Restful Rehabilitation: Sleep’s Essential Role in Occupational Therapy Education, Intervention, and Research

Sleep and rest have always been pillars in occupational therapy’s scope of practice (Meyer, 1922). According to Maslow’s (1970) hierarchy of needs, sleep is a basic human need and an essential occupation across the lifespan. A lack of sleep affects occupations we engage in throughout the day (e.g., work, education, play, socialization). Occupational therapy practitioners routinely address areas that have been strongly connected to poor sleep (e.g., cognitive performance, motor function, emotion regulation) and are poised to address the epidemic of insufficient sleep. Tester and Foss (2018) recommended incorporating sleep knowledge into occupational therapy education curricula. Despite this, many occupational therapy programs are not teaching their students about sleep, and thus most occupational therapy practitioners are unprepared to address sleep (Enam et al., 2023; Hartman et al., 2024; Ludwig et al., 2022). Now, more than ever, sleep health is at the forefront of conversations, with insufficient sleep being touted as a critical public health epidemic (Institute of Medicine, Board on Health Sciences Policy, & Committee on Sleep Medicine and Research, 2006; Hale et al., 2020).

The time is now for occupational therapy practitioners to emphasize sleep education throughout curricula, elevate sleep assessment and intervention, and lead sleep research in an effort to help reduce this public health crisis (Hale et al., 2020). In this column, we propose directions for actions to address the need for sleep in occupational therapy education, interventions, and research. It is time for more occupational therapy practitioners to become competent sleep champions and embrace sleep as the foundation of all occupations.

Educating occupational therapy practitioners in sleep-related knowledge and skills is essential if they are to maximize client outcomes and secure a role for occupational therapy practitioners in addressing sleep disturbances in our communities (Sheth & Thomas, 2019; Tester & Foss, 2018). A considerable gap exists between the Occupational Therapy Practice Framework: Domain and Process (OTPF–4; American Occupational Therapy Association [AOTA], 2020) and practitioner confidence and knowledge concerning sleep. A lack of confidence and inadequate entry-level preparation has been reported by occupational therapy practitioners, with 92% stating they would like more training after graduation from an entry-level program (Hartman et al., 2024; Ludwig et al., 2022). These findings underscore the urgent need for comprehensive education and training to effectively address clients’ sleep-related concerns. Education and training must include (1) intensifying the study of sleep concepts in entry-level education, including capstone/thesis projects; (2) exploring evidence-based sleep interventions; (3) identifying sleep-based continuing education; and (4) collaboration with other professionals currently working in sleep medicine.

Broadly put, occupational therapy programs report 2 hr of entry-level education on sleep concepts (Ludwig et al., 2022; Poole et al., 2024). Considering that sleep is the foundation of health and cuts across all diagnoses, it is appropriate to shift sleep education from a single lecture to a topic that is threaded throughout the entire curriculum. To support this, educational standards and program leadership must fundamentally increase awareness of the foundational nature of sleep. A revival of the specificity of sleep’s importance in the standards established by the Accreditation Council for Occupational Therapy Education (ACOTE^®) is imperative. The 2011 ACOTE standards explicitly identified sleep as a domain for evaluation (Standard B.4.4) and as a determinant for specific sleep interventions (B.5.2; ACOTE, 2011). Updates to the standards in 2018 (B.4.4 and B.4.10) and 2023 (B.3.3 and B.3.6) removed the explicit identification of sleep (ACOTE, 2018, 2023) but instead acknowledged rest and sleep as one area of occupation in the OTPF–4 and categorized sleep as a component of health and wellness. This generalization allows variances in the degree and depth to which the topic of sleep is covered across occupational therapy programs. Students’ and faculty’s understanding of sleep as a biological need and an essential occupation across the lifespan is imperative in the education landscape.

Teaching that sleep is an occupation and that sleep enriches all other occupations is an essential concept across occupational curricula. Sleep theories, the Sleep–Wake Regulation model (Borbély et al., 2016), and circadian rhythm principles are fundamental concepts that should be woven throughout the curricula, including in foundational skill, lifespan, and population-based courses. In addition, adding aspects of sleep assessment and educating occupational therapy practitioners that sleep is crucial to daily rhythms and is, in fact, a self-care activity (Smallfield et al., 2021) is essential. As sleep education becomes more robust in academic programs and occupational therapy practitioners gain sleep knowledge, sleep will become embedded in clinical practice and sleep-focused fieldwork opportunities will be promoted.

