KINE 4354 Public Health Advocacy and Leadership

Assignment 4.1: Advocacy Action Plan Part 2: PEST Analysis

Adapted from:

Sample Templates
,

MindTools PEST Analysis Worksheet
, and

University of Bridgeport Career Development Timeline

Instructions

Use the template below as a worksheet/workspace. The question prompts provided are intended to help you to gain a better understanding of the public health issue or need associated with your advocacy action plan. As you complete this template, you are allowed to make informal notes, use bullet points and copy and past links to websites, articles and other resources that will help you to better identify factors related to your advocacy action plan.

As you complete this template, please keep in mind the following:

· Although it is important to consider macro-level factors (i.e., what is happening at the societal level), for the purposes of this assignment you are asked to place more emphasis on micro-level factors (i.e., what is happening at the community level).

· Although all questions may not apply to your advocacy action plan, be sure to answer each question under all four categories (Political, Economic, Socio-Cultural, & Technology).

Template Components

Step 1: Identify the
Political, Economic, Socio-Cultural and Technological Aspects of the Proposed Change in Your Advocacy Action Plan

KINE 4354 Assignment 4.1: Advocacy Action Plan Part II: PEST Analysis
	Factor	Opportunity	Threat
POLITICAL
Political factors to consider: · When is the country's next local, state, or national election? How could this change government or regional policy? · Who are the most likely contenders for power in your community? What are their views on public health policy, and on other policies that affect your organization? · Depending on the country, how well developed are property rights and the rule of law, and how widespread are corruption and organized crime? · How are these situations likely to change, and how is this likely to affect you? · Could any pending legislation or taxation changes affect your business, either positively or negatively? · How does government approach public health policy, areas of social justice or social responsibility, and environmental protection legislation? What impact does this have, and is it likely to change? · Are there any other political factors that are likely to change?
	Factor	Opportunity	Threat
ECONOMIC
Economic factors to consider: · How stable is the current economy? Is it growing, stagnating, or declining? · What is the financial condition of the organization you plan to work with? Is the organization financially stable? Is there revenue to fund your idea? If not, how will you address this? · Are there any other economic factors that you should consider?
	Factor	Opportunity	Threat
SOCIO-CULTURAL
Socio-Cultural factors to consider: · What is your target population's growth rate and age profile? How is this likely to change? · Are generational shifts in attitude likely to affect what you're doing? · What are your target population’s levels of health, education, and social mobility? How are these changing, and what impact does this have? · What social attitudes and social taboos could affect your advocacy action plan? Have there been recent socio-cultural changes that might affect this? · How do religious beliefs and lifestyle choices affect the population? · Are any other socio-cultural factors likely to drive change for your proposed advocacy action plan?
	Factor	Opportunity	Threat
TECHNOLOGICAL
Technological factors to consider: · Are there any new technologies that you could be using? · In which areas do governments and educational institutions focus their research? Is there anything you can do to take advantage of this to address your proposed advocacy action plan? · Are there existing technological hubs that you could work with or learn from? THINK COLLABORATION! · Are there any other technological factors that you should consider?
Step 2: BRAINSTORM OPPORTUNITIES Now that you have identified some of the changes that are taking place in the proposed setting for your advocacy action plan, look at each of those changes and brainstorm the potential OPPORTUNITIES that might be available for you or for the organization which you are proposing the advocacy effort for.
Potential Opportunities for Your Advocacy Action Plan
1.
2.
3.
Step 3: BRAINSTORM THREATS Now think about the changes and think about how some of those might be barriers to the implementation of your advocacy action plan. How might you plan in a manner that the potential threats might be minimized, or avoided?
Potential Threats for Your Advocacy Action Plan
1.
2.
3.
Step 4: Notes for TAKING ACTION Now it is time to TAKE ACTION! You will take this next step in Assignment 6.1 as you write up your final plan. Use the section below to write your main takeaways as you start to develop the main sections of your advocacy action plan.
My Advocacy Action Plan Notes:

Medication Errors

Unit 8 Medications for Sleep Disorders. 800w. 4 references. Due 10-22-23

1. What screening tools can be used to affirm your initial diagnosis that a patient may meet the diagnostic criteria for a sleep disorder?

2. Describe the pharmacological actions of non-z sleep medications?

3. What problems can occur when benzodiazepines are used to help with sleep?

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.

