Adventist University of the Philippines Informed Consent Form PART I: INFORMATION SHEET INTRODUCTION Dear Respondent, Good day! We, Kristine Charm A. Encapas, Czars Jerome G. Cajayon, Shawn Irish A. Mina, Mary Grace M. Reyes, and Chrizzal May A. Dizon are 4th year nursing students at Adventist University of the Philippines, and we are currently conducting a research study entitled “Determinants of Sleep Quality Among Nurses”. In light of this, we would like to ask a few minutes of your time to participate in this study. Your participation is critical to the success of this study and will be greatly appreciated. Any inquiries, questions, or clarifications regarding our research are welcome at any time. PURPOSE OF THE RESEARCH The purpose of this study is to determine the level of sleep quality affected by environmental, physiological, psychological, and social factors. The data that will be generated from this study will benefit the nursing students to have further knowledge about the significance of sleep quality in the waking performance of nurses. TYPE OF RESEARCH INTERVENTION This research study will primarily use a survey method, with printed survey forms distributed to collect information on few demographic questions and sleep determinants and sleep quality of nurses, which are vital for the results of the study. PARTICIPANT SELECTION The inclusion criteria for this study indicate that the participants have to be: (a) is a Registered Nurse; (b) 21-65 years of age; (c) working in a hospital in the Philippines. VOLUNTARY PARTICIPATION Participation and engagement in this research are entirely voluntary. You are entirely free to participate. If you want to cancel or withdraw from the survey, you can do so by declining or informing the researcher present. However, your participation in this research will be critical and greatly appreciated by the researchers. Your contributions will be encoded with confidentiality and used solely for the purpose of the study. PROCEDURE A. We are inviting you to participate in our study to further discover about Sleep Quality habits and factors. The respondent’s determinants of sleep quality will be assessed through the result of how frequently they perform certain sleep quality habits or practices. The respondent’s degree of sleep quality will be assessed using the Pittsburgh Sleep Quality Index. The study's questionnaires may contain personal topics that might make respondents uncomfortable. If you willingly participate in the study, your sincere and honest answers will be significant. B. A paper form will be provided by the researchers with an informed consent. The respondents are instructed to read and sign the informed consent in order to proceed in the survey. If you wish to participate in the study, kindly fill in the questionnaire honestly and to the best of your knowledge. The questionnaire is divided into three sections: (a) the first contains a cover letter, a criterion list, informed consent, and demographics; (b) the second contains questions on environmental, physiological, psychological, and social determinants of sleep; (c) the third contains the Pittsburgh Sleep Quality Index to determine the sleep quality. Please go through each question carefully and in cases where an item needs to be clarified, kindly contact the researcher and they will cater to your inquiries. Kindly answer the questions completely, with honesty, and to the best of your knowledge.The respondent’s name will not appear in the form. The result of the study will be confidential once the respondent has completed the questionnaire to guarantee that their privacy and identity are protected. DURATION The duration of this study will take approximately 5 -10 minutes by answering the provided questionnaire. RISK Because the questionnaire will request specific personal information, there is a risk of breach of confidentiality. The questionnaire will require some personal information, experiences, and personal habits and performances that might be uncomfortable for you to answer. We, the researchers, assure you that your data will be treated with confidentiality before and after the survey. The information gathered will be kept private to protect the respondent's privacy and identity. BENEFITS The study will greatly benefit the nursing students, educators, administrators, nurses, and future researchers. In addition, the study may provide data about bedtime habits and their relationship to sleep quality among healthcare professionals. Furthermore, this will be used in determining ways to improve sleep quality and all of the information in this study will be utilized as a foundation for future research. REIMBURSEMENTS Participants are under no financial commitments and will not be compensated for participating in this research. CONFIDENTIALITY The collected data will be treated with the utmost confidentiality. The respondents have the right to disclose or not disclose their name. This study will also follow the law of the Republic of the Philippines, in line with this, as mandated by RA 10173, also known as the Data Privacy Act of 2012, we guarantee that your privacy is protected. SHARING OF THE RESULTS The results of this study will be shared with the members of the team, panel members for defense, and respective advisers. Research findings may be shared more broadly through publications if deemed relevant. RIGHT TO REFUSE OR WITHDRAW Participation and engagement in this research are entirely voluntary. You are entirely free to participate, and your decision will have no bearing on your work. If you want to cancel or withdraw from the survey, you can do so by declining or informing the researcher present. WHO TO CONTACT If you have any inquiries, concerns, or clarifications regarding the form or the study, you may contact any of the researchers: Name: Kristine Charm A. Encapas Contact Number: (+63) 9610940633 Email Address: 2054638@aup.edu.ph Name: Chrizzal May A. Dizon Contact Number: (+63) 9502997078 Email Address: 2052645@aup.edu.ph Name: Czars Jerome G. Cajayon Contact Number: (+63) 9614215019 Email Address: 2054627@aup.edu.ph Name: Mary Grace M. Reyes Contact Number: (+63) 9952780828 Email Address: 2043588@aup.edu.ph Name: Shawn Irish A. Mina Contact Number: (+63) 9152141125 Email Address: 2054852@aup.edu.ph PART II: CERTIFICATE OF CONSENT I have accurately read the information sheet as a potential respondent. I confirm that I will answer all the questions with honesty and best of my knowledge. Therefore, by continuing and submitting the