Abstract
This study highlights gaps in occupational therapists’ knowledge regarding how best to assess and treat sleep problems and offers next steps to improve the profession’s capacity to address the occupation of sleep.
Sleep is fundamental to overall health and wellness and provides balance to daily life (Meyer, 1922; Tester & Foss, 2018). Sleep influences pain modulation, wound healing, and recovery from illness or injury (Bhakta & MacRae, 2020). In addition, adequate quality sleep supports the regulation of mood, behaviors, and energy levels that support everyday occupations (Smallfield et al., 2021; Tester & Foss, 2018); conversely, poor sleep can negatively affect occupational engagement (Fogelberg et al., 2017). Last, sleep is relevant across the lifespan because all humans need sleep for optimal function (Smallfield & Lucas Molitor, 2018). Occupational therapy addresses the balance between all areas of occupation across the lifespan.
Beginning with the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy Association [AOTA], 2008), the occupation of rest and sleep has been a separate domain and consists of sleep, rest, sleep participation, and sleep preparation (Gentry, 2013). The Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; AOTA, 2020b) defines sleep as activities related to going to sleep, staying asleep, and establishing health and safety through participation in sleep. Within the OTPF–4, sleep encompasses the social, cultural, spiritual, environmental, and personal needs surrounding sleep. The OTPF–4 is a guide for students and practicing occupational therapists in addressing all components of the occupation of sleep.
A survey assessed physical therapists’ perceptions and attitudes about the need to address sleep issues within their clinical practice (Siengsukon et al., 2015). A large majority of respondents agreed that sleep was important to assess and that addressing sleep may affect outcomes. However, the majority of respondents did not receive education about sleep, and the most common reason given for not routinely assessing sleep was not knowing how. This survey study suggests that physical therapists would benefit from training in sleep assessment and methods to address sleep issues in clinical practice. Occupational therapists’ perceptions and attitudes regarding sleep remain unclear; in addition, further clarity is needed regarding whether the need for sleep education and training extends beyond physical therapy to other allied health care professions, such as occupational therapy.
In prior studies, researchers have examined specific sleep interventions conducted by occupational therapists (such as cognitive–behavioral therapy for insomnia and an occupation-based intervention) to improve sleep in various patient populations (Eakman et al., 2017; Leland et al., 2016), and appropriate sleep interventions that are within occupational therapy’s scope of practice have been identified (Leland et al., 2014). Moreover, progress has been made in advancing occupational therapists’ role in the management of sleep (Ho & Siu, 2018; Sheth & Thomas, 2019) and the consideration of opportunities to integrate sleep into occupational therapy practice, education, and research (Fung et al., 2013). However, occupational therapists’ comfort with their level of knowledge about sleep and how they are assessing and addressing this occupational domain with practice remain unclear. It is also unknown how much education occupational therapists receive on the occupation of sleep in entry-level occupational therapy programs or through continuing education. Therefore, the purpose of this survey study was to assess practicing occupational therapists’ comfort regarding their level of knowledge about sleep, how they are evaluating and addressing sleep in clinical practice, and the amount of sleep-related education they have received.
Method
Study Design and Survey Instrument
This study was a cross-sectional survey of practicing occupational therapists. An electronic survey was developed in three steps. First, the survey was based on a prior survey that assessed practicing physical therapists’ perceptions and attitude about sleep (Siengsukon et al., 2015). Questions were tailored to address the occupational domain of sleep, how occupational therapists evaluate sleep, what education occupational therapists provide to their clients, and which treatments are typically implemented. In addition, questions were included on the amount of sleep education received in entry-level occupational therapy programs and what additional continuing education regarding sleep occupational therapists have received. Second, the survey was reviewed by two occupational therapists with sleep and survey development experience. Consensus was achieved on wording of questions and number of questions included in the survey. Third, the survey was then tested on a trial basis by five practicing occupational therapists for content validity, clarity, and understanding. Modifications were made to the survey on the basis of the responses and feedback.
The final version of the survey consisted of 35 to 41 questions (depending on branching logic) divided into five sections. The first section consisted of 10 questions on demographics, including sex, age, occupational therapy degree received, current employment status, number of years since graduation from an entry-level occupational therapy program, state(s) currently practicing as an occupational therapist, age range(s) of clients primarily treated, and type of occupational therapy practice setting. The second section consisted of 11 questions answered on a 4-point Likert scale ranging from not comfortable to very comfortable that assessed level of comfort with their knowledge of sleep. The third section consisted of four yes-or-no questions on the occupation of sleep. The fourth section consisted of 4 to 10 (depending on response and branching logic) yes-or-no and fill-in-the-blank questions on their process for evaluating sleep, setting goals for sleep, and treatment and education provided regarding sleep. The fifth section consisted of 3 to 4 (depending on response and branching logic) multiple-choice and open-ended questions regarding the type and amount of sleep education received during their entry-level occupational therapy program or continuing education.
