2.-chapter-1-to-2.docx

CHAPTER I THE PROBLEM AND REVIEW OF RELATED LITERATURE INTRODUCTION According to the National Sleep Foundation (2015), sleep is essential for a person’s health and wellbeing. It is also a critical part of maintaining the overall health, especially to college students as it plays an important role in the cognitive learning of the student. The National Sleep Foundation convened experts from sleep, anatomy and physiology, as well as paediatrics, neurology, gerontology and gynecology to reach a consensus from the broadest range of scientific disciplines. The panel revised the recommended sleep ranges. The recommended number of hours of sleep for ages 18-25 which are mostly young adults or college students is at 8-9 hours (Czeisler, 2015). Most of the students tend to stay up late into the night to accomplish their tasks, whereby prioritizing tasks, commonly academics, rather than personal rest and sleep. Students from all year levels, most especially college students, experience sleep deprivation. One of the most common problems of a nursing student will include sleep deprivation. At an alarming rate, sleep deprivation among nursing students has also become a major concern. Nursing is a demanding profession with occupational stress which involves academics, and shift duties all cramped up in four years. Good quality sleep and enough amount of sleep are very important in order to have better cognitive performance, good decision-making, and to avoid health problems as well as psychiatric disorders. When students are sleep deprived, students are more prone to cognitive problems and poor decision-making skills. A good quality sleep is one of the most important things to become a good and active student nurse. Nowadays, student nurses face a lot of

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problems due to heavy school works and balancing their time as a student nurse and a normal teenager. However, the most significant problem a student nurse faces is the sleep deprivation they get due to demands by the academe, and community or hospital duty. This paper will focus on the incidence of sleep deprivation among level IV nursing students of Ateneo de Zamboanga University. This topic was chosen after careful decision and the fact that sleep deprivation has become a major concern among students of this course. Studying this topic on incidence of sleep deprivation, knowing the number of sleep deprived students, how often these students are deprived of sleep, and even possible commonalities for coping mechanism, after accurate interpretation, will help the researchers understand the incidence of sleep deprivation and develop a clearer view on the topic. A research study conducted by Khin Thandar Aung, Mohammad Said Nurumal, and Siti Nurhizwanybinti Zainal (2016) about sleep quality and performance of nursing students found that the majority of college students experienced poor sleep quality. In addition, intense academic demands among college students particularly nursing students because they had the least amount of sleep. Another research study conducted by Cynthia Thomas, Constance McIntosh, Ruth Ann Lamar, and Roberta Allen (2017) about Sleep Deprivation in nursing students found that majority of the participants of the study needed 8 or more hours sleep to feel rested. More alarming, more received 6 hours or less before a clinical experience. This potentially places the students at risk for less than optimal learning in the classroom and more significantly creates potential safety issues in the clinical environment. Being deprived of sleep can become a cause for various types of sleeping disorders. A study conducted by Jane F. Gaultney (2010), focused on the prevalence of sleep disorders in college students, with sleep deprivation being the most common, and its impact on the academic

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performance. The results showed that twenty-seven percent of students were at risk for at least one sleep disorder. African American and Asian students reported less risk for insomnia and fewer poor sleep practices relative to white and Latino students. Students reported insufficient sleep and a discrepancy between weekday and weekend amount of sleep. Students at risk for sleep disorders were overrepresented among students in academic jeopardy. The data indicates that a substantial number of college students may be at risk for sleep disorders or poor sleep hygiene, and that sleep may impact academic success. Considering this, sleep deprivation is a major concern among students, especially level IV nursing students of Ateneo de Zamboanga University, knowing that this course demands both academic excellence, and related learning experience duty. REVIEW OF RELATED LITERATURE Many people suffer from sleep deprivation especially the students who study every night, long nights of not having sleeps because of requirements that need to be passed on the next day. Students suffer a lot from sleep deprivation especially the one who is in college. Pressman, 1997 indicates that sleep deprivation has been shown to impact negatively on a wide range of cognitive, behavioral, physiological, and emotional measures. For example, mood changes including irritability, fatigue, difficulty in concentration, and disorientation to short-term memory alterations due to decreased attention, concentration lapses, and decreased motivation. Illusions, hallucinations, visual misperceptions, and paranoid ideation are also observed with sleep loss. The National Sleep Foundation (NSF), along with a multi-disciplinary expert panel, issued its new recommendations for appropriate sleep durations. The report recommends wider

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appropriate sleep ranges for most age groups. The results are published in Sleep Health: The Journal of the National Sleep Foundation. The National Sleep Foundation convened experts from sleep, anatomy and physiology, as well as pediatrics, neurology, gerontology and gynecology to reach a consensus from the broadest range of scientific disciplines. The panel revised the recommended sleep ranges for all six children and teen age groups. A summary of the new recommendations includes: Newborns (0-3 months): Sleep range narrowed to 14-17 hours each day (previously it was 12-18), Infants (4-11 months): Sleep range widened two hours to 12-15 hours (previously it was 14-15). Toddlers (1-2 years): Sleep range widened by one hour to 11-14 hours (previously it was 12-14). Preschoolers (3-5): Sleep range widened by one hour to 10-13 hours (previously it was 11-13). School age children (6-13): Sleep range widened by one hour to 9-11 hours (previously it was 10-11). Teenagers (14-17): Sleep range widened by one hour to 810 hours (previously it was 8.5-9.5). Younger adults (18-25): Sleep range is 8-9 hours (new age category). Adults (26-64): Sleep range did not change and remains 7-9 hours. Older adults (65+): Sleep range is 7-8 hours (new age category), Czeisler (2015) Sleep is a major aspect in our everyday lives; however, fewer people are getting enough sleep each night and more are slowly becoming sleep deprived. Sleep deprivation is defined as a condition that occurs when an individual does not get enough sleep each night (What Are Sleep Deprivation, 2012). There is an immense amount of research being conducted in order to determine how to overcome sleep deprivation, but in order to surpass any issue, it is important to know who is at risk of being afflicted by it. It is important to understand that people of all ages, and ethnicities are at risk of becoming sleep deprived. More specifically, individuals who have limited time for sleep, such as students, people who work a lot of hours either at either one or more jobs, as well as caregivers. Also, those who have schedules that conflict with circadian

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rhythms such as; shift workers, first responders and individuals who travel for work can also be at risk of suffering from sleep deprivation. Other individuals that could be included would be those whose life style choices do not allow them to receive adequate amounts of sleep such as; individuals who take medication to stay awake, those who abuse alcohol and or drugs, or those who don’t place sleep high on their priority list. Individuals who suffer from various medical conditions such as heart failure, heart disease, obesity, high blood pressure, diabetes, stroke, transit ischemic attack (mini stroke), attention-deficit hyperactivity disorder, and depression can all suffer from sleep deprivation as well (Who is at Risk, 2014) So many people fail to maintain a proper sleep schedule, but sleep is one of the most important aspects of mankind’s everyday life. There are several important aspects to maintaining an adequate The Effects of Sleep Deprivation on Memory, Problem Solving, and Critical Thinking 13 amount of sleep on a nightly basis. These would include: committing new information to memory, maintaining normal body processes such as proper carbohydrate storage and maintaining proper hormone levels, reduced tendency for day time sleepiness, thereby reducing human errors such as medical mistakes and traffic accidents, reduction in irritability and patience, improves concentration and reduces moodiness and laziness. Sleep disorders have been linked with hypertension, irregular heartbeat, and increased cortisol levels, while an adequate amount of sleep assists in maintaining proper immune system function (Benefits of Sleep, 2015) According to the National Heart, Lung and Blood Institute, Sleep Deprivation is defined as a condition that occurs if you don't get enough sleep. Sleep deficiency is a broader concept. It occurs if you have one or more of the following: You don't get enough sleep (sleep deprivation). You sleep at the wrong time of day (that is, you're out of sync with your body's natural clock).

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You don't sleep well or get all of the different types of sleep that your body needs. You have a sleep disorder that prevents you from getting enough sleep or causes poor quality sleep. Sleep deficiency can lead to physical and mental health problems, injuries, loss of productivity, and even a greater risk of death. To understand sleep deficiency, it helps to understand how sleep works and why it's important. The two basic types of sleep are rapid eye movement (REM) and non-REM. NonREM sleep includes what is commonly known as deep sleep or slow wave sleep. Dreaming typically occurs during REM sleep. Generally, non-REM and REM sleep occur in a regular pattern of 3–5 cycles each night. Your ability to function and feel well while you're awake depends on whether you're getting enough total sleep and enough of each type of sleep. It also depends on whether you're sleeping at a time when your body is prepared and ready to sleep. You have an internal "body clock" that controls when you're awake and when your body is ready for sleep. This clock typically follows a 24-hour repeating rhythm (called the circadian rhythm). The rhythm affects every cell, tissue, and organ in your body and how they work. If you aren't getting enough sleep, are sleeping at the wrong times, or have poor quality sleep, you'll likely feel very tired during the day. You may not feel refreshed and alert when you wake up. Sleep deficiency can interfere with work, school, driving, and social functioning. You might have trouble learning, focusing, and reacting. Also, you might find it hard to judge other people's emotions and reactions. Sleep deficiency also can make you feel frustrated, cranky, or worried in social situations. The signs and symptoms of sleep deficiency may differ between children and adults. Children who are sleep deficient might be overly active and have problems paying attention. They also might misbehave, and their school performance can suffer.

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According to Hershner and Chervin (2014). College is a time of intellectual growth and development as young adults’ transition from adolescence to adulthood. Although the worth of college in terms of increased productivity and higher earning potential is rarely debated, there is a significant personal and societal cost of college both in terms of time and money. For optimal return on the investment of time, effort, and money, students need to maximize their learning, academic, and personal growth. Sleepiness from any cause can compromise these goals, through impact on learning, memory, grades, perception of effort, driving performance, and mood. Although sleep deprivation has effects on many aspects of health, this article will focus on areas that may be particularly problematic for college students. According to Hershner and Chervin (2014). Students with sleep disorders probably do not achieve optimal academic performance, and up to 27% of students may be at risk for at least one sleep disorder.57 Students at risk for academic failure (GPA <2.0) were at a disproportionately high risk for sleep disorders. Among those who screened positive for obstructive sleep apnea, 30% were at risk for academic failure. Medical students classified as frequent snorers more frequently failed their Internal Medicine examination (47%) than did occasional snorers (22.2%) or non-snorers (12.8%). After adjustment for age, BMI, and sex, the relative risk for snorers to fail the examination was 1.26 (95% confidence interval: 1.01–1.57).65 Obstructive sleep apnea is suspected to have cognitive effects in both children and adults.66 A higher percentage of students at risk for academic failure screened positive for other sleep disorders including: periodic limb movement disorder/restless legs syndrome (21%),67 insomnia (22%), circadian rhythm sleep disorders (26%), and hypersomnia (21%).57 As nearly one in four students is at risk for a sleep disorder, screening for sleep disorders among students with poor academic performance may well be advisable.