Opportunities exist within the current continuing education structure to advance occupational therapy practitioners’ knowledge and skill in evaluating and addressing sleep. These educational options include AOTA’s sleep promotion resources (https://www.aota.org/practice/clinical-topics/sleep), sleep-specific continuing education courses (e.g., cognitive–behavioral therapy for insomnia [CBT–I], sleep disturbances, sleep assessment, intervention across the lifespan), interactive learning workshops, and scholarly discussions (e.g., Conversations That Matter [https://conversationsthatmatter.org/]). This educational content can be accessed in venues such as AOTA’s Annual Conference & Expo or other occupational therapy, occupational science, or interdisciplinary organization conferences.

In addition to continuing education, occupational therapy practitioners with further training in sleep can support capstone/thesis project development, advocate for the role of occupational therapy in sleep medicine, and develop occupational therapy–based sleep assessments and intervention protocols in their settings (Tester & Foss, 2018). Doctoral program tracks, specialty certifications, or final thesis projects are valuable means by which to build the practice tools and an evidence base to meet these goals. Academic projects could focus on developing educational modules to enhance sleep knowledge (e.g., sleep assessments, interventions, CBT–I, and sleep physiology) for current occupational therapy practitioners. These tools and updated findings should be disseminated at occupational therapy and interdisciplinary conferences (e.g., the AOTA Annual Conference & Expo; the American Congress of Rehabilitation Medicine Annual Conference; or SLEEP, the annual meeting of the American Academy of Sleep Medicine and the Sleep Research Society) to encourage further networking and multidisciplinary collaboration.

It is essential to acknowledge that sleep is a multidisciplinary pillar of health. As such, occupational therapy practitioners should become sleep champions and collaborate with sleep physicians, psychologists, respiratory therapists, and nurses to enhance client care using a multidisciplinary approach to target inadequate sleep. The American Academy of Sleep Medicine, Society of Behavioral Sleep Medicine, and the Sleep Research Society offer world-class interprofessional continuing education opportunities (e.g., at the annual SLEEP meeting) in leading-edge research, including sleep health intervention. Such cross-disciplinary meetings promote the advancement of sleep medicine and offer opportunities for occupational therapy practitioners to champion their role in sleep health promotion.

Occupational therapy practitioners’ holistic view of treatment and sleep health supports the improvement of clients’ sleep across all settings. Efforts are being made to address sleep in practice, yet there is only a limited understanding of what is currently being done in everyday occupational therapy practice. A recent survey of U.S. occupational therapy practitioners found that most (56%) did not evaluate clients’ sleep (Ludwig et al., 2022). Recent systematic reviews have examined current occupational therapy interventions across the lifespan. The most effective interventions identified were relaxation training, sleep hygiene, and cognitive–behavioral interventions (Beisbier & Laverdure, 2020; Gronski & Doherty, 2020; Smallfield & Molitor, 2018). Some identified barriers to addressing sleep were difficulty getting clients to change their sleep habits, minimal contact with caregivers (specifically in a pediatric setting), and limited confidence in sleep knowledge (Beisbier & Laverdure, 2020; Hartman et al., 2024).

Occupational therapy practitioners can advocate to incorporate sleep across practice settings. In inpatient settings, they can provide sleep health education to clients who are transitioning to the next level of care or returning home (Ludwig et al., 2023). Moreover, they can collaborate with the hospital and facility administration to implement sleep protocols that emphasize the importance of quality sleep during patient stays. These protocols may include adjusting room lighting, encouraging out- of-bed activities, minimizing nighttime disturbances, providing sleep aids (e.g., masks and earplugs), and scheduling rest breaks to facilitate recovery alongside rehabilitation. By championing sleep hygiene practices, occupational therapy practitioners can promote sleep, health, and successful recovery in an interprofessional context.

In outpatient settings, occupational therapy practitioners have longer term provider–client interactions, which allow a deeper understanding of clients’ sleep patterns. Clients often do not spontaneously raise sleep concerns during an occupational therapy evaluation or intervention, so occupational therapy practitioners must proactively assess and address sleep-related concerns. To optimize sleep outcomes, they can conduct assessments, compile detailed sleep histories, identify areas within occupational therapy’s scope of intervention, and make appropriate referrals to other health care professionals. Occupational therapy practitioners may be using routines-based approaches, environmental modifications, or sensory integration techniques to support improvements in sleep. We propose that occupational therapy practitioners can seamlessly integrate sleep-related education and interventions into their regular sessions with clients, fostering a comprehensive approach in the outpatient setting.

