THE STUDY ON THE LEVEL OF KNOWLEDGE

AND ATTITUDE TOWARDS OBSTRUCTIVE

SLEEP APNEA AMONG NURSES IN HOSPITAL
TAWAU

DISEDIAKAN OLEH:

DISELIA OLEH:
Encik Mohd Rusle Bin Abduraji Sali

The research proposal is prepared for Degree in Bachelor Medical Health

Sciences OUM part of Project Work course

Date:
I. PROPOSAL INTRODUCTION

A. Title
THE STUDY ON THE LEVEL OF KNOWLEDGE AND ATTITUDE TOWARDS
OBSTRUCTIVE SLEEP APNEA AMONG NURSES IN HOSPITAL X

B. Keyword
_____________________________________________________________________
_____________________________________________________________________

C. Student Name

D. Degree Name and Institution

Bachelor of Medical and Health Sciences with Honors
Open University Malaysia.

E. Supervisor/s
Encik Mohd Rusle Bin Abduraji Sali

F. Synopsis
_____________________________________________________________________
_____________________________________________________________________

II. RESEARCH OBJECTIVES

General Objective.

To assess knowledge and attitudes towards obstructive sleep apnea among Nurses in
Hospital X using a standard validated questionnaire.

Specific Objective

1. To identify the demographic characteristics of respondents.

2. To identify the level of knowledge regarding obstructive sleep apnea among
respondents.
3.
4.

III. RESEARCH BACKGROUND

A. Research Problem and Rationale

In the last 20 years, the recognition of obstructive sleep apnea which is known to be
an important health risk factors had grown and becoming an alarming health issue
(Young, Palta, Dempset, Skatrud, Weber & Badr, 1993). According to Young,
Peppard and Gottlieb (2002), there is an estimated value of between 2-5% in the risk
prevalance of obstructive sleep apnea between adult population which is defined as an
apnea-hypopnea index (AHI) of more than 5 events per hour during sleep. Generally,
obesity problems are rising worldwide and this will indirectly increases the
prevalance of obstructive sleep apnea in a parallel rising trend (Flegal, Caroll, Ogden
& Johnson, 2002). Obstructive sleep apnea can lead to complications and also acting
as an independent risk factor for systemic diseases such as cardiovascular diseases
and diabetes mellitus which can increases the economic burden of a country in
treatment of diseases (AlGhanim, Comondore, Fleethan, Marra & Ayas, 2008).
Undiagnosed or untreated obstructive sleep apnea therefore can lead to negative
outcomes or consequences following the role of obstructive sleep apnea acting as an
independent risk factor. Unfortunately according to the study conducted by Finkel et
al. (2009), there is a high estimated percentage of adults which remains undiagnosed
where 82% are men and 93% are women with moderate or severe obstructive sleep
apnea. The undiagnosed and untreated obstructive sleep apnea may be attributed by a
low level of knowledge regarding the importance of sleep and obstructive sleep apnea
among patients and also among healthcare workers (Kramer, Cook, Claisle, Corwin &
Millman, 1999). According to Wadwha, Jain, Kundu, Nebhinani and Gupta (2020),
there are previous studies that assessed knowledge, attitude and practice regarding
obstructive sleep apnea among healthcare workers where the studies findings reported
that there are lack of knowledge and attitude towards importance of diagnosing and
managing patients with obstructive sleep apnea. Previous studies were mainly
focusing on healthcare workers such as physicians, dentist, anesthetists and also
medical students. However, according to Sheldon, Belan, Neill and Rowland (2009),
nurses who works in a hospital settings also plays an important role in identifying,
screening and facitiltates the management of obstructive sleep apnea. In Hospital
Tawau, patients who are refered to Otorhinolaryngology department to rule out
obstructive sleep apnea mostly have history of admission into ward but are not
referred to Otorhinolaryngology department during or prior to discharge. Instead,
patients are screened for obstructive sleep apnea in other facilities such as government
health centers and private clinics. Nurses can act as an important role in identifying,
screening and discussing patient’s sleep pattern with doctors in order to diagnose or
rule out obstructive sleep apnea. This research is important in identifying nurses
knowledge and attitudes towards obstructive sleep apnea in Hospital Tawau which
can help in the early diagnosis of obstructive sleep apnea and thus can facilitate a
better prognosis of disease and reduces the prevalance of systemic complications
caused by obstructive sleep apnea.
B. Literature Review
Obstructive sleep apnea is one of the sleep disorder which is defined as repeated