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Many people suffering from routine sleep loss are not even aware of it, and many who do realize they are not getting enough sleep are not aware of what it is costing them. Sleep loss creates sleepiness, which can be associated with decrements in vigilance, reaction time, memory, psychomotor coordination, information processing, and decision-making. With increasing sleepiness, individuals demonstrate poorer performance despite increased effort, and they may report indifference regarding the outcome of their performance (Behavioral Medicine, 1996). Behavior Medicine illustrates that not getting enough sleep affects the person in several ways: 1.

Problem solving skills are impaired. Sleep loss noticeably impairs our ability to

comprehend rapidly changing situations, increases the likelihood of distraction, 8 makes us think more rigidly and less flexibly, and reduces our ability to produce innovative solutions to problems. 2.

Communication skills suffer. Sleep loss reduces the words in vocabulary both verbally

and in writing. 3.

Learning and memory suffer. Sleep loss diminishes scores on tests of memory, verbal

fluency and overall creativity. 4.

Motor skills are impaired. Studies show there is a direct connection between sleepiness

and impaired hand-eye coordination. The degree of impairment has led researchers to compare it in severity to drunkenness. One thing is for certain, that chronic sleep loss may lead to deterioration of mood and motivation; decrease in attention, energy, and concentration; and an increase in fatigue, irritability, tension, anxiety, and depression. Individuals suffering from sleep deprivation may have an increased incidence of psychophysical problems such as stomach problems, menstrual

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irregularities, headaches, and increased muscle tension (National Sleep Foundation, 1999). Any one of these consequences of sleep deprivation can seriously affect productivity and performance. Causes of Sleep Deprivation Just like other problems that humanity faces, there is not a single cause for sleep deprivation. If a person suffers from a sleep disorder, it is very likely that the individual will become sleep deprived, the issue is determining which disorder the person suffers from so that help can be sought after to assist in receiving enough sleep. People have been known to suffer from insomnia, sleep terror disorder, narcolepsy, sleep walking, and sleep apnea; these are just a few of the many disorders that individuals can suffer from, which can prevent them from achieving an optimum sleep regimen each night as witnessed by researchers Murphy and Delanty (Murphy, & Delanty, 2007). Along with officially diagnosable sleep disorders, it has been observed through empirical studies such as Hershner and Chervin’s Causes and Consequences of Sleepiness Among College Students that schedules set by colleges and public schools are partially responsible for students being afflicted with sleep deprivation. With class times being set early in the morning and late in the evening as well as work-loads being increased outside of the class room, individuals’ circadian rhythms can become discombobulated, causing them to have an inadequate sleep cycle (Hershner, & Chervin, 2014). The third major factor that can lead to an insufficient amount of sleep is when an individual makes personal and professional commitments beyond that of what is reasonably accomplished. Different careers can lead individuals to go extended periods of time without

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adequate amounts of sleep each night, for example; medical professionals and shift workers. When said individuals do finally have the opportunity to go home and rest, they still have to deal with the demands of their socioeconomic factors such as raising a family and environmental noise pollution (Murphy, & Delanty, 2007). Effects of Sleep Deprivation By failing to obtain an efficient amount of sleep each night, there is an increased possibility of there being one or more adverse effects on the individual’s cognitive capabilities. The actual ability to store information is not completely hindered when a person is suffering from total sleep deprivation; however, when a person is suffering from a lack of sleep, they may tend to lose the ability to filter information; therefore, storing more irrelevant information into their working memory, leaving less room for that which is relevant, making it appear that the memory itself is being hindered. This was clearly observed through the empirical research study titled: The Effects of Two Types of Sleep Deprivation on Visual Working Memory Capacity and Filtering Efficiency, which was conducted by researchers Drummond, Anderson, Straus, Vogel, & Perez (Drummond, Anderson, Straus, Vogel, & Perez, 2012). Sleep loss has been shown to be inversely proportional to academic performance; when one fails to receive an adequate amount of sleep on a nightly basis, the literature states that an individual’s skills in learning capacity, such as memory, attention and problem solving skills are effected the most. Sleep deprivation can also lead to daytime sleepiness. When these factors are all being faced, students are likely to achieve lower test scores and lower grade point averages; however, it has been shown that cognitive function is not hindered as drastically when the

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individuals are working in groups as when working alone (Chiang, Arendt, Zheng, & Hanisch, 2014) An individual’s physical and mental health and abilities have been shown to have direct correlation with sleep deprivation. Research has shown that people who suffer from sleep deprivation, are more likely to have issues with their cognitive abilities, such as memory and problem solving skills when the individual also suffers from hypertension, but the relationship does not end there. The empirical research study Decreased Cognitive/CNS Function in Young Adults at Risk for Hypertension: Effects of Sleep Deprivation, which was conducted by researchers; McCubbin, Peach, Moore & Pilcher have also shown that individuals who do not have hypertension are more likely to develop this issue when constantly depriving themselves of sleep (McCubbin, Peach, Moore, & Pilcher, 2012). The brain is most effectively influenced by the different chemicals that are naturally released by the body, but it is very possible to disorient the brain by not releasing, or releasing too much of, a certain chemical. The empirical research study Neurophysiological Effects of Sleep Deprivation in Healthy Adults, has shown that people suffering from total sleep deprivation have an increase in dopamine output and a decrease in cortisol, thereby requiring an increase in a combined effort of production from the prefrontal and limbic cortical regions. Despite the increase of activity in the brain, individuals still suffer from decreased cognitive performance (Klumpers, Veltman, van Tol, Kloet, Boellaard, Lammerrtsma, & Hoodendijk, 2015) A review of the relevant literature over the past 15 years reveals that insufficient sleep (or partial sleep deprivation) has a variety of adverse effects. Despite the wide range of research methodologies (e.g., qualitative studies, surveys and clinical trials, instruments) and settings (e.g., field studies, and time-isolation laboratories, and sample sizes), the results are quite

