YNEDT-02644; No of Pages 6

Nurse Education Today xxx (2013) xxx–xxx

Contents lists available at ScienceDirect

Nurse Education Today

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Determinants of daytime sleepiness in first-year nursing students:

A questionnaire survey
Ching-Feng Huang a,b,1, Li-Yu Yang b,2, Li-Min Wu b,3, Yi Liu b,4, Hsing-Mei Chen c,⁎
a
Chang Gung University of Science and Technology at Chiayi Campus, 2, W. Sec., Jiapu Rd., Puzi City, Chiayi County 61363, Taiwan
b
School of Nursing, Kaohsiung Medical University, 100, Shih-Chuan 1st Rd, Kaohsiung 80708, Taiwan
c
Department of Nursing, National Cheng Kung University, 1, University Road, Tainan 70101, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Background: Daytime sleepiness may affect student learning achievement. Research studies have found that day-
Accepted 4 November 2013 time sleepiness is common in university students; however, information regarding the determinants of daytime
Available online xxxx sleepiness in this population is still lacking.
Objectives: The purpose of this study was to investigate the determinants of daytime sleepiness in first-year nurs-
Keywords: ing students. In particular, we looked for the relationship between perceived symptoms, nocturnal sleep quality,
Daytime sleepiness
and daytime sleepiness.
Perceived symptoms
Sleep quality
Design: A cross-sectional and correlational design was employed.
Nursing student Participants and Method: Participants were recruited from two nursing programs at an institute of technology
located in southern Taiwan. Ninety-three nursing students completed the questionnaires one month after enroll-
ment into their program.
Results: Approximately 35% of the participants experienced excessive daytime sleepiness at the beginning of
the semester. Six variables (joining a student club, perceived symptoms, daytime dysfunction, sleep disturbances,
sleep latency, and subjective sleep quality) were significantly correlated with daytime sleepiness. Among them,
daytime dysfunction and perceived symptoms were two major determinants of daytime sleepiness, both account-
ing for 37.2% of the variance.
Conclusions: Daytime sleepiness in students should not be ignored. It is necessary to help first-year students identify
and mitigate physical and psychological symptoms early on, as well as improve daytime functioning, to maintain
their daytime performance and promote learning achievement.
© 2013 Elsevier Ltd. All rights reserved.

Introduction
In recent years, daytime sleepiness has been increasingly recognized
as a disorder or disease that must be identified and managed early
(Ohayon, 2008). Daytime sleepiness refers to uncontrollable dozing
off and drowsiness during the daytime, leading to the inability to remain
alert and cautious in performing important daily activities (Johns,
1991). In addition to interfering with daily functioning and affecting
behaviors and job performance, excessive daytime sleepiness is more
likely to cause life-threatening traffic accidents and occupational
injuries related to human error (Luyster et al., 2012; Morrison and
⁎ Corresponding author at: 1, University Road, Tainan, 70101, Taiwan. Tel.: +886 6 235
3535x6272.
E-mail addresses: cfhuang@gw.cgust.edu.tw (C.-F. Huang), a885019@kmu.edu.tw
(L.-Y. Yang), painting@kmu.edu.tw (L.-M. Wu), gn94yliu@kmu.edu.tw (Y. Liu),
hsingmei@ntu.edu.tw (H.-M. Chen).
1
Tel.: +886 5 362 8800x2517.
2
Tel.: +886 7 312 1101x2613.
3
Tel.: +886 7 312 1101x2814.
4
Tel.: +886 7 312 1101x2600.
Riha, 2012). Daytime sleepiness may be directly associated with lower ac-
ademic performance, which adversely affects student learning achieve-
ment (Bahammam et al., 2012).
Mild daytime sleepiness can be overcome by activity or distraction
(Morrison and Riha, 2012), which is difficult for people who engage
in sedentary activities, such as students. Research studies have found
that daytime sleepiness is common in university students. Excessive
daytime sleepiness is particularly frequent, with a prevalence between
24% and 39%. Female students have higher prevalence of daytime sleep-
iness than male students (Lund et al., 2010), and first-year students
have higher prevalence than those in other years (Taher et al., 2012).
In a study of 364 nursing students on excessive daytime sleepiness, no
gender differences were found, yet the problem was more significant
in students aged less than 30 years (Angelone et al., 2011).
Daytime sleepiness may have several causes. Researchers have
found that university students who had lower nocturnal sleep duration
(Regestein et al., 2010) or an irregular sleep–wake schedule (Taher
et al., 2012) were more likely to report daytime sleepiness. However,
Lund et al. (2010) found no association between sleep duration and day-
time sleepiness, inferring that the association may have been diminished
by daytime napping and other factors such as poor time management or