An increasing number of occupational therapy practitioners are gaining expertise in addressing insomnia, a common sleep disturbance seen across practice settings. Occupational therapy practitioners have the skills and knowledge base to understand insomnia and its effects on health outcomes. CBT–I is a highly efficacious, gold standard, first-line treatment (Muench et al., 2022) in which occupational therapy practitioners receive training. CBT–I has well-established clinical guidelines for evaluation and treatment. CBT–I is within the scope of occupational therapy and, paired with consultation and supervision, should be included in the occupational therapy practitioner’s tool kit (Eakman et al., 2022; Smallfield et al., 2021). There are in-person and online continuing education opportunities for CBT–I. Considering the lack of sleep practitioners, occupational therapy practitioners can become entrepreneurs and open clinics that target their community’s sleep needs.

Sleep research aligns with six of the seven research priorities established by the American Occupational Therapy Foundation (2022) and all the research priorities identified internationally for occupational therapy research (Faulkner, 2022). Occupational therapy researchers have initiated thoughtful and essential sleep research to increase our understanding of the effects of insufficient sleep on daily occupations and to bring attention to sleep as a modifiable target when supporting rehabilitation. As occupational therapy practitioners progress as sleep research champions, they have many opportunities that demand an occupational therapy lens to improve sleep measurement, intervention development, and delivery.

Research driven by occupational therapy practitioners builds on the existing literature that has focused on typically developing populations or people experiencing insomnia or psychopathology and that has primarily addressed intervention. Occupational therapy practitioners test and adapt existing interventions in novel populations (e.g., Akbarfahimi et al., 2020; Eakman et al., 2017). Recent systematic reviews by occupational therapy practitioners have identified effective evidence-based interventions in occupational therapy, including (1) sleep preparation activities (e.g., sleep education, coaching), (2) cognitive strategies (e.g., relaxation techniques), and (3) routines-based education (Beisbier & Laverdure, 2020; Gronski & Doherty, 2020; Smallfield & Molitor, 2018). At the forefront of occupational and sleep research, occupational therapy practitioner researchers trained in CBT–I are studying new populations (Eakman et al., 2022; Ludwig et al., 2020, 2024). Others are testing novel interventions using an occupational therapy lens to support sleep (Gutman et al., 2017; Sanders, 2023; Schoen et al., 2017).

Occupational therapy sleep research often uses various measures; to our knowledge, a validated, standardized occupational therapy sleep assessment does not exist. As occupational therapy practitioners, we are interested in measuring sleep and the occupational outcomes that are affected by sleep. Occupational therapy practitioners use various measurement tools developed by sleep researchers to assess sleep. Although these tools provide multifaceted measures of sleep architecture, behaviors, perceptions of sleep, and sleep health, they do not thoroughly address how sleep affects daily occupations (work, school, social life, etc.) and how sleep, as an occupation, may be influenced by personal, environmental, or occupational factors. As Tester and Foss (2018, p. 2) wrote, “The development of assessments that could measure the functional impact of sleep on life participation and daily activities, however, would aid [occupational therapy practitioners] in targeting therapeutic approaches and documenting associated outcomes,” a point that remains true today.

Occupational therapy researchers have numerous opportunities to expand sleep research. The sleep research field seeks researchers from diverse backgrounds to fight the public health epidemic of insufficient sleep. Occupational therapy researchers are missing perspectives in foundational sleep research, intervention development, and implementation research. These researchers can trial and adapt existing sleep interventions in special populations. They also can develop occupational therapy–based sleep assessments that measure sleep as an occupation. Finally, there are opportunities for occupational therapy researchers to contribute their expertise to research pertaining to sleep, such as environmental modifications, lighting effects on circadian rhythms, the effects of sensory integration on sleep, community-based sleep supports, school-based sleep education, supporting sleep during inpatient stays, and family-based interventions. When occupational therapy researchers integrate the construct of sleep into current research, both fields will expand exponentially.

Everyone has an occupational right to a good night’s sleep. Occupational therapy practitioners are well situated to use their holistic, multidimensional approaches to advance sleep education, intervention, and research. In this column, we have suggested specific means by which to incorporate the foundational occupation of sleep into entry-level and continuing education, assessment, intervention, and research endeavors. Our duty as occupational therapy practitioners is to improve and integrate our specialized knowledge into current sleep medicine practices to enhance clients’ lives.

We thank the International Sleep-oriented Group for their ongoing collaborations and support and our respective institutions.