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similar: insufficient sleep has been associated with cognitive problems, mood alterations, reduced job performance, reduced motivation, increased safety risks, and physiological changes. Results from laboratory studies of total sleep deprivation (one or more nights without sleep) were not included in this review, since the focus of this section is on insufficient sleep (partial sleep deprivation) and not on total sleep deprivation. It is important to note that none of the several hundred studies reviewed for this paper showed any positive effects from sleep restriction in healthy adults. While it is true that one night of sleep deprivation can temporarily elevate mood in depressed patients, it has adverse effects on mood in healthy individuals of all ages, including nurses. Depression increases, irritability increases, and people report feeling more stressed when sleep is restricted. Extended sleep times, however, are not associated with improved mood or health and may be associated with poor health. Mortality rates were highest among subjects ages 30 to 100 years who slept 8 or more hours, and lowest among those who slept 7 hours sleep, findings that were identical to those obtained a year later from a prospective study of 82,975 registered nurses (Nurses Health Study). Health Consequences of Sleep Deprivation: memory & cognitive impairment Students think that when they purposely lose sleep by pulling all-nighters, that they are preparing themselves for more success. This is far from the truth, and students are not performing better. Doing all-nighters and losing sleep is not worth beneficial. A study by Curcio, Otenyo- 12 Ferrara, and De Gennaro (2006) explored the idea that sleep plays an essential role in learning and memory. The study observed that there is a corresponding relationship between sleep and memory and synaptic plasticity (Curcio, Ferrara, and De Gennaro, 2006). To test the ideas behind memory retention and sleep loss, researchers Pilcher and Walters (1997) conducted

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a series of cognitive tasks that had participants complete 2 questionnaires that mainly tested concentration and estimated performance. Students were also able to self-report on the amount of effort they perceived to use on the tests. As anticipated, sleep deprived participants performed tasks significantly worse than non-sleep deprived participants on cognitive tasks (Pilcher and Walters, 1997). Surprisingly, participants who were sleep deprived rated their concentration and effort level higher than non-deprived participants (Pilcher and Walters, 1997). Students who were sleep deprived also rated their estimated performance significantly higher than nondeprived participants (Pilcher and Walters, 1997). Although sleep deprived students had the selfperceived notion that they were more concentrated and more likely to perform well compared to non-deprived students, these finding are contrary to the actual facts which show that sleep deprived students will perform worse. The Pilcher and Walters (1997) study shows that college students are unaware to what extent their sleep deprivation has on their ability to complete cognitive tasks and retain memory. Overcoming Sleep Deprivation There are multiple ways in which individuals can work to overcome their sleep deprivation and return to functioning at an appropriate efficiency. Insomnia has been shown to be a lead cause in sleep deprivation, causing individuals to lie awake at night, unable to achieve sleep, or constantly waking throughout the night, there are multiple treatments that have been tested and of these, one seems to stand out. With all the different drugs being used to aid with sleep, acupuncture is actually proving to be an effective aid and more research is going into discovering the true potential of this treatment (YuanFang, Jian-Hua, Neng-Gui, Zhao-Hui, Zhen-Hua, Shu-Jun, & Wen-Bin, 2013).

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Another aid in the fight against sleep deprivation is natural sleep aids. It is remarkable how many natural aids there are, most of which come from leaves, roots and tree bark. Some of these aids include: kava-kava, which is an herbal remedy that relaxes the body and enhances dreaming. Valerian root, which eases nerve and muscle tension as well as relieves anxiety and chamomile, which is a flower that is most often drunk as a tea, aids in reducing restlessness and digestion. There are a plethora of natural remedies that help with releasing Melatonin and Tryptophan, which are natural chemicals in the body that aid in healthy sleep. One should always choose a natural remedy over its synthetic counterpart when available (Kopparapu, Puranik, Nargund, Samuel, Shahapurkar, & Mathew, 2012). A full night of sleep is not always an option with people’s nonstop lives, so the majority of people turn to different stimulants in order to keep them going during the day. Studies have shown that when 20mg of d-amphetamines are ingested orally, the individual returns to a cognitive state that was present prior to being sleep deprived, allowing for an improvement in addition and subtraction as well as logical reasoning tasks. Amphetamines also reduce a person’s response bias by increasing their confidence in their actions and decisions. It has long been believed that nicotine has the ability to aid in the retention and enhancement of cognitive functions, when the individual is sleep deprived, due to the fact that it is a stimulant, but research has actually shown it has no positive effect on the brain’s cognitive capabilities, due to its inability to improve sleep latency. L-deprenyl, like nicotine, fails to improve sleep latency in sleep-deprived individuals thereby negating any improvements on cognitive performance during the sleep deprivation period. These findings were discovered in the empirical research of Stimulant Drug Effects on Performance and Behavior After Prolonged Sleep Deprivation: A

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Comparison of Amphetamine, Nicotine, and Deprenyl (Newhouse, Penetar, Fertig, Thorne, Sing, Thomas, & Belenky, 1992). Why are College Students Sleep Deprived? Poor sleep hygiene is a common factor that increases sleep loss. Sleep hygiene is the promotion of regular sleep (CDC, 2012). Without adequate sleep hygiene, students may find themselves with worse health consequences that encourage sleep deprivation. A study implemented with college students showed that 33% of sleep deprived students took longer than 30 minutes to fall asleep, and 43% of the students studied also reported prematurely waking up more than once on a nightly basis (Forquer et al, 2008). Some people may have the belief that college students have different sleep hygiene depending on their class standing and majors. Although it may be true that some majors have different amount of work load, Forquer et al. (2008) found that there is no differences between freshman, sophomores, juniors, seniors, and graduate students for the time to fall asleep, number of premature waking per night, and total hours of sleep per night. Poor sleep hygiene is a common cause of sleep deprivation among college students; however, other causes such as alcohol consumption also affect students. According to Hershner& Chervin (2014), approximately four out of five college students drink alcohol. Alcohol is known to shorten sleep latency; however, it promotes fragmented sleep in the latter half of the night (Hershner& Chervin, 2014). A study conducted about sleep and alcohol consumption found that 11.6% of students who drank alcohol used it as a sleep aid (Hershner& Chervin, 2014). The use of alcohol for sleep is a dangerous practice that has negative health consequences. In fact, alcohol may increase the risk for obstructive sleep apnea (Hershner& Chervin, 2014). In addition

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to alcohol consumption, college students are also sleep deprived due to other drugs such as caffeine and energy drinks. Caffeine consumption is commonly used in the college lifestyle as a remedy for preserving alertness and most importantly, preventing sleep in times when there is an urgency for studying. Students depend on caffeine products such as coffee and energy drinks for their source of caffeine. The body’s response to highly caffeinated drinks is detrimental to sleep hygiene; for example, intake of 2 to 4 cups of coffee taken at night can increase sleep latency on average from 6.3 to 12.1 minutes, reduce sleepiness, and improve the ability to sustain wakefulness (Hershner& Chervin, 2014). Students who plan to study for long periods of time seek caffeinated dirnks because they are readily available products. Students gravitate to the effectiveness of caffeine consumption, because the effects of caffeine can last 5.5–7.5 hours (Hershner& Chervin, 2014). This suggests that caffeine consumed in the afternoon could impair one’s ability to fall asleep (Hershner& Chervin, 2014). Energy drinks are another form of caffeinated drinks that are popular among college students. Approximately 34% of 18–24 year Otenyo- 8 olds consume them regularly (Hershner& Chervin, 2014). In 2006, it was reported that Americans spent more than $3.2 billion on energy drinks , and the majority (67%) of consumers bought energy drinks to help alleviate the symptoms linked to insufficient sleep (Hershner& Chervin, 2014). Like coffee, the main sources of stimulus in energy drinks is caffeine, which has similar effects on the body. The amount of caffeine in energy drinks varies from 45–500 mg, which explains the potency of these products (Hershner& Chervin, 2014). Students view the effect of caffeine as a benefit to their health; nevertheless, many do not consider the dangerous side effects associated with depriving themselves from sleep.

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Suggestions for how students can improve sleep When students are pulling all fighters to study, and or using distracting technology prior to bedtime, it a form of self-sabotage. It is self-sabotage in a sense that students are preventing themselves from performing in school to the best of their ability. As mentioned in the Pilcher and Walters (1997) study, students are unaware that their choice to deprive themselves from sleep in deterring them from academic achievement. People can improve sleep hygiene by following a few strategies to increase sleep quality. The first strategy is to go to bed and wake up at the same time each day (CDC, 2012). Notre Dame College (2007) suggests that getting on Otenyo- 14 a schedule, will help the body get used to a regular sleep cycle. The second tip is to make sure the one’s bedroom is conducive to a distraction free sleep by making sure the room is quiet, dark, comfortable in temperature, and it is a general relaxing environment (CDC, 2012). The third suggestion is to make sure that one’s bed is comfortable and is used only for sleeping and not for other activities such as reading, or watching TV (CDC, 2012). It is highly recommended that students use common areas and the library instead, because using the bed to complete stress related activity such as schoolwork can be destructive to effective sleep (Notre Dame College, 2007).The fourth recommendation is to avoid large meals before bedtime (CDC, 2012). It is suggested that if one plans to eat before bed to do it about 2 hours prior to bedtime (Notre Dame College, 2007). These tips are based on the CDC’s general assessment of good sleep hygiene so that people can avoid sleep deprivation or other disordered sleep patterns. Students can benefit from these suggestions; however, the college student environment sometimes does not support good sleep.

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THEORETICAL FRAMEWORK Below is the theoretical framework of the study (refer to Figure 1). This research will utilize the theory of Oswald which is the Restoration Theory, conceptualized in 1996, and the theory of Nightingale which is the Environmental Theory, conceptualized during the 19th Century.

Restoration Theory (Oswald,1996)

Environmental Theory (Nightingale, 19th century)

Figure 1: The Theoretical Framework of the study. The Environment Theory of nursing is a patient-care theory. That is, it focuses on the care of the patient rather than the nursing process, the relationship between patient and nurse, or the individual nurse. In this way, the model must be adapted to fit the needs of individual patients. The environmental factors affect different patients unique to their situations and illnesses, and the nurse must address these factors on a case-by-case basis in order to make sure the factors are altered in a way that best cares for an individual patient and his or her needs. (Petepirin, 2016) The focus Environmental theory is to alter the patient's environment in order to affect change in his or her health. The environmental factors that affect health, as identified in the