Please review the rubric to ensure that your response meets the criteria.

https://www.apa.org/monitor/2022/07/ce-sleep-disorders

CONTINUING EDUCATION

Diagnosing and treating sleep disorders

Psychologists have a leading role to play in treating insomnia and other common sleep disturbances

By 

Kirsten Weir
Date created: July 1, 202214 min read

Vol. 53 No. 5
Print version: page 40

·
Sleep

9

CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to:

1. Describe symptoms of common sleep disorders.

2. Understand and access tools available for screening clients for sleep disorders.

3. Describe evidence-based behavioral treatments for insomnia and other sleep disorders.

4. Know when to refer clients to sleep specialists.

For more information on earning CE credit for this article, go to 

CE Corner
.

Psychologists have a leading role to play in treating insomnia and other common sleep disturbances.

Sleep is a biological necessity. But for all its importance, it can be surprisingly hard to get enough. As many as 50 to 70 million U.S. adults have a sleep disorder, according to the American Sleep Association. Those disorders frequently go hand in hand with problems such as depression, anxiety, and posttraumatic stress disorder (PTSD). “Sleep disorders are very common and are often comorbid with mental health conditions. But psychologists get very little training in sleep,” said Jennifer Mundt, PhD, director of the Northwestern University Behavioral Sleep Medicine Training Program, who presented the continuing-education session “Sleep and Its Disorders: A Primer for Mental Health Professionals” for APA in 2021.

In a recent survey of clinical psychologists in the United States and Canada, practitioners reported a median of just 10 hours of sleep training across their education and career, and 95% reported no clinical sleep training during graduate school, internship, or fellowship (Zhou, E. S., et al., 


Behavioral Sleep Medicine

, Vol. 19, No. 6, 2021
). “In medicine, psychology, and society as a whole, we’ve paid so little attention to sleep for so long,” Mundt said.

It is time to start paying attention, Mundt and other sleep experts say. “Sleep is critical to physical and emotional health, and when it’s disrupted, it cuts across both,” said Susan Rubman, PhD, a behavioral sleep medicine specialist and assistant professor of psychiatry at the Yale School of Medicine. “As a basic part of psychological assessment, it’s important to know what normal sleep is and what disordered sleep is so you can treat all aspects of an individual’s concerns appropriately.”

ADVERTISEMENT

Sleep facts and fictions

Sleep disorders come in all shapes and sizes. The most common is insomnia, which is characterized by difficulty falling or staying asleep. About 30% of adults in the United States have symptoms of insomnia, and about 10% have insomnia that is severe enough to cause daytime consequences, according to the American Academy of Sleep Medicine (AASM). And insomnia comes with a host of complications, including increased risk of accidents, poor performance at work or school, and elevated risk of conditions including high blood pressure, heart disease, depression, and substance use disorders. It is also associated with an increased risk of suicide as well as death from other causes.

Insomnia and other sleep disorders often coexist with other psychological complaints. Up to 90% of people with depression have sleep complaints, and two thirds of people undergoing a major depressive episode experience insomnia, according to a review by University of Pittsburgh researchers Peter Franzen, PhD, and Daniel Buysse, MD. Sleep disturbances often precede depressive symptoms, they found, and are associated with worse clinical and treatment outcomes among people with depression (


Dialogues in Clinical Neuroscience

, Vol. 10, No. 4, 2008
).

All that is to say that clinical psychologists are certain to treat patients who have trouble sleeping whether they know it or not. And there are three good reasons to address sleep in practice, said Michael Grandner, PhD, MTR, director of the Sleep and Health Research Program at the University of Arizona. “First, we know that sleep affects health and functioning. Second, sleep is often a way into mental health issues. Asking how someone is sleeping is a great way to start talking about mental health,” he said. “And the third reason is that sleep problems are highly fixable, without medications. And psychologists are in a prime position to fix them.”

Yet there are some common misconceptions about sleep—among the public as well as health care professionals—that prevent people from getting the treatment they need for insomnia and other sleep disorders. One is the belief that good sleep hygiene can cure disordered sleep, Grandner said. Sleep hygiene includes practices like going to bed and waking up at a consistent time, removing electronic devices from the bedroom, and avoiding caffeine, alcohol, and heavy meals near bedtime. While these efforts can improve sleep, they are not a treatment for disordered sleep. “A lot of people confuse sleep hygiene with behavioral sleep therapies. This is a huge misconception,” Grandner said. Hygiene, by nature, is preventive. “Washing your hands can prevent you from getting sick, but it won’t cure an infection. And sleep hygiene can remove some barriers to good sleep, but it’s mostly useless for fixing insomnia,” he added.

Another fallacy is that insomnia is a symptom of mental health disorders. While the two often coexist, they are best thought of as comorbid conditions, said Michael Perlis, PhD, director of the Behavioral Sleep Medicine Program at the University of Pennsylvania Perelman School of Medicine. “When sleep disorders are viewed as a symptom of an illness, people believe there’s no need for targeted action. They believe that by treating the PTSD, anxiety, or depression, insomnia will abate. The past 10 years of research shows us that doesn’t happen,” he said.

