it felt like we were almost in an in-person class." Most students reported completing the modules on a laptop and found them to be "really user-friendly." Students appreciated the asynchronous offering; they were able to "do it on your own time" and "at your own pace" while "balancing all of the other things that are going on right now."
Students had mixed thoughts about the best time to be exposed to sleep education. One student, currently in the first rotation of clinicals, felt it was "okay to have it at this time because then we have more time to practice it during clinicals." Another student highlighted the importance of having knowledge about other conditions that may be affected by sleep disorders, including diabetes and cardiovascular disease, and that "revisiting the sleep aspect" of the cardiovascular effects of sleep apnea "was helpful." Another felt that having exposure to the course after having some general clinical exposure was the best time because "if I didn't have last semester where I had 250 hours of seeing patients and seeing them struggle with sleep issues, I wouldn't have been able to visualize the information I got from the modules."
TEACHING APPROACHES AND LEARNING STRATEGIES
Modules were interactive, allowing students to click on various screen icons to access additional information, definitions, and examples; insert text responses to case presentations; and answer questions when prompted (see Supplemental Content 2, available at http://links.lww.com/NEP/A445). One student appreciated the interactive component because "I find myself multi-tasking if I'm being talked at."
The case-based approach was a favored feature of the online education, "especially in a time when we're not able to attend clinicals" because of the COVID-19 pandemic. Students felt the scenarios helped to "apply what was learned" and "mimic[ked] a real-life scenario that we might see in a clinical setting." Another student mentioned that patients in the cases "looked like people that I have seen come into the primary care office." This approach made learning "easier" by "having it be a person that you could kind of connect to." The case-based scenarios provided students with information on presenting symptoms and allowed them to look through a patient chart to examine parts of the medical history that might provide information relevant to the scenario. One student stated: "I felt like it mimicked what it would be like to have that kind of person come into your office[horizontal ellipsis]with those complaints." Students also found value in having the case continue through to a follow-up visit after making an initial diagnosis and treatment decision. This was explained by one student as: "I was able to see like, did the treatment work, did it not work, now what are we working with?"
The use of pre- and post-quizzes within the modules was beneficial. Students felt the pre-quizzes "gave a clear picture of what I was going to see in the case," "helped me know what to look for," and were "a good roadmap for areas you knew you needed more help on." Students used pre-quiz results to understand "what to focus on a little bit more during the module."
Students were excited to see their improvement from pre- to post-quiz: "With the pre-quiz, I liked the fact that I saw a term and had absolutely no idea what the answer was or really anything to do with that term at all[horizontal ellipsis]going into the post-quiz, I felt really quite proud of myself recognizing, oh I know what that is." Other students echoed this same notion, stating: "It showed me that this was working. I was understanding the information. I could apply it" and "I learned something[horizontal ellipsis]you could see a measurable difference[horizontal ellipsis]you knew you came away with something." During the post-quiz, students were provided with thorough rationales for the correct responses. They valued this feature, claiming that it saved time from "going back to the material." Students suggested that it would have eased anxiety if they knew the pre-quiz was not going to count toward a grade.
Perceptions of Course Content
Students told of personal benefits from participating in the course, including the realization that their knowledge of sleep was lacking and the information they received was beneficial for themselves and their patients. Students spoke about their intentions to incorporate sleep assessments into their own practices.
KNOWLEDGE GAP
Students stated that the course benefitted them by increasing their knowledge about sleep and the importance of sleep. When asked about prior sleep education in undergraduate and graduate courses, most students realized they had none or the education they received was minimal. Their knowledge was limited to basic familiarity with terms and knowing that sleep is important for hospitalized patients. After participating in the program, students felt strongly about the importance of having an increased understanding of sleep. One student described sleep as seeming like "a mysterious area[horizontal ellipsis]I wouldn't have told you it was missing, but now I'm very aware of it." Students wished they had sleep education sooner, claiming "this would've been really helpful to know a long time ago" and "I wish I learned more about this in [undergraduate] nursing school."