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theory, are: fresh air, pure water, sufficient food supplies, efficient drainage, cleanliness of the patient and environment, and light (particularly direct sunlight). If any of these areas is lacking, the patient may experience diminished health. A nurse's role in a patient's recovery is to alter the environment in order to gradually create the optimal conditions for the patient's body to heal itself. In some cases, this would mean minimal noise and in other cases could mean a specific diet. All of these areas can be manipulated to help the patient meet his or her health goals and get healthy. (Petepirin,2016) Nightingales environmental theory is an act of utilizing the environment of the patient to assist him in his recovery. In this study, the researchers aims to know the different environmental, external, and internal factors that causes the nursing students of Ateneo de Zamboanga University to be sleep deprived. Knowing the different causes is not only the goal of the researchers to find out but also the incidence of sleep deprivation among nursing students. Some environmental factors and different causes of sleep deprivation also affects the rate of occurrence of sleep deprivation among nursing students and in this study what the researchers want to know is not the environmental factors that affects the incidence of sleep deprivation but mainly the incidence of sleep deprivation. Another theory, the Restoration Theory, was conceptualized by Oswald in 1996, According to Oswald, the function of sleep is to restore the body during periods of inactivity so that adequate biological functioning is ensured. The tissues of the brain and body are repaired and the chemicals needed for proper functioning are replenished. Specifically, Oswald claims that Non Rapid Eye Movement (NREM) sleep restores biological processes that have deteriorated during the day. Rapid Eye Movement (REM) sleep replenishes and renews brain processes through the process of protein synthesis. A student nurse is expected to function well

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in classroom our in the clinical areas when amount of sleep is sufficient. Sleep is really important and is essential to everyone, but when one is studying occurrence of sleep deprivation cannot really be avoided and this increases the incidence as to why almost all college student are sleep deprived. The restoration theory is necessary for this research because this study involves sleep deprivation. The Environmental theory by Nightingale and Restoration theory by Oswald were chosen to provide knowledge on the possible causes for sleep deprivation of nursing students. These causes will lead to the goal of the study: to identify the incidence of sleep deprivation among level IV nursing students. The correlation of the restoration theory of Oswald and the Environmental theory of Nightingale is a useful theory to find out the different causes of sleep deprivation which would affect the incidence of sleep deprivation among level IV nursing students. The theoretical framework is formulated to identify certain factors or commonalities what causes the students to be sleep deprived and also this theoretical framework also serves as a guide to formulate the conceptual framework needed in order to gather variables that can be tested to determine the incidence of sleep deprivation among nursing students of Ateneo de Zamboanga University.

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CONCEPTUAL FRAMEWORK The following diagram is the Conceptual Framework of the study (refer to Figure 2).

Sleep Deprivation

Causes of Sleep Deprivation

Incidence of Sleep Deprivation

Coping with Sleep Deprivation

Level IV BSN student nurses of ADZU

Figure 2: The Conceptual Framework of the Study The conceptual framework of the study will mainly focus on the Incidence of sleep deprivation among nursing students of Ateneo de Zamboanga Univeristy. Causes of sleep deprivation and also how students handle sleep deprivation will also be included in this research study in order for the researchers to know the commonalities of the causes why a student becomes sleep deprived and how does these causes affect the incidence of sleep deprivation. Coping with sleep deprivation and knowing how sleep deprivation affects the level IV nursing students personally was also included in the study in order for the researchers to know on how they overcome sleep deprivation in order for them to make it through the day of tiring school works and duties.

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There are five variables in the study; First variable is the sleep deprivation, second variable is the causes of sleep deprivation, third variable is the incidence of sleep deprivation fourth variable is to how nursing students cope with sleep deprivation, and lastly the level IV nursing students of Ateneo de Zamboanga University. Sleep deprivation which is the first variable happens when a certain person did not complete the number of hours sleep needed. Sleep deprivation is on the top of the conceptual framework since sleep deprivation is the main reason why this study is created, sleep deprivation is also the main reason why some incidences of sleep deprivation happen, why causes of sleep deprivation arises, and lastly, why most of the students are able to handle or overcome sleep deprivation. Sleep deprivation is further extended into the three branches of variables, these are the, causes of sleep deprivation, incidence of sleep deprivation, and coping with sleep deprivation. All of these variable comes down to the last variable of the study which is the Level IV nursing students of Ateneo de Zamboanga University. The last variable is intentionally placed in the bottom of conceptual framework because it is the students who are greatly affected by sleep deprivation, it is through the students why causes and incidence of sleep deprivation happens, and it is the duty of the students to handle sleep deprivation in order for them to make it through the day of loads of requirements, quizzes, duties and etc.

STATEMENT OF THE PROBLEM This research study aims to determine the Incidence of sleep deprivation among nursing students of Ateneo de Zamboanga University. Specifically, the study aims to answer the following questions: 1. What are the number of hours of sleep of the level IV nursing students on a regular day?

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2. What is the incidence of sleep deprivation among the level IV nursing students? 3. What are the common causes of sleep deprivation among level IV nursing students? 4. How often are the level IV nursing students sleep deprived on a regular week? 5. How do the level IV nursing students cope with sleep deprivation?

SIGNIFICANCE OF THE STUDY This study can be a learning paradigm for the college of nursing to enhance the students’ knowledge about the sleep deprivation. The researcher will focus on the incidence rate of sleep deprivation among the nursing students thus this paper will give a more or less accurate number of students who are sleep deprived. Included in this research is the quantitative value of sleep that the nursing students could have every night. Since sleep plays an important role in memory and learning process this study will be a significant endeavour in promoting normal sleep pattern. This paper will promote awareness to the nursing students that sleep deprivation very is detrimental to health; this would decrease their ability to concentrate and complete complex task especially in the area of duty and in the classroom as well. Although there may be obvious negative consequences as a result of sleep deprivation and though it remains a struggle to find the motivation to modify the behaviours; this study can be a wake-up call for the college of nursing clinical instructors and administrative staff in terms of strategic management for the nursing students who are sleep deprived.

