Critical sleep interventions for nursing students: A pilot study of the Sleep Tool Kit

The primary objective of this study was to investigate the impact of implementing a sleep toolkit on sleep hygiene, patterns, and sleep quality. Previous studies have revealed the negative impact poor sleep hygiene/quality can have on students’ quality of work and patient safety; however, more information is needed regarding how improved sleep practices can impact nursing students’ sleep habits and associated nursing clinical experiences. The research questions were as follows: How does the implementation of a sleep toolkit with a focus on nursing students impact their sleep patterns, and how does the implementation of a sleep toolkit with a focus on nursing students impact their sleep quality?

Researchers hypothesize that education and implementation of a sleep toolkit will result in improved sleep patterns and quality.

The study employed a quasi-experimental design with pre- and post-test single-group designs.

The study design was chosen to determine if the implementation of the sleep toolkit directly impacts sleep hygiene. Data are collected at the pre-test (before the intervention) and post-test (after the intervention). For this study, a sleep toolkit was used as the intervention, comprising both daytime and nighttime habits that affect sleep.

1) How does the implementation of a sleep toolkit with a focus group of nursing students impact their sleep patterns?

2) How does the implementation of a sleep toolkit with a focus group of nursing students impact their sleep quality? (Do the participants report feeling more rested after the implementation of the sleep tool kit?)

A sample of 20-40 participants was selected from the School of Nursing roster, based on availability and interest in participating. Of the students approached, 29 participated in both pre- and post-surveys. The students were provided with educational materials and a toolkit designed to optimize their sleep practices. The pre- and post-surveys included questions related to sleep quantity and quality, as well as sleep hygiene practices.

To communicate with the participants, a link was shared on a classroom bulletin board during scheduled class time. Participants were instructed to click the link to access the survey. Once 40 participants were enrolled, the survey closed. The survey link was set to automatically expire once 40 participants had been reached.

Once a student had agreed to participate in the study, they were provided with a link. When they clicked ‘agree,’ the pre-assessment survey populated for them to complete. At the end of the pre-assessment survey, the nursing student participants proceeded to the sleep tool kit. There were no actual hard stops or mandates in place to require study participants to read and implement the toolkit; independent and voluntary review and implementation were encouraged, as voluntary action may represent how any healthcare consumer reacts to receiving health information materials. In addition, the consent form explained the procedure for participation which involved reading through the sleep tool kit which was emphasized before participants would proceed to the post test questions. The sleep tool kit/sleep hygiene material was delivered as part of the online survey and placed in between the pre and post test questions. After reading through the sleep hygiene material, the students then proceeded to answer the same survey questions.

2.4.1Inclusion criteria

2.4.2Data collection procedures and duration

2.4.3Data storage, confidentiality, or anonymity

Data analysis was done using SPSS 26.0 for Windows software. Descriptive statistics using frequencies and percentages were used to describe the sample as well as all the questions. The online pre-survey and post-survey analyses occurred separately. The online pre-survey and post-survey (available upon request) administered a set of questions about sleep patterns and quality, and the sleep toolkit.^[5]

Prior to analysis, data were screened for completeness, accuracy, and missing values. Only participants who completed both the pre- and post-intervention surveys were included in the final analysis. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were computed to summarize participant characteristics and responses.

To evaluate changes in sleep patterns (average hours of sleep) and sleep quality (self-reported feeling of restfulness) following the implementation of the Sleep Toolkit intervention, both descriptive and inferential statistical analyses were performed.

A paired-samples t-test was conducted to compare the mean hours of sleep before and after the intervention. This test was used to determine whether there was a statistically significant difference in average sleep duration within the same group measured at two different time points. In addition, Cohen’s d was calculated to estimate the effect size of the intervention. Cohen’s d values were interpreted as follows: 0.2 = small effect, 0.5 = medium effect, and 0.8 = large effect, indicating the magnitude of change regardless of statistical significance. For participants’ feelings of being well-rested (Yes/No) and habits that affect sleep (for example, caffeine limitation, light exposure), the McNemar’s test was used to assess whether statistically significant differences existed between pre- and post-intervention responses.

All statistical tests were two-tailed, and a p-value of less than .05 was considered statistically significant. Results were summarized in tables showing pre- and post-intervention means, standard deviations, effect sizes (Cohen’s d), and p-values. Findings were reported in aggregate form to maintain participant confidentiality.

Ethical approval for this study was obtained from the University’s Institutional Review Board (IRB) prior to data collection. Participation in the study was voluntary, and informed consent was obtained from all participants before completing the pre-intervention survey. Participants were informed about the study’s purpose, procedures, potential risks, and potential benefits, as well as the right to withdraw at any time without penalty or academic consequences.

Confidentiality and anonymity were strictly maintained throughout the study. No personal identifiers, such as names or student identification numbers, were collected. Data were stored on a password-protected computer accessible only to members of the research team. Results were reported in aggregate form to ensure that individual responses could not be linked to specific participants.

Of the 40 participants invited, 29 nursing student participants started at least the preintervention survey study. All the 29 participants were in their sophomore year. The nursing student participants completed their first semester of nursing school courses, which included patient care skills and comprehensive health assessment. Twenty-six participants completed both pre- and post-surveys.

According to Table 1, participants reported slightly more (6.93) hours of sleep pre-intervention compared to post-intervention. The standard deviation decreased from 1.28 during the pre-intervention to 1.09 during the post-intervention.