survey form to the researchers, I voluntarily allow myself to participate and give consent to the collection of my personal information and responses. By choosing to sign this form, it means I have fully understood the benefit in participating in this study and that I have voluntarily expressed my acceptance to participate in the Data Collection of the research. Printed Name of the Respondent (Optional): ___________________________________ Signature of the Respondent: _______________________________________ Date: ____________________ For the Researchers: I have accurately explained the information sheet to the potential respondent. I confirm that the respondent was given an opportunity to inquire regarding the study and all questions were answered clearly and correctly to the best of my ability. I confirm that the respondent has not been coerced into participating and that the respondent’s decision to participate is purely voluntary. Kristine Charm A. Encapas Student Researcher Czars Jerome G. Cajayon Student Researcher Chrizzal May A. Dizon Student Researcher Mary Grace M. Reyes Student Researcher Shawn Irish A. Mina Student Researcher Raul V. San Diego, RND, RN, MAN Adviser DEMOGRAPHIC Sex: Male Female Age: _________ Marital Status: Single (never married) Married Separated Widowed Annulled DETERMINANTS OF SLEEP DURING THE PAST ONE MONTH HAVE YOU SHOWN ANY OF THE FOLLOWING BEHAVIORS? Please check the box which describes how often each behavior happens. Please answer all questions. Very True Somewhat Neutral Somewhat Very to Me True to Untrue of Untrue Me Me of Me A. ENVIRONMENTAL 1. I prefer to sleep using the air conditioner. 2. I prefer to sleep using electric fan 3. I prefer to sleep with the lights turned off. 4. I prefer not to use electronic devices hours before going to sleep. 5. I cannot sleep in noisy surroundings. 6. I cannot sleep when my environment is dirty (e.g., dirty linen, blanket, and pillows, etc.). 7. I cannot sleep with uncomfortable bedding (e.g., wrinkled bed, uneven bed level, hard pillows, etc.). 8. I can sleep only when there is white noise (e.g., gentle rain showers, functioning fan, air conditioning, and radio/TV static). 9. I can sleep only when there is pink noise (e.g., light to medium rainfall, wind rustling through leaves, and heart beats). B. PHYSIOLOGICAL 1. I’m having a hard time sleeping because of body aches and pains. 2. I’m having a hard time sleeping because of my sleep conditions (e.g., difficulty of breathing, sleep apnea, insomnia, etc.) 3. I cannot sleep because of an empty stomach. 4. I cannot sleep after eating too much before bed. 5. I can sleep better after exercising. 6. My sleep is stimulated after meditation. 7. My sleep is stimulated after achieving a comfortable or preferred position. 8. I often encounter the feeling of being paralyzed during sleep. 9. I’m having a hard time sleeping because I drank coffee earlier in the day. 10. My sleep is stimulated after consuming alcohol. 11. My sleep is stimulated after smoking cigarette/s. 12. I can sleep better after taking sleeping aids (e.g., Benadryl, melatonin, or Valerian root). C. PSYCHOLOGICAL 1. I cannot sleep because of anxiety. 2. I cannot sleep because of the fear of not being able to wake up. 3. I cannot sleep thinking of my work the following day. 4. I cannot sleep because of my financial concerns. 5. I can sleep when I have performed my work well. 6. I can sleep when I am able to perform my bedtime routines. 7. I can sleep well when I am at peace with myself. 8. I cannot sleep well when I remember sad events in my life. 9. I cannot sleep well when I think of my past mistakes. 10. I cannot sleep due to traumatic events. D. SOCIAL 1. I can sleep better when I am with my family and loved ones. 2. I cannot sleep when I have conflicts with my family. 3. I cannot sleep when I have conflicts with my friends. 4. I cannot sleep when I have conflicts with my coworkers/supervisors. 5. I sleep late when I have conversations through social media. 6. I can sleep well only when I know the person sleeping with me. 7. I cannot sleep before having a significant social event. 8. I can sleep well after spending time with my family. 9. I can sleep well after spending time with my friends. 10. I can sleep well after spending time with my coworkers. Pittsburgh Sleep Quality Index (PSQI) Instructions: The following questions relate to your usual sleep habits during the past one month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past one month. Please answer all questions. 1. During the past one month, what time have you usually gone to bed at night? _________________ 2. During the past one month, how long (in minutes) has it usually taken you to fall asleep each night? ________ 3. During the past one month what time have you usually gotten up in the morning? ___________________ 4. During the past one month, how many hours of actual sleep did you get at night? (This may be different from the number of hours you spend in bed.) ____________________ 5. During the past one month, how often have you had trouble sleeping because you… Not during the past month Less than once a week Once or twice a week Three or more times a week No problem at all Only a very slight problem Somewhat of a problem A very big problem Very good Fairly good Fairly bad Very bad a. Cannot get to sleep within 30 minutes b. Wake up in the middle of the night or early morning c. Have to get up to use the bathroom d. Cannot breathe comfortably e. Cough or snore loudly f. Feel too cold g. Feel too hot h. Have bad dreams i. Have pain j. Other reason(s), please describe: 6. During the past month, how often have you taken medicine to help you sleep (prescribed or “over the counter”)? 7. During the past month, how often have you had trouble staying awake while driving , eating meals, or engaging in social activity 8. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done? 9. During the past month, how would you rate your sleep quality overall? No bed partner or roommate Partner or roommate in other room Partner in same room but not same bed Partner in same bed Not during the past month Less than once a week Once or twice a week Three or more times a week 10. Do you have a bed partner or roommate? If you have a roommate or bed partner, ask him/her how often in the past month you have had? a. Loud snoring b. Long pauses between breaths while asleep c. Legs twitching or jerking while you sleep d. Episodes of disorientation or confusion during sleep e. Other restlessness while you sleep, please describe:
