Each year during orientation, I would talk to the new students about the importance of self-care behaviors. These behaviors include eating well, exercising, staying hydrated, taking time with loved ones, and getting enough sleep. And yet, every year after a few months into the program many students have already cut back or cut out one or more of these. As the workload builds quickly with assignments and projects to complete, pages of required reading, the time needed to review and study the material continually, and oh yes, the examinations – the mindset of “there isn’t enough time” starts to creep in. The first things to go are the exact things that support their health and well-being and their success. I can’t speak for you, but I did the same thing when I was in PA school. My answer to everyone’s request to get together or do something was, “no, I have to study.” I would stay up each night just trying to get through all the reading and review my notes. Even though I knew that sleep was necessary for health and well-being, the only time I listened to that knowledge was the night before an exam. I would close my book no later than 7 or 8 in the evening, relax, watch TV, and then go to bed at a reasonable hour. The next morning I got up at my usual time and never opened a book or reviewed my notes in an attempt to cram a little more before the test. My philosophy was if I didn’t know it by 8 PM the night before I wasn’t going to know it. Fortunately, this pattern served me well.
Every year I would tell the students that sleep is the most important habit to maintain, especially before an exam. I would share the research about how a lack of sleep significantly affects learning and performance, especially on examinations. Yet, when I would arrive on campus the day of a test, I would find students had been there since 5 AM studying and would keep studying until I literally had to tell them to put their notes away so we could start the exam. Even after over 25 years of teaching, this habit has been near impossible to break with students.
We are fortunate to have such highly motivated students, and because the program rigor is demanding and requires a minimum academic threshold to be maintained so they can stay in the program, the stakes are high. Even so, I believe the message about self-care and its importance needs to be stronger. We, as their teachers, have the opportunity to work toward instilling the importance of well-being not only as they are students, but as they become clinicians. I have heard many times from students that even though they are not taking care of themselves during the program that they will when they graduate. I think we all know that it doesn’t work. If we don’t foster and encourage that behavior now, chances are pretty high they certainly won’t do it later. But even after doing this for as long as I have, and though my students acknowledged the importance of self-care and initially vowed they would maintain those habits when the stress went up – self-care went out the window. What became most important was passing the test.
I thought for a long time that if I just provided the evidence to the students about the importance of sleep on learning and performance that would make a difference. If I shared that it would help with their ability to learn, retain the information and perform on exams, they would eagerly adopt this new behavior. Yet, we all know old habits die hard. Pulling all-nighters in undergrad is still a badge of honor. Whatever study habits they brought with them from their undergrad education were the ones they clung to – even when it became apparent they were not working in PA school.
So how can we, as teachers, help and support our students in developing and maintaining not only good sleep habits but also self-care? Simply knowing the facts doesn’t seem to be enough. We need a behavior change, and we all know how difficult that can be. But imagine, if we could get our students to embrace this one essential aspect of self–care, they could take it into their future lives as a clinician and also teach their patients about it. According to Stranges et al., (2012), sleep deprivation isn’t just a college student issue; it is a “global health epidemic.”
As an educator and clinician, I still think we must know what the current research says about sleep, lack of sleep, learning and performance. So here is a brief summary.
What the research says about sleep, lack of sleep, learning and academic performance
How much do we need?
Although we are all different, there is agreement across the literature that most adults, including college-age individuals, should get somewhere between 7-9 hours of sleep a night, with 8 hours being the sweet spot. Sufficient sleep is defined as sleep duration where awakening occurs spontaneously and one feels refreshed and alert for the day (NSF, n.d.; Scullin, 2018). Research has established that adequate sleep supports memory retention (Rasch and Born, 2013).
What is sleep deprivation?
Sleep deprivation is inadequate sleep to support full daytime alertness – which can lead to daytime sleepiness. Daytime sleepiness is defined as the inability or difficulty in maintaining alertness during the awake periods of the day and is the most common result of sleep deprivation (Hershner and Chervin, 2014).
Sleep deprivation leads to daytime sleepiness. Students who are sleep deprived and, therefore sleepy during the day cannot sustain focus or attention, which directly affects learning ability and retention. Lack of sleep affects one’s mood, motivation, and ability to make sound decisions or engage in effective problem-solving. Not getting enough sleep lowers performance and skill proficiency and can cause mistakes, accidents or injuries due to fatigue and lapses in focus (Healthy Sleep, 2018). More recent studies have shown that sleep deprivation also has a negative impact on student grades especially on examinations (AASM, 2017). Evidence suggests an association between sleep and GPA, where students who routinely get adequate sleep (8-9 hours/night) had higher GPAs than those who got less than 6 hours a night (NSF, n.d.).
Research provides clear support that the quality and quantity of sleep can have a profound impact on learning, memory, and performance (Healthy Sleep, 2008; NSF, n.d.; Potkin and Bunney, 2013; Rasch and Born, 2013). A 2017 study found that 71% of college students fail to get at least eight hours of sleep per night (Patrick et al., 2017). This research supported an earlier study that found that 70% of students were getting insufficient sleep (Hershner and Chervin, 2014). Those in medical-related majors were found to be more likely to have inadequate sleep as compared to other majors (AASM, 2017). Sixty percent of college students reported feeling tired, sleepy or like they are dragging themselves through the day (Hershner and Chervin, 2014). I suspect most of us do not find these statistics surprising as we have all witnessed those students who nod off in class or simply appear to be tired all the time. And while we all may have pulled an “all-nighter” here and there during our educational experiences, students today are chronically sleep-deprived. When surveyed, over 80% of students believe that inadequate sleep and daytime sleepiness impact their academic performance and they rank sleep second only to stress as factors affecting their educational success (Hershner and Chervin, 2014).
So what can we do? In addition to sharing with students the importance of sleep as it relates to learning, retention, and performance, and not just on examinations, this could be something that is explored when a student is not performing well. Inquiry into their study habits and sleep habits could illuminate that lack of sleep is part of the issue. After reading the research about sleep, it got me thinking about how teachers could help motivate students to at least try better sleep habits. Obviously, the inclusion of self-care and the effects of lack of sleep could be included as part of a course or seminar, self-study module, or brown bag lunch discussion topics. Providing the opportunity for open discussion, sharing and learning what their classmates do around sleep can be enlightening, informative, and at times entertaining. Or perhaps we can do what one professor did to address this issue. He challenged his students. Students would receive extra credit if they averaged eight or more hours of sleep during final exams week. Sleep was measured using actigraphy. The results showed that final exam performances were better in those students who slept eight or more hours. The study also helped to show students that it is possible to get appropriate amounts of sleep during final exams week and still have enough time to study (Scullin, 2018). Although this was a small study with some flaws, I think it speaks to one creative way to address the issue of poor sleep with our students. In my experience, I have found that hearing from their peers about what helps them perform their best in the program can be a strong motivator and can have a significant, influential effect.
Evidence-based Helpful Sleep Tips
Can you think of ways to motivate your students to get enough sleep?
If you want to read more:
American Academy of Sleep Medicine. [AASM]. (2017, Nov 6). College students: Getting enough sleep is vital to academic success. Retrieved from https://aasm.org/college-students-getting-enough-sleep-is-vital-to-academic-success/
American Academy of Sleep Medicine. [AASM]. (2008). Sleep deprivation. Retrieved from https://aasm.org/resources/factsheets/sleepdeprivation.pdf
Baert S., Omey E., Verhaest D., & Vermeir A. (2015). Mister Sandman bring me good marks! On the relationship between sleep quality and academic achievement. Soc Sci Med. 130, 91-8.
Healthy sleep (2008). Harvard Medical School. Division of Sleep Medicine. Retrieved from http://healthysleep.med.harvard.edu/healthy/
Hershner, S. D., & Chervin, R. D. (2014). Causes and consequences of sleepiness among college students. Nat Sci Sleep. 6, 73–84. doi: 10.2147/NSS.S62907
National Sleep Foundation[NSF]. (n.d.). White paper: How much sleep do adults need? Retrieved from https://www.sleepfoundation.org/professionals/whitepapers-and-position-statements/white-paper-how-much-sleep-do-adults-need
Patrick, Y., Lee, A., Raha, O., Pillai, K., Gupta, S., Sethi, S., … Moss, J. (2017). Effects of sleep deprivation on cognitive and physical performance in university students. Sleep and biological rhythms, 15(3), 217–225. doi:10.1007/s41105-017-0099-5
Potkin, K. T., & Bunney, W. E. (2012). Sleep improves memory: The effect of sleep on long term memory in early adolescence. PLoS One, 7(8). doi:10.1371/journal.pone.0042191
Rasch, B., & Born, J. (2013). About sleep's role in memory. Physiological Reviews, 93(2), 681–766. doi:10.1152/physrev.00032.2012
Scullin, M. K. (2019). The Eight Hour Sleep Challenge During Final Exams Week. Teaching of Psychology, 46(1), 55–63. https://doi.org/10.1177/0098628318816142
Stranges, S., Tigbe, W., Gómez-Olivé, F. X., Thorogood, M., Kandala, N. B. (2012). Sleep problems: An emerging global epidemic? Findings from the INDEPTH WHO-SAGE study among more than 40,000 older adults from 8 countries across Africa and Asia. Sleep, 35, 1173–1181. doi:10.5665/sleep.2012