episodes of both obstructive apnea and hypopnea that occurs during sleep and it is a
common medical problem nowadays (American Thoracic Society, 1994). Obstructive
sleep apnea affects an estimated percentage of 2 to 4 percent of middle-aged adults
based on the epidemiologic studies (Young, Palta, Dempset, Skatrud, Weber & Badr,
1993). However, only a small number of cases are diagnosed and treated where the
problem is related to insufficient knowledge and awareness regarding obstructive
sleep apnea among healthcare workers which includes doctors and also nurses in
hospital setting besides the public population (Rosen, Rosekind, Rosevear, Cole and
Dement, 1993). Obstructive sleep apnea are manifested by several signs of upper-
airway collapse during sleep, insomnia and hypersomnolence. According to Krakow,
Melendrez, Ferreira, Clark, Warner, Sisley and Sklar (2001), obstructive sleep apnea
symptoms includes snoring, choking, gasping and also snorting. Patients who are
diagnosed with obstructive sleep apnea often complain of having insomnia, multiple
awakening during sleep, reduced total sleeping time, early morning awakenings and
also fragmented sleep. Daytime sleepiness and chronic fatigue are the most significant
and common complaints of patients who are diagnosed with obstructive sleep apnea
(Mannarino, Di Filippo and Pirro, 2012). Severity of the symptoms are often
associated with the increase in weight gain, aging or menopause in women and
usually progress over years which can lead to systemic complications and also
decrease in quality of life. According to Horstmann, Hess, Bassetti, Gugger and
Mathis (2000), sleepiness caused by obstructive sleep apnea can affect daily activities
and causes disabling and dangerous events such as increase in the risk of motor-
vehicle accident and injury in workplace. Besides that, obstructive sleep apnea are
also an independent risk of systemic diseases especially involving cardiovascular and
neurocognitive function. According to Mannarino, Di Filippo and Pirro (2012),
obstructive sleep apnea have a strong association with diseases which can affect the
quality of life for example hypertension, diabetes, coronary artery disease, heart
failure, stroke and also neurocognitive and mood disorders. In the diagnosis of
obstructive sleep apnea, a complete and focused history taking and also physical
examination can help to identify patients who are at risk for sleep apnea. Furthermore,
patients characterictics such as male sex, age of more than 40 years old, snoring,
choking, gasping, observed apnea and had a history of hypertension can be screened
for obstructive sleep apnea (Flemons, Whitelaw, Brant & Remmers, 1994). Screening
of obstructive sleep apnea can be done by using STOP-BANG questionnaire (Tan,
Yin, Dam, Cheung and Lee, 2016) while Epworth Sleepiness Scale questionnaire is
used to screen for sleepiness where it measures an individual’s chances or likelihood
to fall asleep during daily routine (Johns, 1991). In the diagnosis of obstructive sleep
apnea, sleep studies are needed to confirm the diagnosis and clinical suspicion
regarding sleep apnea, to measure the severity of obstructive sleep apnea and also to
provide guidelines for the therapeutic choices that can be offered to patients
(Mannarino, Di Filippo & Pirro, 2012). Polysomnography is the gold standard for the
diagnosis of obstructive sleep apnea where patient’s sleep activities are recorded
during sleep which includes pulse oximetry, electro-oculogram,
electroencephalogram, nasal or oral air flow measurements, movements of chest wall,
electromyogram and also electrocardiogram (Park, Ramar & Olson, 2011). According
to Veasey and Rosen (2019), obstructive sleep apneas are defined as a near or
complete cessations of airflow for at least 10 seconds during sleep with the presence
of ventilatory effort and hypopnea where it is a reduction in air flow of more than
30% associated with concurrent reduction in saturation of oxyhemoglobin by more
than 3% or with arousals from sleep. Apnea-hypopnea index (AHI) is the number of
apneas and hypopneas measured within a hour of sleep collectively. A patient is
diagnosed with obstructive sleep apnea when his or her AHI is 5 or more events per
hours where 5 to 15 is mild, 16 to 30 is moderate and more than 30 events per hour is
considered to be severe obstructive sleep apnea. According to Mannarino, Di Filippo
and Pirro (2012), management of obstructive sleep apnea consist of behavioral,
medical and surgical options that are available based on the AHI and compliance of
patients towards the treatement being offered where management of obstructive sleep
apnea involves multidisciplinary approach for a long-term basis.