Target Population
A convenience sample of occupational therapists who served as fieldwork clinical instructors for students in the master’s of occupational therapy program at Colorado State University and Concordia University Wisconsin were invited by email to participate in this study in November 2020. Additionally, the survey link was posted on the AOTA general forum site. Instructions provided at the beginning of the survey indicated that only practicing occupational therapists were eligible to complete the survey.
Data Collection and Analysis
The survey was built into and managed by Research Electronic Data Capture (REDCap) software (Version 12.0.13) hosted at the University of Kansas Medical Center (Harris et al., 2009, 2019). An email with an explanation of the purpose of the survey and a link to access the survey was sent to nearly 1,500 clinical site instructors. A week after the initial email, a reminder email was sent asking that the survey be completed within the week. After opening the link to the survey, a detailed explanation of the study’s purpose and a statement indicating consent to participate were provided. This study was conducted in accordance with the University of Kansas Medical Center’s institutional review board.
Data were downloaded from the electronic survey into a Microsoft Excel spreadsheet. Descriptive analyses were conducted. Means were calculated for continuous variables, and frequency distributions were calculated for categorical data.
Results
Demographic Characteristics
A total of 169 occupational therapists completed the survey. Of the respondents, 94% were female, and the mean age was 40.5 yr (Table 1). Most participants (70%) held a master’s degree in occupational therapy, and the majority (77%) were working full time. Experience levels ranged from entry level (1–5 yr of practice) to well-established clinician (>30 yr). The two most common practice settings were outpatient clinics (29%) followed by acute care and hospital settings (25%). Twenty-four states were represented, with most participants from Colorado and Wisconsin.
Demographic Characteristics of the 169 Occupational Therapists Who Completed the Survey
Note. PRN = as needed.
Five people did not respond.
More than one category could be chosen.
Occupational Therapists’ Comfort With Level of Knowledge of Sleep
The highest response rate on sleep physiology was “somewhat comfortable” with basic sleep physiology (44%) and “not comfortable” with advanced sleep physiology (62%; Table 2). For knowledge of epidemiology of sleep, the most selected answer was “somewhat comfortable” (43%) followed by “not comfortable” (41%). The most selected response was “not comfortable” for assessment of sleep quality (52%), sleepiness (49%), and screening for potential sleep disorders (62%). Almost half (49%) of the participants felt “somewhat comfortable” with interventions to address sleep issues and with promoting healthy sleep habits and quality sleep.
Responses to Sleep Knowledge Categories
Note. Some percentages may not total 100 because of rounding.
The Occupation of Sleep
The majority agreed that sleep is considered an occupation (87%), an activity (83%), and an activity of daily living (83%). Most of the participants (85%) reported being comfortable talking with their clients about sleep.
Evaluating Sleep, Establishing Sleep-Related Goals, Treating Sleep, and Providing Education About Sleep
The majority of participants (56%) reported that they do not evaluate their client’s sleep (Table 3). Of the 75 (44%) participants who stated that they do evaluate their patients’ sleep, 11% routinely administered a sleep questionnaire. The two most commonly reported assessments were the Insomnia Severity Index (Bastien et al., 2001; 25%) and the Sleep Disorders Symptom Checklist (Klingman et al., 2017; 25%).
Occupational Therapy Process Questions
Note. CBT–I = cognitive–behavioral therapy for insomnia; CPAP = continuous positive airway pressure; ICU = intensive care unit; SCI = spinal cord injury.
More than one category could be chosen.
n = 168 for this question.
Of the participants, 30% reported establishing client goals to improve sleep preparation or sleep participation (see Table 3). On the follow-up open-ended question to provide examples of sleep-related goals, the three most common goal themes were creating and adhering to a bedtime routine (25%), sleep hygiene routine (23%), and increasing duration of sleep (21%). A variety of treatments used to address sleep-related goals were reported (see Table 3). The three most common treatments used were creating a sleep schedule (27%), using relaxation tools (25%), and environmental modifications and education on the sleep environment (25%).
Most of the participants (66%) reported that they provide education about sleep preparation and sleep participation. For those who provide this education, a follow-up question was asked on what type of education was provided. The most common types of education were supportive bedtime routines (41%), sleep hygiene education (40%), and environmental modifications (17%). In addition, 19% responded “yes” to educating about other sleep-related topics. The three most common types of other sleep-related education were increasing activity for sleep (9%), sensory education (9%), and positioning for select populations (6%; see Table 3).