While treating mental health conditions does not guarantee improvement of comorbid insomnia, the reverse is more likely: Treating insomnia can make mental health disorders more manageable. A meta-analysis of randomized controlled trials showed that poor sleep is causally related to mental health difficulties and that greater improvements in sleep quality lead to greater improvements in mental health (Scott, A. J., et al., 


Sleep Medicine Reviews

, Vol. 60, 2021
). For that reason, some sleep experts argue that insomnia should be treated even before other mental health problems, if the patient is not in crisis. “When insomnia is left alive, it complicates the treatment of everything else,” said Donn Posner, PhD, adjunct clinical associate professor at Stanford University School of Medicine and founder of Sleepwell Consultants, which offers sleep interventions for patients and workshops for providers. “Every time you see chronic insomnia, you need to treat it.”

CBT-I: Front-line insomnia treatment

Almost anything can trigger a night of tossing and turning, from stress to pain to stormy weather. “There are a million causes of short-term insomnia. But there is one main culprit behind chronic insomnia—conditioned arousal,” said Grandner. “When sleep becomes problematic, the bed becomes the war zone. And then the expectation that sleep will be stressful creates the very activation that makes sleep difficult.”

The best treatment to address that conditioned arousal is cognitive behavioral therapy for insomnia (CBT-I), a targeted intervention that typically lasts four to eight sessions. In fact, CBT-I is one of psychology’s best success stories. The treatment is so effective that it is recommended as a front-line treatment for insomnia by a variety of professional groups, including the Department of Veterans Affairs/Department of Defense Health Affairs, the American College of Physicians, and the AASM.

Even in cases of short-term insomnia, CBT-I is about as effective as sleeping pills. In a meta-analysis that included 21 studies, researchers concluded that behavioral therapy produces similar outcomes as pharmacotherapy for the acute treatment of primary insomnia (Smith, M. T., et al., 


The American Journal of Psychiatry

, Vol. 159, No. 1, 2002
). But for chronic insomnia, CBT-I is at a distinct advantage. A meta-analysis concluded that the intervention is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes (Trauer, J. M., et al., 


Annals of Internal Medicine

, Vol. 163, No. 3, 2015
). “In the long term, there’s an advantage for CBT-I because it actually addresses the underlying behavioral and thought patterns that perpetuate the insomnia,” Mundt said. “And it has a high rate of success.”

CBT-I is also a successful option for patients with insomnia and depression. In a study of internet-delivered CBT-I, Kerstin Blom, PhD, at the Karolinska Institutet in Sweden, and colleagues found that in patients with both diagnoses, CBT-I was more effective than CBT for depression when treating insomnia. More surprising, the two were equally effective for reducing depression severity. At a 3-year follow-up, both the CBT-I and CBT for depression groups continued to experience similar reductions in depression severity, but the insomnia treatment continued to have superior effects on sleep (


Sleep

, Vol. 38, No. 2, 2015
; 


Sleep

, Vol. 40, No. 8, 2017
).

Other research also supports the idea that CBT-I can improve depression. A systematic review of 18 studies concluded that CBT-I is a promising treatment for depression in people who also have insomnia and produces effects of roughly the same magnitude as antidepressant medications. In-person therapy had the most evidence supporting its efficacy, while evidence for telehealth CBT-I was mixed. However, the authors concluded there is promise for a stepped-care approach in which telehealth progresses to in-person therapy for patients as needed (Cunningham, J. E. A., & Shapiro, C. M., 


Journal of Psychosomatic Research

, Vol. 106, 2018
).

There’s further evidence that treating insomnia might even prevent depression from developing in the first place. In a study by researchers at Henry Ford Health and the University of Oxford, participants with insomnia were randomized to receive either digital CBT-I or sleep education. In those with minimal to no depression at baseline, the incidence of moderate-to-severe depression one year later was reduced by half in the CBT-I group compared with the sleep education control condition (Cheng, P., et al., 


Sleep

, Vol. 42, No. 10, 2019
).

Research also supports the use of CBT-I in patients with insomnia and other mental health conditions. One randomized trial by Lisa Talbot, PhD, at the San Francisco VA Medical Center, and colleagues found that an eight-session CBT-I intervention improved sleep and overall psychosocial functioning in people with PTSD compared with participants in a waiting list control group. There was also some evidence that CBT-I may reduce the frequency of nightmares in people with PTSD (


Sleep

, Vol. 37, No. 2, 2014
).

Meanwhile, Grandner and colleagues explored the connection between COVID-19 pandemic-related stress and anxiety, suicidal ideation, and sleep. They found that COVID anxiety was correlated with suicidal ideation—but that association was fully accounted for by insomnia severity. Treating the insomnia, in other words, may help to reduce suicide risk in people with high stress or anxiety (


Psychiatry Research

, Vol. 290, No. 113124, 2020
).

Recognizing other sleep disorders

Insomnia, while common, is hardly the only sleep disorder that psychologists are likely to encounter in their practice. About 25 million adults in the United States—more than a quarter of adults ages 30 to 70—have obstructive sleep apnea, according to the AASM. This disorder occurs when muscles in the throat relax, blocking the airway. People with obstructive sleep apnea repeatedly stop breathing for short periods during sleep, disrupting sleep continuity and causing daytime fatigue. Untreated, sleep apnea can increase the risk of serious conditions, including diabetes, heart disease, and mood and psychiatric disorders.

The front-line treatment for obstructive sleep apnea is positive airway pressure (PAP), a face mask device that pushes air into the airway to keep it open during sleep. While PAP treatment is effective, adherence can be an issue. Psychologists can help patients learn to tolerate the device. “People who specialize in behavioral sleep medicine can help with adherence and anxiety for PAP. When patients are struggling to wear the mask or have anxiety or claustrophobia, we can use exposure treatments to help them get comfortable using the device,” Mundt said.

Nightmares are another common complaint, especially in people who have been exposed to trauma. Counter to popular belief, nightmares are treatable. Imagery rehearsal therapy (IRT) is one of the most used and well-supported interventions for nightmares in people with PTSD, and several protocols are available. A meta-analysis of these cognitive behavioral interventions found IRT had large effects on the frequency of nightmares, sleep quality, and PTSD symptoms. Further, the combination of IRT and CBT-I resulted in even greater improvements in sleep quality (Casement, M. D., & Swanson, L. M., 


Clinical Psychology Review

, Vol. 32, No. 6, 2012
). “It’s helpful to ask patients about nightmares because they are so common, especially with trauma,” Mundt said. “And patients aren’t necessarily going to bring them up, because they don’t even know that treatments are out there.”

Another challenging condition is hypersomnia, which causes excessive sleepiness even after a full night’s sleep. Examples of central disorders with hypersomnolence include conditions such as narcolepsy and Kleine-Levin syndrome, a rare disorder that causes excessive sleep, hunger, and behavioral changes. Hypersomnia can also be idiopathic, meaning it has no known cause. Secondary hypersomnia can be associated with certain medical disorders (such as epilepsy, hypothyroidism, or nervous system disorders), mood disorders such as depression and bipolar disorder, or other causes, such as side effects from medications. “These disorders are less common, but they frequently go undiagnosed or misdiagnosed for years,” Mundt said.

She and her colleagues are developing a cognitive behavioral therapy for hypersomnia (CBT-H). An initial pilot study suggested the treatment may reduce depressive symptoms and improve self-efficacy in people with hypersomnia and coexisting depression (Ong, J. C., et al., 


Journal of Clinical Sleep Medicine, Vol. 16, No. 12, 2020

). “The main treatment for hypersomnia is medication to help with alertness. This is an adjunctive treatment to address the psychosocial impacts of hypersomnia,” Mundt said.

“There’s often comorbid depression and anxiety and issues with stigma and navigating work and relationships. CBT-H is designed to help people deal with those challenges.”

Sleep training for psychologists

Given the frequency of sleep disruption in the general population—and among people with mental health disorders in particular—it is important for clinicians to recognize the signs. Clinical psychologists should make a point to inquire about their patients’ sleep habits, Grandner said. “Sleep problems are part of practically every diagnosis in the DSM,” he said.

Yet it is also important to recognize that treating insomnia and other sleep disorders requires specialized training. For psychologists who are trained in CBT, learning CBT-I is not especially difficult, Grandner said. “The treatment is highly manualized, and you don’t need to be board certified in behavioral sleep medicine to become competent in CBT-I.” However, being competent in CBT-I does require training in principles of sleep medicine that go beyond the traditional behavioral and cognitive tools, and various training options are available online and in person at institutions such as the University of Pennsylvania, University of Oxford, University of Arizona, and others. (See 

Screening tools and other resources
.)

Perlis and Posner, who lead training courses in CBT-I and are coauthors of a treatment manual on the intervention, argue that many more psychologists would benefit from these trainings—and so would their patients. Currently, most of the participants in Perlis’s training courses come from allied fields such as social work and occupational therapy, he said. “We clinical psychologists designed CBT-I. We produced the evidence base. Why are we not the ones delivering it?” he asked. “We need more people in clinical psychology to come aboard and start seeking training.”