C. Significance of Research
Obstructive sleep apnea is a sleep disorder that leads to insufficient amount and poor
quality of sleep. There are several studies and reports worldwide that suggested
obstructive sleep apnea as an important medical disorder which should be given more
attention to be overcome. According to the American Academy of Sleep Medicine,
sleep problems are common in USA where 46% of population are having sleep apnea,
34% with frequent snoring, 30% reported symptoms of insomnia and finally 25%
reported excessive daytime sleepiness (McCann, 2010). Whereas according to
Altevogt and Colten (2006), there are approximately 50-70 million of Americans
suffered from sleep disorders chronically that bring negative outcomes toward their
health and mortality. In Singapore, the prevalence of obstructive sleep apnea was 2 to
4% where the highest prevalence is among Malay population (Puvanendran & Goh,
1999). As for Malaysia, researchers from University of Malaya conducted studies in
year 2007 and estimated that the prevalence of obstructive sleep apnea on middle-
aged adults are 9% in men and 4% in women respectively while the prevalence of
obstructive sleep apnea among the general population is between 2% to 4% which are
almost comparable to Singaporeans (Liam, Pang, Shyamala & Chua, 2007). Whereas
among Koreans, the prevalence of obstructive sleep apnea is 4.5% in men and 3.2% in
women (Pillar & Shehadeh, 2008).
According to Wright, Hull and Czeisler (2002), obstructive sleep apnea can
predispose a person to medical illness where admission into hospital may be required.
Thus, nurses are in a unique position where they are continuously monitoring patients
throughout day and night arising opportunities to witness episodes of apnea and also
detection of excessive snoring. According to Sheldon, Belan, Neill and Rowland
(2009), undiagnosed obstructive sleep apnea may be present in hospital wards and
nurses working in hospital settings could play an important role in helping doctors to
identify patients with obstructive sleep apnea which includes identifying risk factors,
conducting obstructive sleep apnea screening and also facilitates further management
for the investigations and treatments of obstructive sleep apnea. Obstructive sleep
apnea are often undiagnosed due to the difficulty in recognition of obstructive sleep
apnea signs and symptoms which occurs during sleep. Therefore, the identification of
patients with risk of obstructive sleep apnea and monitoring patient’s sleep patterns in
hospital setting may help in the diagnosis of obstructive sleep apnea (Lee, Low &
Twinn, 2007).
Therefore, the research title of “The Study On The Level Of Knowledge And Attitude
Towards Obstructive Sleep Apnea Among Nurses In Hospital Tawau” is significant
where the research can help to access the level of knowledge and the attitude of
nurses in Hospital Tawau towards obstructive sleep apnea. Findings on the research
can be used to illustrate the ability and tendency of hospital settings especially among
nurses in identifying patients at risk of obstructive sleep apnea where patients who are
suspected to have obstructive sleep apnea can be referred to doctors for further
management. This will eventually help to improve treatment outcomes and can
prevent complications caused by obstructive sleep apnea through early diagnosis of
the sleep disorder. Besides, suggestions can be given and implementations can be
carried out based on the research findings in order to give a quality and thorough
hospital service for current and future references.

