Rest Assured: Empowering Nurses to Tackle Sleep Disorders in Cancer Care

Cancer patients and survivors are known to suffer from insomnia more than the general population. That is why screening for sleep disorders in cancer care, which is not typically done, was the focus of a pilot study recently published in The Journal of Continuing Education in Nursing.

The School of Nursing’s Kelly Foltz-Ramos, PhD, RN, FNP-BC, CHSE-A, assistant professor and director of simulation and innovation, and Suzanne S. Dickerson, PhD, RN, professor and associate dean of the research doctoral program, were the lead authors of the study, “Educating Nurses in Sleep Screening, Brief Intervention, and Referral for Treatment.”

“The real problem is that patients are not screened for sleep, and if they are asked about their sleep, nothing is done,” Foltz-Ramos said. “In cancer patients and survivors especially, sleep disorders can have a huge negative impact on their health, while they are receiving treatment, during recovery and long term into survivorship.” 

Often if cancer patients report a problem sleeping, it is attributed to their treatment or to the cancer, and the first line of treatment is usually medication. However, Foltz-Ramos and Dickerson recognized that brief behavioral therapy (based on cognitive behavioral therapy) has proven effective for addressing sleep disorders. It was a matter of training nurses, who are uniquely positioned to screen and begin intervention to address the problem.

“We know there is opportunity to improve sleep for these patients by empowering registered nurses to play a role by screening and giving a brief behavioral intervention,” Foltz-Ramos said.

In their study, the researchers developed online educational modules with in-situ simulation scenarios to train nurses in sleep disorders screening and providing brief intervention or referral to treatment (SBIRT).

“We chose the SBIRT model, which has been used for alcohol use screening, because this approach applies well in clinical practice settings and includes the necessary components,” Dickerson said. These components are following up with brief interventions and referral for other treatment — in this case, sleep-wake issues requiring sleep medicine expertise.

While Sleep-SBIRT could eventually be implemented to transfer nursing education to the clinical setting to impact outcomes for patients with all types of diagnoses, the focus on cancer patients was of particular interest to the late Grace E. Dean, PhD, RN, a School of Nursing professor and oncology nurse researcher. In 2019, Dean completed a pilot study with lung cancer patients with insomnia in which nurses delivered effective insomnia treatment.

“Dr. Dean recognized the need to train nurses to provide this in everyday oncology practice. She went on to write for funding to develop an online training module with simulation feedback that nurses could complete that would inform the nurses of common sleep-wake disturbances. Our recent paper describes the initial feedback of the program. This was her research program legacy — to promote awareness of sleep-wake problems for cancer patients in clinic nurses. Her work set the stage for addressing sleep needs for future oncology patients,” Dickerson said.

The training program, which was implemented with registered nurses in ambulatory clinics in a comprehensive cancer care center, included the online modules that could be completed as their schedules permitted and from any connected computer. The content covered the most common sleep disorders: obstructive sleep apnea, circadian rhythm sleep disorders, parasomnias, narcolepsy, restless legs syndrome and insomnia. Patients who screened positive for insomnia were offered brief behavioral therapy for insomnia (BBTI) and the rest were given a referral to a primary care provider.

The nurse participants were scheduled for the simulation and worked in pairs, in the clinic setting, with each taking a turn to participate or observe each scenario.

“Many of the nurses were very open about not having this knowledge before, even reporting that they didn’t understand how bad their own sleep was until after participating in the training and simulation. We found that self-reflection piece very interesting — when you’re more aware of sleep disorders in yourself, it makes you more aware of how it impacts other people. We will definitely think about that moving forward,” Foltz-Ramos said.

Foltz-Ramos is already also thinking forward to redeploying an improved training. The modules would be updated, and innovative strategies may be applied, such as making the simulation available via virtual reality to address scheduling obstacles for busy nurses.

Co-authors with Kelly Foltz-Ramos and Dickerson include Cheryl A. Oyer, PhD; Donna Fabry, DNP, CNS, RN; and Grace E. Dean, PhD, RN, all of the School of Nursing. This study was supported by the University at Buffalo School of Nursing, Patricia H. Garman Behavioral Health Nursing Endowment Fund, and the National Institutes of Health Grant #R01NR018215.

By TERRA OSTERLING