0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.11.005

Please cite this article as: Huang, C.-F., et al., Determinants of daytime sleepiness in first-year nursing students: A questionnaire survey, Nurse
Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.11.005
2 C.-F. Huang et al. / Nurse Education Today xxx (2013) xxx–xxx
irregular sleep patterns. Researchers have suggested that the evaluation
of factors affecting daytime sleepiness should include other sleep hygiene
and lifestyle factors (Morrison and Riha, 2012), including tea or coffee
consumption and sleep environment variables such as temperature,
light, and noise (Buboltz et al., 2002).
Health and disease problems, in addition to sleep problems,
are also considered important factors causing daytime sleepiness
(Ohayon, 2008; Volna and Sonka, 2006). University students gener-
ally do not suffer from diseases, yet they might experience some
physical or psychological symptoms. Lee et al. (2008) analyzed the
physical examination records of 19,349 freshmen from 11 universities
and found symptoms including chest tightness, stomachache, head-
ache, and anxiety or depression. These symptoms were occasionally
experienced by approximately 30%–40% of freshmen, usually experi-
enced by 1.9%–6.3% of freshmen, and experienced more frequently
in female students than in male students. In addition, 6%–16.4% of
freshmen had abnormal levels of uric acid, liver enzymes (SGOT or
GPT), hemoglobin, and cholesterol. In a study conducted by Angelone
et al. (2011), daytime sleepiness in university students was significantly
correlated with musculoskeletal disease, abdominal pain, and asthma
after adjusting for variables such as age, gender, nocturnal work, bedtime,
and smoking.
Education is the foundation upon which nursing students are
cultivated to be professional nurses. Therefore, identifying the im-
portant factors that affect students' learning helps to improve their
learning achievement. Although the prevalence of daytime sleepi-
ness in university students has been investigated, research regarding
the determinants of daytime sleepiness in this population is still
lacking. In addition, first-year students tend to feel stressed when they
face new environments and challenges after enrollment. Therefore,
the purpose of this study was to identify the status and determinants
of daytime sleepiness in first-year nursing students, particularly the re-
lationship between nocturnal sleep quality, perceived symptoms, and
daytime sleepiness. We expected that the study findings could help im-
prove the factors affecting daytime sleepiness in first-year students,
thereby facilitating their learning achievement.
Methods
Design and Participants
A cross-sectional and correlational design was used. Data were
collected through self-administered questionnaires. Non-probability
sampling was used to recruit first-year students from two daytime
nursing programs (2-year and 4-year BSN programs) at an institute of
technology located in southern Taiwan. The inclusion criteria were
(1) age 18 years or older, (2) living in a dormitory, and (3) not being
in the researchers' class. The participants willing to participate in this
study had to complete an informed consent form; for those younger
than 20 years old, a parental informed consent form was obtained. A
total of 99 participants were recruited from mid to late October 2012.
To ensure homogeneity in the study sample, 6 male students were
excluded, yielding a sample size of 93 female students.
The sample size was calculated using post-hoc power analysis based
on G-power statistical software for multiple regression analysis (Faul
et al., 2009) with an effect size of 0.37 and an α of 0.05. Fifteen predictor
variables and a sample size of 93 yield a power of 0.96.
Instruments
Demographics
The demographic questionnaire collected information on age,
gender, educational program, student loans, part-time work, student
club participation, coffee consumption, tea consumption, and daytime
napping.
Please cite this article as: Huang, C.-F., et al., Determinants of daytime sleepiness in first-year nursing students: A questionnaire survey, Nurse
Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.11.005
Epworth Sleepiness Scale
The Epworth Sleepiness Scale (ESS) developed by Johns (1991) was
used to measure daytime sleepiness. The ESS consists of 8 items that ask
respondents to rate the chances that they would doze off during daily
activities such as reading, riding as a passenger in a car for an hour,
sitting quietly, and talking to someone over the past month. Each item
is rated from 0 (would never doze) to 3 (high chance of dozing). The
total score ranges from 0 to 24, with a higher score indicating a higher
chance of daytime sleepiness. An ESS greater than 10 is defined as
excessive daytime sleepiness. The ESS has acceptable reliability and va-
lidity and has been widely used. Cronbach's α for a study of 104 medical
students was 0.73 (Johns, 1992). The current study adopted the Chinese
version of the ESS translated by Chen et al. (2002). Cronbach's α for this
study of 93 participants was 0.72.
Pittsburgh Sleep Quality Index
The Pittsburgh Sleep Quality Index (PSQI) was developed by Buysse
et al. (1989). The PSQI is composed of 19 items covering seven com-
ponents: subjective sleep quality, sleep latency, sleep duration,
sleep efficiency, sleep disturbances, use of sleep medication, and day-
time dysfunction. The global score ranges from 0 to 21, with a higher
score indicating poor sleep quality. The PSQI has a sensitivity of 90%
and a specificity of 87% at a cutoff point of 5, with a score equal to 5
or lower indicating better sleep, while a score greater than 5 indicates
poor sleep. Cronbach's α for the original PSQI in the study of 148 adults
was 0.83 (Buysse et al., 1989). The current study adopted the Chinese
version of the PSQI translated by Tsai et al. (2005). In their study, the
PSQI had a Cronbach's α of 0.83 for 208 adults and 0.72 for 51 patients
with primary insomnia. Cronbach's α for this present study was 0.79.
Perceived Symptom Scale
The Perceived Symptom Scale includes sleep problems, changes in
body weight, headache, stomachache, changes in the menstrual cycle,
and worrying about poor liver function. The scale was developed
based on the 33-item Cohen–Hoberman Inventory of Physical Symp-
toms (CHIPS; Cohen and Hoberman, 1983). The researchers first held
meetings to discuss the appropriateness and cultural differences of the
CHIPS and then conducted small-group interviews with 10 students.
These students discussed the scale with one another for 30 min, and
then the researchers joined the discussion and added four items
(worrying about poor liver function, changes in the menstrual cycle,
dry mouth, and frequent urination) as suggested by students. Subse-
quently, the modified version of the scale was administered to 154 nurs-
ing students to determine its reliability, and the results showed a
Cronbach's α of 0.91. However, several items (syncope, nasal bleeding,
muscle and ligament cramps, shortness of breath, and dry mouth)
occurred with relatively infrequency and had a low (less than .20)
corrected item-total correlation, so they were eventually omitted. In
addition, to reduce confusion regarding symptoms, similar items were
merged; for example, “migraine” and “headache” were merged into
the item “headache,” yielding a total of 18 items in the scale. Each
item is rated from 0 (never) to 4 (always). The total scale score ranges
from 0 to 72. A higher score indicates more frequent symptoms. Given
that the dependent variable used in this study was daytime sleepiness,
sleep problems were not incorporated into the calculation of the total
score and the analysis. Cronbach's α for this 17-item scale was 0.88.
Data Collection
This study was reviewed by the institutional review board of the
university hospital where the study was conducted (No. 101-2677B).
All participants and the parents of participants under the age of
20 years were required to complete an informed consent form in which
the purpose of the study; time involved; data collection procedures; po-
tential benefits, rewards and risks to subjects; and subject confidentiality
and rights were described. All participants were also informed that the
 C.-F. Huang et al. / Nurse Education Today xxx (2013) xxx–xxx 3