D. References
AlGhanim, N., Comondore, V. R., Fleetham, J., Marra, C. A., & Ayas, N. T. (2008). The
economic impact of obstructive sleep apnea. Lung, 186(1), 7-12.

Altevogt, B. M., & Colten, H. R. (Eds.). (2006). Sleep disorders and sleep deprivation: an
unmet public health problem.

Finkel, K. J., Searleman, A. C., Tymkew, H., Tanaka, C. Y., Saager, L., Safer-Zadeh, E., ... &
Avidan, M. S. (2009). Prevalence of undiagnosed obstructive sleep apnea among
adult surgical patients in an academic medical center. Sleep medicine, 10(7), 753-
758.

Flegal, K. M., Carroll, M. D., Ogden, C. L., & Johnson, C. L. (2002). Prevalence and trends in
obesity among US adults, 1999-2000. Jama, 288(14), 1723-1727.

Flemons, W. W., Whitelaw, W. A., Brant, R., & Remmers, J. E. (1994). Likelihood ratios for a
sleep apnea clinical prediction rule. American Journal of Respiratory and Critical Care
Medicine, 150(5), 1279-1285.

Horstmann, S., Hess, C., Bassetti, C., Gugger, M., & Mathis, J. (2000). Sleepiness-related
accidents in sleep apnea patients. SLEEP-NEW YORK-, 23(3), 383-392.

Indications and standards for use of nasal continuous positive airway pressure (CPAP) in
sleep apnea syndromes. American Thoracic Society. Official statement adopted
March 1944. (1994). American Journal of Respiratory and Critical Care Medicine,
150(6), 1738–1745. doi:10.1164/ajrccm.150.6.7952642
Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth
sleepiness scale. sleep, 14(6), 540-545.

Krakow, B., Melendrez, D., Ferreira, E., Clark, J., Warner, T. D., Sisley, B., & Sklar, D. (2001).
Prevalence of insomnia symptoms in patients with sleep-disordered
breathing. Chest, 120(6), 1923-1929.

Kramer, N. R., Cook, T. E., Carlisle, C. C., Corwin, R. W., & Millman, R. P. (1999). The role of
the primary care physician in recognizing obstructive sleep apnea. Archives of
Internal Medicine, 159(9), 965-968

Lee, C. Y., Low, L. P. L., & Twinn, S. (2007). Older men’s experiences of sleep in the hospital.
Journal of Clinical Nursing, 16, 336–343.
Liam, C. K., Pang, Y. K., Shyamala, P., & Chua, K. T. (2007). Obstructed breathing during
sleep and obstructive sleep apnoea syndrome--assessment and treatment. The
Medical journal of Malaysia, 62(3).

Mannarino, M. R., Di Filippo, F., & Pirro, M. (2012). Obstructive sleep apnea
syndrome. European journal of internal medicine, 23(7), 586-593.

McCann, K. (2010). The Association Between Sleep Disturbances and Reduced Quality of Life
Varies By Race. American Academy of Sleep Medicine.

Park, J. G., Ramar, K., & Olson, E. J. (2011). Updates on definition, consequences, and
 management of obstructive sleep apnea. In Mayo Clinic Proceedings (Vol. 86, No. 6,
pp. 549-555). Elsevier.

Pillar, G., & Shehadeh, N. (2008). Abdominal fat and sleep apnea: the chicken or the
egg?. Diabetes care, 31(Supplement 2), S303-S309.

Puvanendran, K., & Goh, K. L. (1999). From snoring to sleep apnea in a Singapore
population. Sleep research online: SRO, 2(1), 11-14.