RELEVANCE TO PATIENTS AND SELF
Students found the content to be "applicable to a lot of us and probably a lot of our patients." One student echoed this point: "I thought it was really relevant and I'm really glad I had a chance to do [the modules] because I know we'll confront [sleep related-issues] all the time." Another recognized that as NPs, they may be the primary point of contact for sleep issues: "If somebody's having trouble sleeping, they might be more inclined to come and see me first before they go and talk to their therapist about it, or talk to a psychologist, or a psychiatrist." Students with clinical experience confirmed this, stating, "I have patients with obstructive sleep apnea all the time, but I didn't know so much about something that I see on a very regular basis."
Because students see patients with sleep complaints regularly, they felt it was important for them to be educated about varied sleep topics, including medications. One stated: "We'll all see people [with insomnia] that have already been prescribed something or are taking something over-the-counter[horizontal ellipsis]myths versus facts that are available on[horizontal ellipsis]Google or Web M.D. are not sufficient[horizontal ellipsis]having some better baseline knowledge about them would be beneficial."
Students also voiced interest in having additional training in behavioral approaches to treating sleep disorders. One student noted, "It would be useful to have more training in brief intervention, when and how to think clinically about alternatives because a lot of our patients come in and just say, 'I'm not sleeping.' And we're like, great, here's Ambien. And I want more information about how to do that well but also use different strategies." Another student echoed this sentiment: "I think we've often heard about cognitive behavioral therapy (CBT), especially for insomnia and it's touted as this great intervention that's as good as meds, but I have no idea how it works[horizontal ellipsis]it would be useful to be able to practice that within the module."
Students highlighted that sleep-related issues are prevalent among their clinical populations. They expressed the relevance of having some education on sleep and sleep disorders for the benefit of their patients and intend to incorporate this new knowledge into their own practice: "I am definitely curious to be able to talk to my patients about [this]." Students also identified the need for more specialized information related to their specialty tracks: "I'd be interested in learning more about the neurobiology of sleep as it relates to different mental illnesses[horizontal ellipsis]we see it so commonly and I'm often left wondering[horizontal ellipsis]how to sort of pick apart what's organic and what's not, especially with different mental illnesses."
Students highlighted the relevance of sleep education for themselves, stating that having information on strategies to manage working night shift as a new nurse would have been helpful early in their career. One student mentioned that "it stresses me out [to think about the] ramifications this has had on my body [after] all of these years of rotating shifts." A few students mentioned having nurses come in and talk to them about their night shift experiences before they graduated but claimed they received little education about how to prevent the negative consequences of night shift work. One student mentioned, "I wish that I had these modules then[horizontal ellipsis]I've been working as a nurse for three years doing rotating shifts and its awful, going back and forth."
RELEVANCE TO CAREER AND CLINICAL PRACTICE
Students came to realize that sleep issues fall under their scope of practice. They noted that patients with sleep problems are prevalent among their clinical populations and voiced the intention to incorporate this new set of knowledge into their own clinical practice. One student stated: "As primary care providers, I think it's really interesting to have [sleep] in the back of our minds as part of our differentials because so often you'll have somebody come in with complaints of mood complaints. And then[horizontal ellipsis]you start digging into it and actually it's just a sleep issue[horizontal ellipsis]it's something that we can manage."
Students' eyes were opened to new areas of clinical practice they felt adequate and confident to handle on their own versus referral to a specialist. For example, a student who felt that some of the intervention/management content was "a bit beyond what I would be handling as a primary care provider," felt that topics such as jetlag were important: "I don't think that I would feel that I would need to almost waste your time as a sleep specialist on jetlag when I could handle that. But sleep apnea and restless leg [syndrome] I would definitely say, I'm more comfortable referring." Another student stated: "Knowing about this is really helpful[horizontal ellipsis]we'll know what we can deal with ourselves and what we need to refer to a sleep specialist or a neurologist for."