study findings would be used only for research purposes; no personally Table 2
identifiable information would be disclosed, and they could withdraw Scores of major variables (n = 93).

from the study at any time without affecting their academic performance. Variables n (%) Mean ± SD
Prior to data collection, the researchers, with the approval of school
ESS 9.00 ± 3.82
authorities, hung posters and distributed leaflets in the class mailboxes. ≦10 59 (63.4)
The posters and leaflets listed the purpose of the study, an outline of N10 34 (36.6)
the questionnaires, and information regarding the study procedure, Perceived symptoms 18.52 ± 10.63
PSQI 7.49 ± 2.69
information confidentiality, and rewards for participation. The study
≦5 24 (25.8)
was promoted at every class meetings, inviting the students willing N5 69 (74.2)
to participate to complete an informed consent form, provide contact in- Subjective sleep quality 2.30 ± 0.69
formation and fill out the questionnaires in the office of the researchers. Daytime dysfunction 1.45 ± 0.79
If unable to complete the on-site questionnaires, the students could Sleep disturbance 1.23 ± 0.53
Sleep duration 1.13 ± 0.84
bring the questionnaires home to complete and then return them to
Sleep latency 0.97 ± 0.80
the researchers and receive a reward in return. Sleep efficiency 0.42 ± 0.73

Note. ESS: Epworth Sleepiness Scale; PSQI: Pittsburgh Sleep Quality Index.
Data Analysis

The data were analyzed using SPSS 18.0 version for Windows
(SPSS Inc., Chicago, IL). The analysis methods included (a) descriptive
analyses; (b) bivariate analyses such as chi-square, t-test, and Pearson
correlation analyses; and (c) multiple regression analysis conducted
using the forward method. A p value of less than 0.05 was adopted as
the threshold of statistical significance.
infrequently was sitting and talking to someone (0.35 [SD = .65]). The
chance of dozing off during daily activities for at least half of the past
month ranged from 5.4% to 66.7% (see Table 3).
Nocturnal Sleep Quality

Data/Results
The demographics of the 93-student sample are summarized in
Table 1. The mean age was 19.87 years (SD = 1.95), with a range of
18.13 to 29.13. Student club participation was the only demographic
variable significantly associated with daytime sleepiness. The students
who joined student clubs reported significantly lower scores of daytime
sleepiness than those who did not.
Daytime Sleepiness
The ESS scores ranged from 2 to 19, with a mean score of 9.00
(SD = 3.82). Thirty-four participants (36.6%) reported excessive daytime
sleepiness (ESS N 10) (Table 2). The top 3 daily activities in which partic-
ipants would doze off were, in descending order, lying down to rest in
the afternoon (1.85 [SD = 0.90]), riding as a passenger in a car for an
hour (1.71 [SD = 0.94]), and sitting quietly in a public place (1.61
[SD = 0.89]). The activity during which the participants dozed off most
Table 1
Demographics of participants (n = 93).
Variables n (%) ESS mean ± SD p value
The global PSQI scores of the 93 participants ranged from 3 to 15, with
a mean of 7.49 (SD = 2.69). Sixty-nine students (74.2%) were identified
as poor sleepers (PSQI N 5). The mean sleep duration was 6.68 h
(SD = 1.27), and the mean sleep latency was 16.11 min (SD = 14.19).
Twenty-nine participants (31.2%) had a sleep efficiency lower than 85%,
and no one used sleep medications. Of the 9 factors causing sleep distur-
bances, the 3 most frequent were waking up in the middle of the night
or too early in the morning (34.4%, 1–2 times per week), inability to fall
asleep in 30 min (29.9%, 1–2 times per week), and feeling cold (28.0%,
1–2 times per week). Eighty-six participants (92.5%) reported mild
to severe daytime dysfunction, which was mild in 47 respondents
(50.5%), moderate in 29 respondents (31.2%), and severe in 10 respon-
dents (10.8%). Thirty-two students (34.4%) had poor or very poor self-
reported subjective sleep quality. Overall, among the seven domains
of the PSQI, the 3 with the highest self-reported scores were, in de-
scending order, subjective sleep quality, daytime sleep dysfunction,
and sleep disturbances (Table 2). In addition, significant differences
(6.75 vs. 9.78, p = .001) were found in daytime sleepiness between
two groups: good nocturnal sleepers (PSQI ≤ 5) and poor nocturnal
sleepers (PSQI N 5).
Perceived Symptoms