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Sleep deprivation is and largely under-recognized health issue which may require a multidimensional approach to be able to transform previous behaviour. This study will therefore pave the way for other researchers to investigate deeply about the causes and effects and other factors that lead to the problem sleep deprivation among nursing students.

SCOPE AND LIMITATION OF THE STUDY The problem of this study will solely focus only in the Incidence rate of sleep deprivation among level IV nursing students of Ateneo de Zamboanga University. The goal of the study is to determine the incidence level of sleep deprived level IV nursing students and also to determine what are the commonalities that causes them to be sleep deprived and how does the level IV nursing students handle sleep deprivation. The scope area of the study will include the premises of Ateneo de Zamboanga University, Main Campus. The study participants for this research study will be chosen from the fourth year college, nursing students from both groups A and B. The reason for the selection of this group is due to the fact that the level IV nursing are considered to have stressful RLE duties and also the level IV nursing students have lots of quizzes, requirements, and Sunday Review examination, by this the researchers are expecting a great number of incidence of sleep deprivation among the level IV nursing students. By using the Total Enumeration as for gather the study participants, an estimate of 102 (excluding the researchers) or the total population of level IV nursing students will be selected as study participants

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DEFINITION OF TERMS Sleep Deprivation. This refers to the condition of not having enough sleep translating enough sleep into numbers, it means the college students ages 18-25 years old cannot complete the recommended sleeping hours which is 8-9 hours per night. Student Nurses. The nurses from this study are the level IV student nurses currently enrolled to the program Bachelor of Science in Nursing (BSN) S.Y. 2018-2019. Quality of Sleep This refers to the amount of sleep that the students nurses can have while juggling academic requirements as well as the student nurses related learning experience (RLE) duty. Incidence This refers to the frequency, occurrence or rate of sleep deprivation of level IV student nurses in Ateneo de Zamboanga University

CHAPTER II RESEARCH METHOD This chapter will be discussing the Research Design, Research Locale, Participants of the Study, Instrument of the Study, Data Gathering Procedure, Plan of Analysis, and Ethical Considerations. This will be needed to determine the Incidence of Sleep Deprivation among Level IV Nursing Students S.Y. 2018-2019 of Ateneo de Zamboanga University . RESEARCH DESIGN This research study will be using a descriptive research design with quantitative measures. According to Earl Babbie (2010), quantitative measures emphasize objective measurements and the statistical, mathematical, or numerical analysis of data collected through polls, questionnaires, and surveys or by manipulating pre-existing statistical data using computational techniques. This research study will seek to find out Incidence of Sleep Deprivation among Level IV Nursing Students S.Y. 2018-2019 of Ateneo de Zamboanga University. Descriptive research design with quantitative measures will be used to describe and interpret the number of hours of sleep of the level IV nursing students on a regular day, the incidence of sleep deprivation among level IV nursing students, the common causes of sleep deprivation among level IV nursing students, and lastly how students cope with sleep deprivation.

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RESEARCH LOCALE The research will be conducted in Zamboanga City, Philippines, particularly Ateneo de Zamboanga University is the only school Jesuit school that exists in Western Mindanao. The school was founded in the year 1912 as Escuela Catolica and the second oldest Jesuit school to be named Ateneo. In 2001, the Commission on Higher Education officially declared Ateneo de Zamboanga a university. PARTICIPANTS OF THE STUDY The study participants of this research will be select nursing students of Ateneo de Zamboanga University. Participants for this study will be chosen from the Level IV nursing students. The reason for the selection of this group is due to the fact that the level IV nursing students are those who have accumulated the most exposure to Related Learning Experience (RLE), whether in a hospital or community set-up. The population of the study will be 102 (excluding the researchers) level IV nursing students of Ateneo de Zamboanga University. The sample for this research study will be taken from all the 102 level IV nursing students using the total population sampling by studying and examining the entire population to get the most accurate findings for the study of incidence of sleep deprivation. Inclusion Criteria: The study participants for this research will be chosen based on the following criteria: a) bona fide student of Ateneo de Zamboanga University, b) level IV Bachelor of Science in Nursing student, c) having Related Learning Experience (RLE) duty, d) been to a health center or hospital duty, & e) those who are sleep deprived.

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Exclusion Criteria: Those who are not chosen for this study will be chosen based on the following criteria: either, a) not bona fide student of Ateneo de Zamboanga University, b) not a level IV Bachelor of Science in Nursing student, c) not having Related Learning Experience (RLE) duty, d) never been to a health center or hospital duty, & e) those who are not sleep deprived. INSTRUMENTS OF THE STUDY This study will utilize a research instrument in order to obtain the needed data for this study. A self-administered questionnaire with different parts will be formulated by the researchers. Prior to conduction the gathering of the data, a consent will be given to the study participants as an approval sheet and making sure that all data gathered will be highly confidential. The draft of the questionnaire will be drawn out based on the researcher’s readings, previous studies, literature published and unpublished thesis relevant to the study. The self-administered questionnaire will contain four (4) parts. The first part of the instrument talks about the demographic data. This part of the instrument will solicit the study participant's name, age, year and section. A follow up question will be asked whether the participant has been sleep deprived for the past few weeks. If the participant answered “yes, I have been sleep deprived then he or she can proceed in answering the rest of the instrument and if the study participant, he or she will be asked to return the questionnaire. The second part of the questionnaire talks about the incidence of sleep deprivation, this part of the instrument will solicit the number of nights in which they are deprived of sleep in a week. In those nights of being sleep deprived, the study participants will be asked as to how many hours they sleep