With newfound appreciation for sleep and how much it can impact other conditions, students had increased confidence in discussing sleep-related topics with their patients. Students stated: "I will approach sleep issues in the future with more confidence," and "I feel like it's something that[horizontal ellipsis]needs to be screened[horizontal ellipsis]at every visit because things can change so quickly for people[horizontal ellipsis]." One student summarized the general applicability of sleep education for NPs: "It just really brought to light how much[horizontal ellipsis]sleep literally impacts so much of your health[horizontal ellipsis]my biggest takeaway[horizontal ellipsis]now with every patient[horizontal ellipsis]following up on diabetes, high blood pressure, whatever[horizontal ellipsis]I'm always going to ask[horizontal ellipsis]about their sleep now because it's obviously[horizontal ellipsis]so intertwined with[horizontal ellipsis]their actual health. [horizontal ellipsis]As primary care providers we focus so much on[horizontal ellipsis], 'How can I manage their [conditions]?'[horizontal ellipsis]I definitely will bring that into my practice and make sure that I'm asking people[horizontal ellipsis]basic questions about how they[horizontal ellipsis]sleep."
Another student told of already incorporating some of the content: "I've been doing some telemedicine visits with my preceptor for primary care[horizontal ellipsis]I used some of the points for [restless legs syndrome] actually. Just yesterday was able to utilize that[horizontal ellipsis][and suggested] that we[horizontal ellipsis]check complete blood count and iron levels."
DISCUSSION
Primary care providers may miss opportunities to assess for sleep-related complaints, as many medical and nursing school curricula traditionally lack significant education about sleep and its impact on overall health. Equipping primary care practitioners, inclusive of NPs, with skills to assess, treat, and manage various sleep health conditions can begin to address this gap.
This study qualitatively examined NP students' perceptions of an asynchronous, case-based sleep e-learning program. The data supported two overarching themes of students' perceptions of the course design and course content. Overall, NP students provided feedback regarding the design, delivery, and format of the program, providing valuable information that should be considered by educators when developing curricula. Furthermore, student feedback provided the authors with insights regarding adaptations to be considered for future offerings of the sleep medicine course.
Our results provide suggestions on how to best meet the needs of NP students regarding sleep training. First, we recommend case-based learning approaches, especially scenarios that include a follow-up component, where learners can evaluate if the treatment recommendations they made "fixed the problem." Similar to our study, online, interactive simulation-based learning also proved beneficial for educating undergraduate-level nursing students about sleep (Ye & Smith, 2015). Case-based learning is a student-centered, well-established education strategy where students actively engage with content and apply their knowledge to real-world scenarios (Mackavey & Cron, 2019). It is often used in health care, helping students develop critical thinking (McLean, 2016), and it has been shown to be effective online in advanced practice nursing curricula (Mackavey & Cron, 2019).
Using a pre- and post-quiz learning assessment is also beneficial for a multitude of reasons, including analyzing learners' baseline knowledge of the topic and increasing their attentiveness by identifying gaps in knowledge. Studies have shown that testing following the activity is associated with increased retention compared to pretesting (Latimier et al., 2019). Using a pre- and posttest approach, a study (Valerio & Heaton, 2014) that evaluated the effects of an online educational program on NPs' knowledge of OSA found that students who completed a 53-minute narrated PowerPoint session had a significant improvement in posttest scores. Results of our study confirmed that the pre- and post-quiz approach assisted students to identify their own learning needs and served as a self-identified indicator of knowledge gain at the end of a module.
NP students in our study reported having minimal exposure to sleep education prior to engaging in our modules and previously felt unequipped to address or discuss sleep issues with their patients in a primary care setting. Prior studies also highlighted lack of sleep education preparation (Meaklim et al., 2020) and lack of confidence to manage and discuss sleep with patients (Chang et al., 2020; Mindell & Owens, 2003; Stansbury et al., 2022). Exposure to sleep education increases providers' intentions to discuss sleep with patients (Valerio & Heaton, 2014). By providing sleep training to primary care providers, the management of one sleep disorder, OSA, is noninferior compared to the management by sleep specialists (Chai-Coetzer et al., 2013; Pendharkar et al., 2016; Tarraubella et al., 2018). Furthermore, general practice nurses can effectively deliver cognitive behavioral therapy for insomnia with appropriate training (Espie et al., 2007), further highlighting the benefits of exposing both graduate and undergraduate nurses to sleep education. In this study, NP students voiced intentions to discuss sleep with their patients and expressed interest in having additional training in the treatment and management of sleep disorders for treatments that fall under their scope of practice, indicating their interest in being able to manage sleep-related issues independently.
Participants in this study had differing opinions on when to offer sleep education within NP curricula. Vertical integration of basic science and clinical work in medical education (Eisenstein et al., 2014) supports having emphasis on active learning during the entirety of an educational curricula, as adult learners benefit from seeing the relevance of topic (Knowles et al., 2005; Merriam & Bierema, 2013). Utilization of active learning methods such as case-based modules, whether self-directed or in small groups (McLean, 2016), has been shown to be effective (Carson & Wilcox, 2019) regardless of timing and is increasingly used in nursing education (Bristol et al., 2019).
In addition to perceived benefits to their patients, NP students voiced how the foundational components of the sleep educational content was valuable to their own lives, especially early in their nursing careers. In a four-year longitudinal study, Hasson and Gustavsson (2010) discovered that the first three years after graduation from nursing school was associated with a pronounced decline in sleep quality. Stress and shiftwork are common for nurses, so having an understanding of ways to optimize their own sleep to promote health is potentially beneficial. As such, education related to sleep deprivation and fatigue mitigation strategies is highly important in nursing curricula to prevent negative consequences from poor sleep and burnout. Having a personal interest in subject material may contribute to students' valuing sleep educational content even more.
General sleep education is important and valued for all NP tracks. However, tailoring more specific sleep education to specialty practice would be beneficial for students. The types of patients that NPs see in their respective specialty tracks vary. Thus, a psychiatric NP might gain more value in neurobiology of sleep and its relation to mental health, whereas a primary care NP may have more value in brief behavioral interventions for jetlag or insomnia. This information is helpful to consider in further developing sleep training and education.
LIMITATIONS AND IMPLICATIONS FOR FUTURE RESEARCH
Our findings are limited to a single cohort of graduate students at a single institution. Future studies should address nursing education at multiple institutions and include both graduate and undergraduate nursing programs. Furthermore, although students stated intentions to incorporate sleep assessments into their own practice, we are unable to confirm if self-reported knowledge gains and intentions were applied. Previous research focused on sleep education for NPs echoes this acceptance and intentions of incorporating sleep assessments into clinical practice, with 97.4 percent of participants indicating they were likely or very likely to evaluate their patients for OSA (Valerio & Heaton, 2014). Future research should seek to longitudinally track the effects of sleep training on nurses' clinical behaviors and ultimately on quality outcomes among adults with sleep disturbances and disorders.
CONCLUSION
Sleep education is not routinely prioritized in master's-level NP curricula, despite the growing need for mitigating poor sleep outcomes in patients. Our focus groups revealed that NP students are willing to assume ownership of sleep assessment and treatment for their patients as they willingly embraced sleep education, identified knowledge gain, and stated intentions to apply their learned skills in practice. This is critical, as it highlights a need for nursing curricular changes to ensure all nurses have the proper education and skills to meet the needs of patients with sleep problems.
Furthermore, students had positive perceptions of both the course design and content and, as such, provided valuable and foundational Level 1 data in the Kirkpatrick model to guide continued growth of this program of research. Partnerships and collaborations between schools of nursing and sleep medicine departments will be instrumental to embedding accurate and evidence-based sleep education into nursing curricula.
Overall, this study highlighted the feasibility of increasing curricular exposure to sleep medicine and ensuring NPs have proper education to recognize and identify implications of poor and disordered sleep in their patients. All NP students should have similar baseline education regarding sleep. Thereafter, education should be tailored to each specialty track.
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