Educational program The Perceived Symptom Scale scores ranged from 0 to 52, with a
4-year 52 (55.9) 9.21 ± 4.06 .551 mean of 18.52 (SD = 10.63). Among the 18 symptoms, the 5 most highly
2-year 41 (44.1) 8.73 ± 3.52 scored, in descending order, were fatigue (2.01, SD = 1.15), acne (1.71,
Student loans
SD = 1.28), worrying about poor liver function (1.49, SD = 1.29),
No 56 (60.2) 8.45 ± 3.36 .086
Yes 37 (39.8) 9.84 ± 4.35 constipation (1.47, SD = 1.34), and dysmenorrhea (1.43, SD = 1.24).
Part-time work The frequency of these symptoms for at least half of the past month
No 89 (95.7) 8.93 ± 3.87 .425
Yes 4 (4.3) 10.50 ± 2.52
Student club participation
No 27 (29.0) 10.22 ± 3.66 .048 Table 3
Yes 66 (71.0) 8.50 ± 3.80 Scores of situations causing daytime sleepiness (n = 93).
Coffee consumption
Situation Mean (SD) n (%)
No 80 (86.0) 9.04 ± 3.81 .816
Yes 13 (14.0) 8.77 ± 4.07 Lying down to rest in the afternoon 1.85 (0.90) 62 (66.7)
Tea consumption As a passenger in a car for an hour without rest 1.71 (0.94) 53 (57.0)
No 40 (43.0) 9.15 ± 4.16 .744 Sitting, inactive in a public place 1.61 (0.89) 46 (49.5)
Yes 53 (57.0) 8.88 ± 3.58 Sitting and reading 1.26 (0.85) 34 (36.6)
Daytime napping Sitting quietly after a lunch without alcohol 1.17 (0.90) 31 (33.3)
No 57 (61.3) 8.79 ± 3.95 .507 Watching TV 0.63 (0.70) 8 (8.6)
Yes 36 (38.7) 9.33 ± 3.63 In a car, while stopped for a few minutes in the traffic 0.41 (0.68) 8 (8.6)
Sitting and talking to someone .35 (0.65) 5 (5.4)
Note. Analyzed by t-tests.

Please cite this article as: Huang, C.-F., et al., Determinants of daytime sleepiness in first-year nursing students: A questionnaire survey, Nurse
Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.11.005
4 C.-F. Huang et al. / Nurse Education Today xxx (2013) xxx–xxx

was 58.1%, 41.9%, 45.2%, 38.7%, and 32.3%, respectively. The perceived Table 5
symptom with the lowest score was dizziness/syncope (6.5%), followed Determinants of daytime sleepiness (n = 93).

by chest tightness/chest pain (8.6%). Model Variables B B SE Beta F Adj. R2 R2 change

1 Constant 5.18 0.66 44.47⁎⁎⁎ .321

Correlations Between Daytime Sleepiness and Other Variables
A Pearson correlation was performed to identify the relationships
between daytime sleepiness and the continuous variables (Table 4).
The results showed that ESS was significantly correlated with perceived
symptoms (r = 0.57), daytime dysfunction (r = 0.47), sleep disturbance
(r = 0.45), sleep latency (r = 0.27), and overall sleep quality (r = 0.28),
indicating that the presence of more perceived symptoms was correlated
with more sleep problems and greater daytime sleepiness.
Determinants of Daytime Sleepiness
To identify the determinants of daytime sleepiness, a multiple
regression analysis including the variables that had significant associa-
tions with daytime sleepiness (student club participation, perceived
symptoms, daytime dysfunction, sleep disturbance, sleep latency, and
overall sleep quality) was performed. The results (Table 5) showed that
perceived symptoms and daytime dysfunction were two major determi-
nants of daytime sleepiness. Of these two, perceived symptoms was first
entered into the model, with an adjusted R2 of 32.1%; and daytime dys-
function was subsequently entered into model 2, which added another
adjusted R2 of 5.1%, yielding an overall model with an adjusted R2
of 37.2%. Collinearity diagnostics was also performed, with a Durbin–
Watson statistic of 2.14.
Discussion
Overall, the ESS score of the participants in this study was 9.0, and
approximately 35% of the participants experienced excessive daytime
sleepiness at the beginning of the semester. These findings are similar
to those (8.78, 35.44%) of the study by Taher et al. (2012) but higher
than those (6.33 to 8.03, 14.4% to 24%) from other studies on students
(Bahammam et al., 2012; Kang and Chen, 2009; Lund et al., 2010) and
on Taiwanse patients with heart failure (19%, Gau et al., 2011; 24%,
Chen et al., 2013). In the eight situations causing daytime sleepiness,
sitting, being inactive in a public place, sitting and reading, and sitting
quietly after a lunch without consuming alcohol were more directly
associated with student learning achievement in class. Approximately
33% to 50% of participants reported dozing off during at least half of
the days in the past month, suggesting the necessity for reducing day-
time sleepiness in students.
The finding that perceived symptoms were the most important
determinant of daytime sleepiness is consistent with the study by
Angelone et al. (2011) who confirmed the associations between daytime
sleepiness and diseases and symptoms. Illness was one of the important
Perceived symptoms 0.21 0.03 0.57 .328
2 Constant 4.09 0.74 28.22⁎⁎⁎ .372
Perceived symptoms 0.16 0.03 0.46
Daytime dysfunction 1.29 0.45 0.27 .057
Note. R2: R-square; adj. R2: adjusted R-square.
⁎⁎⁎ p b .001.
reasons for missing lectures in a study by Bati et al. (2013) that included
663 health science students. In the current study, the majority of partici-
pants were female students aged approximately 20 years, so changes in
the menstrual cycle were also taken into consideration. During ovulation,
an increased progesterone level may lead to an increase in daytime slow
wave sleep and sleepiness (Dzaja et al., 2005). Moreover, the students'
perceived symptoms may be attributable to physical responses to stress
rather than to disease. Guo et al. (2009) proposed that university stu-
dents tend to have a “sub-health” status due to changes in their daily life-
style. “Sub-health” status refers to a state in which an individual who has
no defined illness experiences changes in physical functions, including
weakness, muscle soreness, and dizziness (i.e., chronic fatigue syndrome)
and psychological symptoms such as worry, dispiritedness, and anxiety
(Liang et al., 2006) due to environment, stress, and abnormal lifestyle.
In the current study, we could not confirm the existence of such condi-
tions because we did not explore sub-health status in the participants.
However, our study results showed that over 58% of the students had ex-
perienced fatigue; approximately 40% of the students had experienced
acne and worry about poor liver function; and approximately one-third
of students had experienced constipation, menstrual cycle changes, dys-
menorrhea, and muscle soreness for at least half of the past month. These
findings suggest that health-related problems are prevalent and result in
daytime sleepiness among student populations.
Poor nocturnal sleep quality was reported by 74.2% of the students in
this study. Those who had greater daytime dysfunction, more sleep dis-
turbances, longer sleep latency, and poorer subjective sleep quality
were more likely to experience daytime sleepiness. The finding is com-
parable with previous research findings (Ohayon, 2008; Volna and
Sonka, 2006). Among the above factors, only daytime dysfunction was
an important determinant of daytime sleepiness. Those who are unable
to raise their spirits and interest in engaging in daily activities are more
unlikely to remain awake during the daytime and are therefore more
likely to experience daytime sleepiness. Daytime dysfunction may be at-
tributed to lack of energy, lack of social activities, depression, or sleep
problems (Chen et al., 2013). In the current study, we found that day-
time dysfunction was strongly correlated with perceived symptoms,
and of these symptoms, the most common was fatigue. Similarly, this
finding most likely explains why students who joined student clubs

Table 4
Correlational matrix between variables and ESS (n = 93).

ESS 1 2 3 4 5 6 7

Age (1) −.14

Perceived symptoms (2) .57⁎⁎⁎ −.08
Sleep efficiency (3) .12 −.05 .26⁎⁎
Sleep duration (4) .09 −.09 .22⁎ .27⁎
Daytime dysfunction (5) .47⁎⁎⁎ −.07 .44⁎⁎⁎ .14 .18
Sleep disturbance (6) .45⁎⁎⁎ −.07 .49⁎⁎⁎ .20 .23⁎ .38⁎⁎⁎
Sleep latency (7) .27⁎⁎ −.03 .30⁎⁎ .25⁎ .09 .27⁎⁎ .37⁎⁎⁎
Subjective sleep quality (8) .28⁎⁎ .08 .34⁎⁎ .01 .29⁎⁎ .43⁎⁎⁎ .32⁎⁎ .45⁎⁎⁎

Note: ESS: Epworth Sleepiness Scale.

⁎ p b .05.
⁎⁎ p b .01.
⁎⁎⁎ p b .001.