According to Table 2, there is no statistically significant difference (p-value = .329) in the number of self-reported hours of sleep between the pre-intervention and post-intervention periods for the participants. With almost the same 6.93 and 6.80 average number of hours of sleep reported during the pre- and post-intervention, respectively. Further still no statistical significance exists between self reported number of hours of sleep during the pre and post intervention as shown in Table 3.

Do the participants report feeling more rested after implementing the sleep toolkit? A total of 26 nursing students completed pre- and post-intervention assessments of subjective restedness following implementation of the sleep toolkit. When asked, “Considering the number of hours of sleep you obtain every 24 hours, do you feel rested?”. According to the findings in Table 4, before the intervention, 34% of the participants reported feeling well-rested, compared to 41% after the intervention. Furthermore, the proportion of individuals who did not feel well-rested decreased from 66% before the intervention to 59% after the intervention, indicating a slight improvement in restfulness following the intervention, although this was not statistically significant (p-value = 1.00).

Additional information was collected to determine if there was a change in sleeping habits among participants before and after administering the sleep tool kit (intervention).

There was no statistically significant difference in the habits that affect sleep before (pre-intervention) and after (post-intervention) administering the sleep toolkit. Three participants (10%) reported that the area in which they slept was exposed to bright light before administering the sleep toolkit (preintervention), while 4 participants (18%) reported the same after administering the sleep toolkit.

Close to half (48%) of the participants reported that they always limit caffeine before the intervention, while 13 (3%) reported that they sometimes limit caffeine before bed. During the post-intervention, the same number (48%) of participants reported that they always limit caffeine before bed, while 2 (9%) reported that they sometimes limit caffeine before bed.

The implementation of the sleep intervention toolkit did not have an impact on the sleep habits that affected the sleep of the participants. The results of our study found no statistically significant difference in sleep habits before and after administering the sleep toolkit. With 48% of participants reporting that they always limit their caffeine intake both pre- and post-intervention, while the proportion who reported sometimes limiting caffeine increased slightly from 3% to 9%, this difference was not statistically significant. This could be because students often feel pressured by their assignments, and therefore, despite all the interventions, they still sleep for a few hours.

The findings of this study are contrary to those of other studies, which reported significant behavioral changes among their participants after reducing pre-bedtime light exposure and caffeine consumption following a sleep intervention (16-18). The interventions directly targeting environmental light exposure and caffeine consumption can yield measurable improvements in sleep outcomes.

There is no statistical difference. Analysis of self-reported restedness scores revealed no statistically significant difference in feelings of restedness before and after the implementation of the sleep toolkit. The findings of this study indicate that the implementation of a Sleep Toolkit among nursing students did not result in a statistically significant improvement in sleep duration or feeling of restfulness. This outcome suggests that while participants may have gained knowledge about sleep hygiene, behavioral changes affecting actual sleep patterns may require a longer period or more intensive intervention to take effect.

These findings are consistent with those of Almojali and colleagues in 2017, who found that despite increased education and awareness of sleep hygiene, university students continued to experience insufficient and poor-quality sleep, largely due to academic demands and lifestyle stressors.^[16] Conversely, the results of this study are contrary to those of Hershner and Chervin, who found that comprehensive sleep education combined with behavioral follow-up led to significant improvements in students’ sleep quality and academic functioning.^[12] The discrepancy may be explained by differences in intervention intensity, duration, and participant engagement.

These findings are notable in the broader literature, which demonstrates that sleep interventions, such as sleep hygiene education and cognitive behavioral therapy for insomnia (CBT-I), can improve sleep quality and related outcomes in university and nursing student populations. However, effect sizes are often modest, and not all interventions yield improvements in all domains. For example, meta-analyses have shown moderate improvements in sleep quality but smaller or non-significant effects on sleep duration and daytime functioning, with considerable heterogeneity in intervention content and delivery.^[17—19] Furthermore, study results specifically targeting nursing students have highlighted persistent challenges with poor sleep quality and daytime sleepiness, even after educational interventions.^[6]

The lack of observed change in subjective restedness in this cohort may reflect the limited intensity or duration of the toolkit, variability in individual sleep needs, or the influence of external factors such as academic workload and technology use, which are well-documented contributors to sleep disturbance in this population.^[6] These results emphasize the need for further research to optimize intervention content, delivery, and outcome measurement in nursing student sleep health initiatives.^[9,17—19]

This is a pilot study with a small sample size, which limits its generalizability to a broader population. Additionally, with a limited number of participants, the study may have low statistical power, making it challenging to detect small but meaningful changes in sleep habits.

The sleep toolkit may have been administered over a brief period, which might not be enough to influence entrenched behaviors such as caffeine intake or light exposure.

Honesty may be an issue, as participants often fail to report the results of changes in habits, such as caffeine consumption and light exposure. Self-report is subject to recall bias, social desirability bias, and inaccurate reporting. Objective measures (e.g., actigraphy for sleep, light meters, or caffeine logs) were not used.

The results of this study indicate that a brief sleep toolkit intervention alone may not be sufficient to induce meaningful changes in sleep patterns and quality. There is a need to implement future interventions that are longer, more intensive, or involve environmental modifications (e.g blackout curtains) to effectively change sleep-affecting habits, quality, and pattern.

The findings also suggest that self-reported sleep behaviors may be resistant to change without reinforcement, structured support, or ongoing monitoring. Ultimately, this study’s results highlight the need for further research that combines education, environmental adjustments, and behavioral reinforcement to enhance sleep hygiene and outcomes in target populations.