Addressing sleep hygiene is something all clinicians can do with their patients. But sleep hygiene alone is not sufficient for treating clinically significant insomnia, Rubman said. If sleep problems persist for more than a few weeks, it is important to refer patients to a physician or psychologist who is certified in behavioral sleep medicine or has training in CBT-I. Too often, patients receive sleep education but do not improve, and then they mistakenly conclude that behavioral interventions didn’t work for them and may turn to sleeping pills instead. That is a missed opportunity, since their insomnia is likely to improve or resolve if they are treated with CBT-I. “Clinicians need a good understanding of variations in normal sleep and the limits of sleep hygiene, and they need to recognize when to refer someone to a specialist,” she said. “The goal is to intervene to prevent an acute problem from becoming a chronic problem.”

Screening tools and other resources

Epworth sleepiness scale

(Johns, M. W., 
Sleep, Vol. 14, No. 6, 1991)

Insomnia Severity Index

(Morin, C. M., et al., 
Sleep, Vol. 34, No. 5, 2011)

Sleep Disorders Symptom Checklist-25

(Klingman, K. J., et al., 
Sleep Medicine Research, Vol. 8, No. 1, 2017)

STOP-Bang questionnaire for sleep apnea

(Tan, A., et al., 
Sleep Medicine, Vol. 27–28, 2016)

Society of Behavioral Sleep Medicine
 (resources, education, and provider directory)

International Directory of CBT-I Providers

Web-based course in CBT-I

Further reading

Cognitive behavioral treatment of insomnia

Perlis, M. L., et al., Springer, 2005

Principles and practice of sleep medicine, 7th edition

Kryger, M. H., et al., Elsevier, 2022

Behavioral treatments for sleep disorders

Perlis, M., et al. (Eds.), Elsevier, 2011

Treatment plans and interventions for insomnia: A case formulation approach

Manber, R., & Carney, C. E., Guilford Press, 2015

Emily Grace and the what-ifs: A story for children about nighttime fears

Gehring, L. B., Magination Press, 2016

1. What screening tools can be used to affirm your initial diagnosis that a patient may meet

the diagnostic criteria for a sleep disorder?

Having a sleep disorder can be crippling to a person’s life and relationships. Research has

expressed that it can exacerbated, or quality of life can be decreased, and fatigue and sleepiness

can have very bad consequences. The screening tool that I would use for distinguishing insomnia

would be the Athens Insomnia Screening (AIS). The consistency and reliability of the AIS

determines for me to be invaluable tool in the clinical practice. this tool helps determine the

factors that affect the inability to sleep. The AIS has 8 items that are used for screening insomnia.

The first 5 items pertain to sleep induction, awakening during the night, final awakening, total

sleep duration, and sleep quality. The last three refer to wellbeing, functioning capacity, and

sleepiness during the day

2. Describe the pharmacological actions of non-z sleep medications?

Zolpidem, Zaleplon, and Eszopiclone are examples of non-z sleep medications. Nonbenzodiazepines work by enhancing a very important neurotransmitter called GABA at the

GABA A receptor. The nonbenzodiazepine hypnotics facilitate GABA A transmission by

preferential binding to the 1a receptor subunits.

3. What problems can occur when benzodiazepines are used to help with sleep?

Benzodiazepines can be used for a short term for insomnia, however there are side effects from

the use of benzodiazepines such as addiction. There are additional medications to explore for

long term use for insomnia they are associated with residual daytime sedation, rebound

insomnia, and anterograde amnesia that can be controlled by their pharmacokinetic properties.

There is a low abuse potential for these classes of drugs when taken for an extended period,

withdrawal and tolerance to the hypnotic effects can become prevalent, and long-term use has

not been studied systematically.

Degree:  Master of Science in Nursing 

There are many ways of knowing. Think about how you learn in both your personal and professional life. Discuss various ways you have gained knowledge through your observational experiences during your capstone practicum by answering the following questions:

• What is the focus of your capstone practicum?
• What have you observed thus far?
• How do you determine if the information presented is valid and accurate?
• Review the “hierarchy of evidence” model and determine where you seek most of your information for both your personal and professional life and why.
• Provide personal examples.
• Include at least 2 scholarly articles supporting your statements.

 choose a research question, review the relevant literature, examine the question’s potential significance to nursing, and pragmatically examine the feasibility of studying the research question. Draft a PICOT Question. Review Chapter 2 for more information.