Please cite this article as: Huang, C.-F., et al., Determinants of daytime sleepiness in first-year nursing students: A questionnaire survey, Nurse
Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.11.005
 C.-F. Huang et al. / Nurse Education Today xxx (2013) xxx–xxx
had significantly lower daytime sleepiness than those who did not.
The average number of hours spent per week on club activities was
only 1.78 (the longest was 9), which is unlikely to affect students'
schoolwork. Therefore by joining student clubs, students may reduce
the chance of dozing off and enhance their interactions with peers.
The finding may serve as a reference for teachers in encouraging stu-
dents to join student clubs.
Age and educational program were not correlated with daytime
sleepiness in this study. Information about daytime sleepiness in differ-
ent educational programs is still limited and inconsistent. Pagel and
Kwiatkowski (2010) found that daytime sleepiness affected high school
and college students based on age group and educational level. In a
study by Giri et al. (2013), postgraduate medical students had a higher
prevalence of daytime sleepiness than undergraduates and interns. By
contrast, in a study by Taher et al. (2012), daytime sleepiness did not
differ among students with different levels of education, even though
first-year pharmaceutical students had higher prevalence of excessive
daytime sleepiness than second- to fourth-year students. In our study,
the lack of a significant difference between the two educational pro-
grams may be attributed to the similarity in their age profiles and that
they were all freshmen.
Limitations
This study used a cross-sectional, subjective self-report question-
naire design. In retrospect, participants' memory regarding all of the
variables over the past month may have been limited, and the findings
can only reflect daytime sleepiness during a particular semester. We
could not recruit enough male nursing students to participate in this
study, so the study results can only reflect the conditions among female
nursing students. Likewise, the sample group of participants was too
narrow and concentrated (from the same institute, nursing major,
first-year in college, in only two programs), which limits the generaliz-
ability of the study findings to students at different universities and
educational programs. This study did not explore the effects of emotion-
al factors such as anxiety and depression on daytime sleepiness, which
should be investigated in the future. In addition, a longitudinal study
design may be beneficial for assessing the effects of daytime sleepiness
on students' academic achievement.
Conclusions
Nocturnal sleep quality (as measured by daytime dysfunction, sleep
disturbance, sleep latency, and overall sleep quality), perceived symp-
toms, and student club participation were significantly correlated with
daytime sleepiness (Table 6). Age, educational program, part-time
work, student loans, tea and coffee consumption, and daytime napping
showed no significant correlations with daytime sleepiness in first-year
university students. Perceived symptoms and daytime dysfunction
were the two major determinants of daytime sleepiness (Table 6). The
study findings add to the understanding of daytime sleepiness in first-
year female nursing students for nursing educators and suggest that
daytime sleepiness and poor nocturnal sleep quality in students should
not be ignored. Sufficient knowledge of sleep, including information on
Table 6
Finding summary of daytime sleepiness (n = 93).
Correlates of daytime sleepiness
Student club Perceived Daytime Sleep Sleep Overall sleep
participation symptoms dysfunction disturbance latency quality
Determinants of daytime sleepiness
Perceived symptoms (32.8%) Daytime dysfunction (5.7%)
Please cite this article as: Huang, C.-F., et al., Determinants of daytime sleepiness in first-year nursing students: A questionnaire survey, Nurse
Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.11.005
5
sleep physiology and influencing factors, is necessary for effective sleep
promotion (McIntosh and MacMillan, 2009). In particular, the concept
of and attitude toward sleep hygiene should be enhanced, and the
importance of sleep in learning and health should be emphasized to
students during freshman orientation or class meetings.
The study findings also suggest that teachers should help students,
particularly those who frequently doze off in class, to identify and
mitigate their health problems early on after enrollment in the program.
Multiple teaching methods are recommended to replace tedious lectures,
facilitating learning motivation and interaction opportunities and further
reducing the chance of dozing off among students (Bati et al., 2013).
Joining appropriate student clubs or engaging in health-promoting
activities is encouraged to improve students' health-related physical
fitness, thereby helping them to stay awake and maintain strength
during the daytime.
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Please cite this article as: Huang, C.-F., et al., Determinants of daytime sleepiness in first-year nursing students: A questionnaire survey, Nurse
Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.11.005