Research focused doctoral nursing education in the 21st century: Curriculum, evaluation, and postdoctoral considerations.

The AACN position statement on The Research-Focused Doctoral Program in Nursing: Pathways to Excellence was revised in 2022 by an AACN Task Force charged with creating a new vision for the PhD and similar programs in nursing. This document, which was informed by hundreds of academic nursing stakeholders, yields expectations and recommendations for PhD program curriculum, program evaluation, post-doctoral competencies, and resources. Results of an AACN 2021 survey indicated increased enrollment in PhD programs 2017-2000. Fifteen percent of students were enrolled in BSN-PhD, programs, 70 % of schools reported external review, and overall average time to degree completion was 5 years. Considerations for the education for the research doctorate include development of curriculum that fosters the scholarship of discovery and scientific inquiry and implements systematic evaluation of program outcomes while advancing postdoctoral competencies and resources, including the post-doctoral fellowship. Comprehensive assessment of the PhD program promotes ongoing program analysis and quality. Postdoctoral fellowships advance the science of nursing via the creation of a culture and workforce for nursing research. Successful postdoctoral programs have mentors, resources, and infrastructure to adequately enable the fellow to progress in their line of inquiry and develop as an investigator.

Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement.

Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.

Delaying Middle School and High School Start Times Promotes Student Health and Performance: An American Academy of Sleep Medicine Position Statement.

ABSTRACT: During adolescence, internal circadian rhythms and biological sleep drive change to result in later sleep and wake times. As a result of these changes, early middle school and high school start times curtail sleep, hamper a student's preparedness to learn, negatively impact physical and mental health, and impair driving safety. Furthermore, a growing body of evidence shows that delaying school start times positively impacts student achievement, health, and safety. Public awareness of the hazards of early school start times and the benefits of later start times are largely unappreciated. As a result, the American Academy of Sleep Medicine is calling on communities, school boards, and educational institutions to implement start times of 8:30 AM or later for middle schools and high schools to ensure that every student arrives at school healthy, awake, alert, and ready to learn.

Risk assessment for CPAP nonadherence in adults with newly diagnosed obstructive sleep apnea: preliminary testing of the Index for Nonadherence to PAP (I-NAP).

PURPOSE: Identification of risk for continuous positive airway pressure therapy (CPAP) nonadherence prior to home treatment is an opportunity to deliver targeted adherence interventions. Study objectives included the following: (1) test a risk screening questionnaire to prospectively identify CPAP nonadherence risk among adults with newly diagnosed obstructive sleep apnea (OSA), (2) reduce the questionnaire to a minimum item set that effectively identifies 1-month CPAP nonadherence, and (3) examine the diagnostic utility of the screening index. METHODS: A prospective, longitudinal study at two clinical sleep centers in the USA included adults with newly diagnosed OSA (n=97; AHI≥5 events/h) by polysomnogram (PSG) consecutively recruited to participate. After baseline participant and OSA characteristics were collected, a risk screening questionnaire was administered immediately following CPAP titration polysomnogram. One-month objective CPAP use was collected. RESULTS: Predominantly, white (87%), males (55%), and females (45%) with obesity (BMI 38.3 kg/m2; SD 9.3) and severe OSA (AHI 36.8; SD 19.7) were included. One-month CPAP use was 4.25 h/night (SD 2.35). Nineteen questionnaire items (I-NAP) reliably identified nonadherers defined at <4 h/night CPAP use (Wald X2[8]=34.67, p<0.0001) with ROC AUC 0.83 (95% CI 0.74-0.91). Optimal score cut point for the I-NAP screening questionnaire were determined to maximize sensitivity (87%) while maintaining specificity>60% (63%). CONCLUSION: A risk screening questionnaire employed immediately after titration PSG may reliably identify CPAP nonadherers and permit the delivery of targeted interventions to prevent or reduce nonadherence. This novel approach may enhance cost-effectiveness of care and permit appropriate allocation of resources for CPAP adherence.

Pupillometric assessment of sleepiness in narcolepsy.

PURPOSE: Excessive daytime sleepiness is highly prevalent in the general population, is the hallmark of narcolepsy, and is linked to significant morbidity. Clinical assessment of sleepiness remains challenging and the common objective multiple sleep latency test (MSLT) and subjective Epworth sleepiness scale (ESS) methods correlate poorly. We examined the relative utility of pupillary unrest index (PUI) as an objective measure of sleepiness in a group of unmedicated narcoleptics and healthy controls in a prospective, observational pilot study. METHODS: Narcolepsy (n = 20; untreated for >2 weeks) and control (n = 56) participants were tested under the same experimental conditions; overnight polysomnography was performed on all participants, followed by a daytime testing protocol including: MSLT, PUI, sleepiness visual analog scale (VAS), ESS, and the psychomotor vigilance test (PVT). RESULTS: The narcolepsy and control groups differed significantly on psychomotor performance and each measure of objective and subjective sleepiness, including PUI. Across the entire sample, PUI correlated significantly with objective (mean sleep latency, SL) and subjective (ESS and VAS) sleepiness, but none of the sleepiness measures correlated with performance (PVT). Among narcoleptics, VAS correlated with PVT measures. Within the control group, mean PUI was the only objective sleepiness measure that correlated with subjective sleepiness. Finally, in an ANCOVA model, SL and ESS were significantly predictive of PUI as measure of sleepiness. CONCLUSION: The role of PUI in quantifying and distinguishing sleepiness of narcolepsy from sleep-satiated healthy controls merits further investigation as it is a portable, brief, and objective test.

Gender differences in the clinical manifestation of obstructive sleep apnea.

Obstructive sleep apnea (OSA) has been historically described as a disease primarily of men. However, it is now widely recognized that OSA in women is not as rare as was originally believed. The alarming degree to which OSA is clinically underdiagnosed in women raises the critical concern that women manifest OSA differently. The purpose of this review is to examine the issue of clinically significant gender differences in OSA disease manifestation, which pose unique challenges to diagnosis and management. Within this review, current findings regarding gender differences in OSA polysomnographic features and demographic factors, symptom presentation, functional status, comorbidities, health care utilization, and therapeutic management have been reviewed. Further research in this field is proposed to examine the impact of gender on functional status in individuals with OSA, and the potential gender differences in therapeutic management, particularly the response to continuous positive airway pressure (CPAP) treatment. Additional studies describing the clinical manifestations in men and women at different levels of OSA severity may substantially contribute to the ability to identify and treat OSA in women across a wide spectrum of disease severity.

Predictors of health-related quality of life in patients with obstructive sleep apnoea.

AIM: This paper is a report of a study to identify the common symptoms and demographic and physiological factors of obstructive sleep apnoea that are predictive of health-related quality of life in a Chinese population. BACKGROUND: Health-related quality of life impairment in obstructive sleep apnoea is an increasingly important consideration, but little is known about the factors that influence quality of life in this population. METHOD: A total of 108 Chinese patients with newly diagnosed obstructive sleep apnoea were recruited in 2003 and assessed for health-related quality of life, daytime sleepiness, depression and anxiety. Associations between symptoms, demographic and physiological factors and quality of life were examined by Pearson linear correlation. Hierarchical multiple regression were used to determine predictors of overall quality of life and its dimensions. RESULTS: Forty-six patients (42.6%) had depressed mood and 21 (19.4%) were anxious. Fifty-nine (54.6%) were hypersomnolent. The severity of symptoms of sleepiness, depression, and anxiety was statistically significantly inversely correlated with each domain and the total score for health-related quality of life. No statistically significant correlation was observed between disease severity and quality of life. Controlling for age and gender, anxiety and sleepiness predicted 45.2% of the variance of overall quality of life (R(2) = 0.452, P < 0.001). Anxiety was the strongest predictor of overall and each domain of health-related quality of life. CONCLUSION: Assessment of mood in patients with obstructive sleep apnoea should be an essential part of nursing practice. Comprehensive evaluation of symptoms, especially mood disturbance, is important for improving quality of life for these patients.