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during those nights including power naps in the afternoon. The third part of the questionnaire talks about the causes of why nursing students are sleep deprived, a select that all apply (close ended) type of questionnaire will be utilized. The researchers will give 10 different options regarding the causes of why nursing students are sleep deprived. The study participants will be given a chance to specify what causes him or her to be sleep deprived if the given options did not match their idea. This part of the instrument will answer the question “What are the common causes of sleep deprivation among level IV nursing students?” The last part of the questionnaire aims to determine as to how the level IV nursing students cope with sleep deprivation. this part of questionnaire will be answerable by the use of a 4 point Likert Scale in which the participant has to agree, very much agree, disagree, or very much disagree to the given statement. The likert questionnaire will have a total number of 10 items that is focused as to how do level IV nursing students cope with sleep deprivation whether during duty or at school. Reliability Test To fully know the incidence of sleep deprivation among level IV nursing students, a test retest reliability will be used. It will measure the reliability obtained by administering the same test twice over a period of time (one to two months) to the group of individuals. In order to measure the test retest reliability, the researchers will give the same test to same respondents on two separate occasions. The first test given can be referred as T1 and the second test can be referred as the T2 known as the test retest reliability coefficient. The closer each study participant’s scores are on T1 and T2, the more reliable the test measure. Validity Test

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The different instrument of the study used in this research were referred to the adviser for the face validity for assessments of the appropriateness and suitability of the instruments. The face validity is the degree to which a procedure appears effective in terms of its stated aims. With the recommendation of the adviser or to the experts in the research field, the research instruments will be then subjected to a validity testing in order to modify or improve testing items that seemed to be vague to the study participants. DATA GATHERING PROCEDURE The data gathering will begin with a letter made by the researchers for the dean of the college of nursing to allow the researcher to conduct a study. Indicated in the letter is to ask permission to invite the 102 level IV nursing students excluding the researhcers to be the participants of the study entitled Incidence of Sleep Deprivation among Level IV Nursing Students S.Y. 2018-2019 of Ateneo de Zamboanga University. After the researchers are done choosing their study participants, a letter will then be handed informing the participants of what the focus, significance, and goals of the study are. This letter will also ask for their consent to answer a self-administered questionnaire prepared by the researchers which contains 4 parts. A specific date and time will be announced to the study participants for them to answer the questionnaires. The study participants must answer the questions truthfully, independently and without the help of others in order to obtain the desired result. When they are done answering the researchers will immediately collect the questionnaires and check it and tally the results. The data obtained will be analysed using the frequency table and the central tendency mode. The test will took place at the Nutrition Lab and Amphitheater,

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BC building, Ateneo de Zamboanga University Main Campus for approximately 30 to 40 minutes PLAN OF ANALYSIS The gathered data obtained from the participants will undergo a process which utilized a descriptive quantitative statistics. The obtained data will be interpreted by the use of the different statistical tools. The statistical tool that will be utilized in this study will be the frequency distribution table and central tendency mode. The central tendency “mode” or the most frequently occurring number found in a set of numbers will be identified. The results will be tabulated in a frequency table to help identify the mode in each of the different options provided to the study participants. To answer the question “What are the number of hours of sleep of the level IV nursing students on a regular day?” the researchers will utilize the central tendency “mode” in order to identify the most occurring hour in which the study participants are sleep deprived on a regular day. The data obtained will be interpreted by the use of a pie chart in order to classify the different hours of sleeps the study participants had. The use of the pie chart will also aid the researchers on discussing the most significant and the least significant data obtained. To answer the question “What is the incidence of sleep deprivation among the level IV nursing students?” it will be analysed by the use of the central tendency “mode” or the most frequently occurring number found in a set of numbers. The results will be tabulated in a frequency table and will be interpreted by the use of a bar graph presenting the different days in which the study participants became sleep deprived and the different number of hours of sleep in which the study participants had during the days of July 08, 2018 to July 14, 2018. The use of the

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bar graph will also aid the researchers in identifying and discussing the most and the least significant data obtained. To answer the question “How often are the level IV nursing students sleep deprived on a regular week?” the researchers will utilize the central tendency “mode” in order to identify the days in which most of the study participants are sleep deprived on a regular week. The data obtained will be interpreted by the use of a bar graph in order to classify the different days in which the study participants became sleep deprived. The use of the bar graph will also aid the researchers on discussing the most significant and the least significant data obtained. To answer the question “What are the common causes of sleep deprivation among level IV nursing students and “How do level IV nursing cope with handle sleep deprivation” the data obtained will again be analysed by the use of the central tendency mode. The results obtained will be tabulated on a frequency table in order to identify the mode and will then be interpreted by the use of a tabular form. For the common causes of sleep deprivation, the use of a tabular form will rank the questions or set of choices from most agreed question or choice from the least agreed question or choice. For the question “How do level IV nursing students cope with sleep deprivation?” since the data obtained for this question is a likert type scale, each question will be ranked as to whether the study participants strongly agree, agree, disagree, and strongly disagree. The use of the tabular form will also aid the researchers in identifying and discussing the most and the least significant data obtained. ETHICAL CONSIDERATIONS The ethical consideration is to ensure the safety of the students in research and who assist in making sure that human rights are not violated. The research also helps to protect the institution

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and the researchers against potential legal implications from any behavior that may be deemed unethical. The first ethical consideration is the approval of the dean of College of Nursing. Second, the student should voluntary participate in the research, they can withdraw from the research anytime. Third, the students must be properly informed regarding the purpose of the consent of the study and that there will be no harm for them. Lastly, Ethical standards also protect the confidentiality and anonymity of the subjects.