Rosen, R. C., Rosekind, M., Rosevear, C., Cole, W. E., & Dement, W. C. (1993). Physician
education in sleep and sleep disorders: a national survey of US medical
schools. Sleep, 16(3), 249-254.

Sheldon, A., Belan, I., Neill, J., & Rowland, S. (2009). Nursing assessment of obstructive
sleep apnea in hospitalised adults: A review of risk factors and screening
tools. Contemporary Nurse: A Journal for the Australian Nursing Profession.

Tan, A., Yin, J. D., Tan, L. W., van Dam, R. M., Cheung, Y. Y., & Lee, C. H. (2016). Predicting
obstructive sleep apnea using the STOP-Bang questionnaire in the general
population. Sleep medicine, 27, 66-71.

Veasey, S. C., & Rosen, I. M. (2019). Obstructive sleep apnea in adults. New England
Journal of Medicine, 380(15), 1442-1449.

Wadhwa, R., Jain, A., Kundu, K., Nebhinani, N., & Gupta, R. (2020). Knowledge about
obstructive sleep apnea among medical undergraduate students: A long way to
go!. Indian Journal of Psychiatry, 62(6), 713.

Wright, K. P., Jr., Hull, J. T., & Czeisler, C. A. (2002). Relationship between alertness, per-
formance, and body temperature in humans. American Journal of Physiology:
Regulatory, Integrative and Comparative Physiology, 238, R1370–R1377.
Young, T., Palta, M., Dempsey, J., Skatrud, J., Weber, S., & Badr, S. (1993). The occurrence
of sleep-disordered breathing among middle-aged adults. New England Journal of
Medicine, 328(17), 1230-1235.

Young, T., Peppard, P. E., & Gottlieb, D. J. (2002). Epidemiology of obstructive sleep apnea:
a population health perspective. American journal of respiratory and critical care
medicine, 165(9), 1217-1239.

IV. MATERIALS AND INSTRUMENTATION

A. Instrumentation / Instrumen Kajian

A cross sectional study will be used to assess the level of knowledge and attitude
towards obstructive sleep apnea among nurses in Hospital Tawau. A questionnaire
will be distributed to nurses in Hospital Tawau.
Data Collection Method / Kaedah Pengumpulan Data
Convenient sampling technique will be used to invite nurses in Hospital Tawau to
participate in the study where the information sheet, consent form and questionnaires
will be attached together and distributed through “google form” by the researchers at
Hospital Tawau. Raw data from the questionnaires will be collected in excel form.
B. Analysis Methods
All of the answers from the questionnaires will be collected and analyzed using
Statistical Package for Social Sciences (SPSS). Demographic information of the
respondents will be analyzed by using descriptive analysis involving mean,
percentages and standard deviation including the level of knowledge and attitude of
respondents towards obstructive sleep apnea. While inferential statistics, a Pearson
Correlation Test will be used to identify if there is relationship between the level of
knowledge and attitude of respondents towards obstructive sleep apnea.
V. RESEARCH APPROACH

A. Research Methodology
Survey with using descrpitve-quantitatve method

B. Research Activity
Based to Gantt Chart, state the research activities and research milestone.

Research Activity Year 2021

J F M A M J J A S
Research Proposal
Introduction / Literature
review
Methodology
Data collection/ analyse
data
Discussion
VIVA

Research Milestone
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VI. RESEARCH FINDING

A. Expected Outcome
There is a low level of knowledge and attitude towards obstructive sleep apnea among
nurses in Hospital Tawau.
 SUPERVISOR ACKNOWLEDGEMENT (TO BE FILLED BY SUPERVISOR
ONLY)
I acknowledged that the Research Proposal is made through discussion processes with
me and the researcher and the write-up is owned by the researcher him/her self,
except those cited the resources.

I agree / disagree* to allow the researcher to present this Research Proposal to the
Faculty level.

Remarks (if any):

…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………

Supervisor Signature and Stamp : Date:

*where it is applicable