Sleep Education Received by Occupational Therapists
Of the participants, 33% reported receiving education about sleep in their entry-level occupational therapy program. Of those who received education about sleep, 47% reported receiving 2 to 3 hr of education about sleep in their entry-level occupational therapy program. The majority of participants (78%) reported not having any continuing education in the past 2 yr about sleep or sleep-related topics. In addition, 92% reported that occupational therapists should receive more education to evaluate and treat sleep preparation and sleep participation problems after graduating from an entry-level occupational therapy program (Table 4).
Occupational Therapy Education Questions
Discussion
This survey study provides critical insight into the assessment of occupational therapists’ comfort with their level of knowledge about sleep, how occupational therapists evaluate and address sleep, and how much education occupational therapists receive regarding sleep in entry-level occupational therapy programs and for continuing education. Despite being included as an occupational domain in the OTPF since 2008, the majority of responding occupational therapists did not evaluate their clients’ sleep participation or sleep preparation. Moreover, the majority did not receive sleep-related education in their entry-level occupational therapy program or through continuing education courses. However, most of the participants reported being comfortable talking with their clients about sleep (85%) and providing education about sleep preparation and sleep participation (66%).
Demographic Characteristics
The participants’ demographic characteristics in this study mirror the field of occupational therapy. Of the participants, 94% were female, which is reflective of the current gender distribution for occupational therapists (AOTA, 2020a). In addition, participants reported practicing in a variety of practice settings, and all levels of practice experience were represented, which reflects the scope of the profession and enhances the generalizability of the results.
Occupational Therapists’ Comfort With Level of Knowledge of Sleep
Most of the participants (>50%) responded “somewhat comfortable” or “not comfortable” to questions assessing level of comfort with their knowledge about sleep, indicating a general lack of comfort with a variety of sleep-related topics. These responses could be the result of limited education on the topic of sleep because 66% of participants reported not receiving education in entry-level occupational therapy programs about sleep preparation or sleep participation; moreover, 78% of participants did not receive continuing education on sleep in the past 2 yr. This finding provides evidence for the need to provide continuing education regarding sleep to currently practicing occupational therapists and to establish robust learning opportunities about sleep in entry-level occupational therapy curricula.
The Occupation of Sleep and Evaluating Sleep, Establishing Sleep-Related Goals, Treating Sleep, and Providing Education About Sleep
Although strong agreement (87%) was found among respondents that sleep was an occupation, only 44% of respondents reported that they evaluate their client’s sleep; moreover, only 11% administer a sleep questionnaire. This finding may be because of a lack of education on what screening or assessment tools are available or appropriate to use. Several structured interview screening tools have been developed and validated, such as the Structured Clinical Interview for DSM–5 Sleep Disorders instrument (Taylor et al., 2018) and the Sleep Disorders Symptom Checklist (Klingman et al., 2017). Both screening tools provide assessment of sleep disturbances, and results may warrant further evaluation. In addition, a decision tree created and validated in the physical therapy field to screen patients for sleep disturbances and to determine when a referral to a physician is warranted could be used across other allied health professions (Siengsukon et al., 2021). Collaboration with other disciplines (such as physicians board certified in sleep medicine, psychologists, behavioral sleep medicine providers, physical therapists, and social workers) may be warranted to comprehensively assess and address the client’s sleep issue.
Participants provided examples of a variety of different treatments used to support the occupation of sleep. The most reported treatment was the use of education, specifically sleep hygiene education. A sleep hygiene discussion can be variable depending on the source of information (environmental or social structure for nighttime; Stepanski & Wyatt, 2003). Additionally, sleep hygiene education is a generic treatment that does not focus on factors that influence sleep such as circadian rhythm, sleep homeostasis, or arousal levels (Cajochen et al., 2010; Grandner, 2017; Stepanski & Wyatt, 2003). Depending on the factors influencing sleep, occupational therapists likely need to do more than educate their clients on sleep hygiene to help them improve their sleep. Interventions provided by occupational therapists for sleep should have strong evidence-based support and should be provided by practitioners who have adequate knowledge and training to provide the interventions.
Only 30% of participants reported establishing sleep-related goals to improve sleep preparation or sleep participation. This low percentage indicates that occupational therapists may need additional education about the occupation of sleep, how to write goals pertaining to sleep, and appropriate interventions to address sleep goals. The sleep goals that respondents reported primarily centered around changing routines for sleep, including creating and following a bedtime routine or implementing relaxation techniques during the day or before bed. Depending on the client’s sleep issues, goals targeting factors that influence sleep physiology (circadian rhythm or sleep homeostasis), arousal levels, or sleep hygiene (behaviors and environmental factors promoting sleep) may be warranted (Cajochen et al., 2010; Grandner, 2017). Understanding factors contributing to successful sleep and factors disrupting sleep will aid in setting specific goals and implementing appropriate interventions to optimize sleep quality and quantity.