Self-efficacy in sleep apnea: instrument development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use continuous positive airway pressure.

STUDY OBJECTIVES: The purpose of this study was to evaluate the Self-Efficacy Measure for Sleep Apnea (SEMSA) designed to assess adherence-related cognitions. DESIGN: Subjects completed the questionnaire prior to the initiation of continuous positive airway pressure (CPAP) treatment. Test-retest reliability of the instrument was evaluated by having a subset of subjects complete the SEMSA a second time at home, 1 week later, returning the questionnaire by mail. PATIENTS: 213 subjects with newly diagnosed obstructive sleep apnea were recruited from the clinic populations of 2 sleep disorders centers. MEASUREMENTS AND RESULTS: Content validity was confirmed by a panel of expert judges. Confirmatory factor analysis validated the 3 a priori sub-scales: risk perception, outcome expectancies, and treatment self-efficacy. The internal consistency of the total instrument was 0.92. Test-retest reliability coefficients (N = 20) were estimated to be 0.68, P = 0.001, for Perceived Risk; 0.77, P more more than 0.0001, for Outcome Expectancies; and 0.71, P = 0.0005, for the Treatment Self-Efficacy subscale. Subject responses indicated that approximately half of the subjects did not perceive problems with concentration, sexual performance, sleepy driving, or an accident as related to sleep apnea. More than 60% of the subjects acknowledged most of the benefits of CPAP presented to them, but only 53% associated CPAP use with enhanced sexual performance. Frequently identified barriers to treatment use were nasal stuffiness, claustrophobia, and disturbing bed partner sleep. CONCLUSION: These findings indicate that the SEMSA has strong psychometric properties and has the potential for identifying patient perceptions that may indicate those most likely to not adhere to treatment.

Outcome measurement in sleep medicine practice and research. Part 1: assessment of symptoms, subjective and objective daytime sleepiness, health-related quality of life and functional status.

The documentation of treatment outcomes has gained increased importance as those responsible for paying for healthcare focus on the delivery of cost-effective care. The practitioner and researcher, challenged with documenting the clinical significance of their endeavors, must depend on conceptually appropriate, valid and reliable instruments. Outcomes of particular relevance for sleep disorders include self-reported general symptoms, subjective and objective daytime sleepiness, neurobehavior, health-related quality of life (HRQL) or functional status, incidence of accidents and cardiovascular morbidity, and health care utilization and cost. This paper will limit its focus to the outcomes of self-reported general symptoms, subjective and objective daytime sleepiness, and HRQL or functional status. In addition to describing measures that could be applied to evaluate these outcomes, this paper will also discuss factors affecting the selection of outcome measures for use in research and practice, and consider evidence generated with the application of these instruments in research. Reductions in self-reported symptoms, such as snoring and daytime hypersomnolence following treatment, have been documented with the application of measures with strong psychometric properties such as the Survey Screen for Sleep Apnea and Epworth Sleepiness Scale. In addition to statistical reliability, calculation of the effect size and standardized response mean indicate that these changes are also clinically meaningful. Similar improvements have also been demonstrated using the Multiple Sleep Latency Test (MSLT), although the resulting increased latency has not typically been within normal values. Important improvements following treatment have been documented with the Maintenance of Wakefulness Test (MWT). Evidence suggests that the MWT may be more sensitive in situations, such as narcolepsy, where there are high levels of physiologic sleepiness, reserving the MSLT where the physiologic sleep tendency is more restricted, such as in obstructive sleep apnea (OSA). Patients>> perceptions of the benefit of treatment to their daily lives have been documented by such generic measures of HRQL, such as the SF-36 and Nottingham Health Profile. However, the impact of sleep disorders and the benefit of treatment on those aspects of daily behavior likely to be most affected have more clearly been demonstrated with the utilization of disease-specific HRQL measures such as the Functional Outcomes of Sleep Questionnaire and the Calgary Sleep Apnea Quality of Life Index. 2001 Harcourt Publishers Ltd