Sleep Education Received by Occupational Therapists
Two-thirds of respondents did not receive any education in their entry-level occupational therapy program about sleep preparation or sleep participation. Of those who did receive sleep education, the majority of the participants (83%) reported that they received 1 to 3 hr of education about sleep as part of their entry-level occupational therapy curricula. It is questionable whether this amount of time is sufficient education for entry-level occupational therapists to appropriately address the occupation of sleep. A survey of entry-level occupational therapy sleep education curricula may be the next step to better understand the scope of sleep education in occupational therapy programs.
Of the participants, 92% indicated that occupational therapists should be better prepared to evaluate and treat issues related to the occupation of sleep after graduating from an entry-level occupational therapy program. This finding indicates that practicing occupational therapists would like to have more knowledge on sleep and how to support the occupation of sleep in their occupational therapy practice. This finding further supports the need to create a robust knowledge base about the occupation of sleep in occupational therapy curricula and to continue to build on this knowledge in continuing education courses.
A few interesting discrepancies were noted in the survey results. Although 85% of responding occupational therapists reported they consider sleep an occupation, less than half (44%) reported they evaluate their client’s sleep. This inconsistency may be because of lack of education received during their entry-level occupational therapy program on sleep preparation and sleep participation or lack of continuing education on sleep-related content. In addition, when responding to the sleep knowledge questions, the majority were “not comfortable” assessing sleep quality (52%), assessing sleepiness (49%), or screening for potential sleep disorders (62%). However, 85% reported being comfortable discussing sleep with their client. This finding raises the question about how occupational therapists are talking about sleep when they are “not comfortable” with assessing sleep. This discrepancy could be because the survey did not clearly define what is meant by discussing sleep with clients. The second possible explanation for this inconsistency is the potential that occupational therapists have just enough knowledge about sleep to feel comfortable discussing it with their clients, yet they choose to use generic methods of assessment, such as a single question in a client interview. They then use generic treatments because of comfort level as well. This discrepancy further supports the need to provide education to occupational therapists about evidence-based assessments, goals, and treatments related to sleep as an occupation.
Limitations
A major limitation of this study is that email invitations to participate in this study were sent to fieldwork clinical instructors for two universities, which is reflected in the number of respondents from the two states where the universities reside. Therefore, the results may not be generalizable to other areas of the country, although the respondents were from 24 different states. Another limitation of this study is that 94% of the respondents were female; however, this is representative of the occupational therapy profession, as shown in the AOTA (2010) survey reporting that 92% of occupational therapy practitioners are female. Another limitation is that we did not explore whether demographic characteristics predicted response. For example, occupational therapists working in acute care may have a higher prevalence of patients reporting sleep disturbances than other settings. In addition, because rest and sleep have been deemed an occupation in the OTPF since 2008, it is possible that recent graduates have more experience with assessing and addressing the occupation of sleep than occupational therapists who graduated more than 13 yr ago. Future larger scale studies are needed to explore how demographic characteristics may contribute to answering questions in the survey.
Implications for Occupational Therapy Practice
The occupation of rest and sleep has been a domain in the OTPF since 2008. However, it was unclear whether occupational therapists were assessing and addressing the occupation of sleep in clinical practice and, if they were, what methods they were using. Occupational therapists’ comfort with their level of knowledge about sleep and the amount of sleep education they have received was also not clear. Therefore, the purpose of this survey study was to assess practicing occupational therapists’ comfort regarding their level of knowledge about sleep, how they are assessing and addressing sleep in clinical practice, and the amount of sleep-related education they have received. The results of this study have the following implications for occupational therapy practice: ▪ Occupational therapists need education on sleep to enhance knowledge of pertinent sleep-related topics so that they can effectively address the occupation of sleep. ▪ Continuing education programs on sleep-related topics should be considered as a possible effective method to enhance sleep knowledge and to facilitate integration of sleep knowledge into occupational therapy practice. ▪ Effective implementation of evidence-based treatment warrants further consideration. ▪ Although progress has been made in advancing occupational therapists’ role in the management of sleep (Ho & Siu, 2018; Sheth & Thomas, 2019), solidifying the role of occupational therapists in assessing and addressing sleep within a multidisciplinary team warrants further consideration.
Conclusion
This study is the first to assess occupational therapists’ comfort with their level of knowledge regarding sleep, how occupational therapists assess and address sleep in clinical practice, and how much sleep education occupational therapists have received. This survey illustrates the depth and breadth of how occupational therapists address the occupation of sleep across patient populations and practice settings. The results indicate that more resources are needed for occupational therapists to evaluate and treat sleep-related issues with their clients. It is evident that there is a desire and need for continued development of educational materials supporting both occupational therapy students and practicing occupational therapists in their knowledge of the occupation of sleep.
Footnotes
Acknowledgments
Catherine Siengsukon is the owner and chief executive officer of Sleep Health and Education, LLC. This study was supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant T32-HD-057850. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.