751760

research-article2018
CNRXXX10.1177/1054773817751760Clinical Nursing ResearchLynch et al.

Research Article
Clinical Nursing Research
1­–17
Adolescent Stress © The Author(s) 2018
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DOI: 10.1177/1054773817751760
https://doi.org/10.1177/1054773817751760
Cluster Randomized journals.sagepub.com/home/cnr

Trial

Stephanie Lynch, PhD, RN, FNP, PMHNP1,

Conni DeBlieck, DNP, MSN, RN1,
Linda C. Summers, PhD, RN, FNP, PMHNP1,
Anita Reinhardt, PhD, RN1,
and Wanda Borges, PhD, RN, ANP2

Abstract
High school students experience a variety of stressors. Mental health issues
are critical to their health. The “Adolescent Stress Treatment (AST) Study:
A Cluster Randomized Trial” compared the efficacy of two stress reduction
devices, the EnergyPod™ and the SleepWing™. The EnergyPod™ is a
device that provides a semiprivate acoustical and visual environment for
rest, stress reduction, and sleep. The SleepWing™ is a smaller device
offering similar benefits. High school students were offered the opportunity
to participate in the AST study when they exhibited signs of agitation. The
students completed the Profile of Mood States–Short Form (POMS-SF)
pre- and postintervention. Total Mood Disturbance (TMD) was measured
from the POMS-SF and significant improvement postintervention (p < .001),
regardless of intervention used. POMS-SF subscales were all significantly
improved no matter which device was used. All participants in the study
dramatically improved their mood after being in either therapeutic device.

1New Mexico State University, Las Cruces, USA

2University of San Francisco, CA, USA

Corresponding Author:
Stephanie Lynch, School of Nursing, College of Health and Social Services, New Mexico State
University, 1335 International Mall, MSC: 3185, Las Cruces, NM 88003, USA.
Email: srlynch@nmsu.edu
2 Clinical Nursing Research 00(0)

Keywords
adolescents, stress, POMS (Profile of Mood States), energy pod, distress

Adolescence remains the most turbulent time of emotional and social devel-
opment in the life of humans. An increasing desire for independence and
reliance on peers for support places adolescents in the position of choosing
between “doing the right thing” and “fitting in” (Parasuraman & Shi, 2014).
Behaviors that can begin or peak in adolescence can include suicide, vio-
lence, substance use/abuse, sexually transmitted infections, and teen preg-
nancy. There may also be changes in lifestyle choices such as unhealthy diet,
lack of exercise, and lack of sleep (Aspy et al., 2012; Parasuraman & Shi,
2014). School nurses are often the source of treatment when the stress levels
become overwhelming or the behaviors result in poor outcomes, despite
many school nurses previously reporting having little training for dealing
with such behavioral emergencies (Ramos et al., 2013). Presently school
nurses have few resources to address behavioral emergencies within the
school setting. The Adolescent Stress Treatment (AST) study presents find-
ings that describe a method used when addressing behavioral emergencies in
adolescents. These methods are presently being utilized by school nurses in
four high schools in southern New Mexico.
As school nurses are now often the primary providers of mental health
services for many adolescents, they also find themselves the on-site providers
of behavioral health emergency management services (Ramos et al., 2013).
Behavioral health emergency management is defined as the initial action
undertaken by the school nurse for an urgent or emergent behavioral health
problem. Ramos and colleagues (2013) surveyed 360 nurses regarding their
experience with emergency behavioral management in the following areas
that are stressful to students and nurses: suicide, child abuse, depression, vio-
lence at school, bullying, substance abuse, alcohol abuse, and dating vio-
lence. Two thirds of the nurses reported that they had provided emergency
management for problems regarding child abuse, neglect, depression, and
violence in the previous school year. Forty percent reported that they had
little training for dealing with behavioral health emergencies, and there were
limited resources for effectively managing these emergencies. Providing
school nurses with information about effective interventions that may be used
for emergent behavioral health problems is essential. This study presents the
findings that describe two devices to address behavioral emergencies in ado-
lescents, which are presently being utilized by school nurses in four high
schools in a southwestern state.
Lynch et al. 3

Figure 1. EnergyPod™.

Background
School nurses frequently recommend agitated students lay on the nurse’s cot
until they feel calm. Agitated, anxious, or distressed students frequently
remain in the nurses’ office for long periods of time and require additional
security staff, and some students are sent home with their parents, all of
which results in missing class time.
In 2009, an EnergyPod™ (Figure 1) was purchased for a high school in
Southern New Mexico. The purpose of this device was to address fatigue due
to sleeplessness in the schools’ adolescents. One day in the fall of 2009, two
male adolescents who had been fighting were brought into the school nurses
office by the security guard. The adolescents were separated. Adolescent A
was asked to rest on the nurse’s cot and Adolescent B was offered a rest in the
EnergyPod™. Twenty minutes later, to the surprise of the nurse and the secu-
rity guard, Adolescent B emerged from the EnergyPod™ relaxed, willing,
and able to return to class. Adolescent A continued to show distress and
aggressive behavior. At that point, Adolescent A verbalized his willingness to
enter the EnergyPod™. He too emerged after 20 min, relaxed and ready to
return to class. The success of the EnergyPod™ as a stress management
device spread quickly among students, teachers, and staff. School personnel
began bringing distressed and agitated students to the school nurse to spend
time in the EnergyPod™. Students who had been previously offered the
4 Clinical Nursing Research 00(0)

EnergyPod™ returned on their own initiative requesting additional 20-min

sessions. From this point onward, the school nurse placed distressed and agi-
tated adolescents in the EnergyPod™. While anecdotally the EnergyPod™
decreased stress in adolescents, no published literature was found to demon-
strate this effect.

Literature Review
Adolescent participation in risky lifestyle activities and behaviors that cause
injuries, substance use and abuse, early and unprotected involvement in sex-
ual behaviors, inadequate exercise, and poor dietary patterns can lead to
adverse health outcomes in the short-term and chronic diseases in adulthood
(Aspy et al., 2012; Summers, 2003; Summers et al., 2003). Based on the cur-
rent knowledge, the percentage of adolescents at high risk is expected to
increase, and the overall health status of adolescents is expected to decrease
over the next few decades. Stress in adolescents can lead them to risky
behaviors.
Among health care providers, there is a concern about the provider’s abil-
ity to intervene in a stressful situation (Ramos, Sebastian, Stumbo, McGrath,
& Fairbrother, 2017; Summers et al., 2003). Ramos purported that from 540
adolescents who had visited school-based health centers (SBHCs), 47.4%
had at least one unmet need for guidance from the provider, with 18% describ-
ing stress as the unmet need. In a survey of 1,611 adolescents involving ado-
lescent disclosure of important health issues, Summers et al. (2003) found
that adolescents spoke infrequently with nurses or physicians about impor-
tant health care concerns, and regardless to whom adolescents spoke, they
found the information “useless” 74% of the time. The researchers also found
a relationship between gender and health disclosure: Girls were more likely
to disclose health problems to someone, most often their peers. Regardless of
gender, the majority of adolescents in the study admitted to riding with a
driver who had been drinking. This illustrates the need for health care provid-
ers to elicit disclosure thereby avoiding lost opportunities for intervention at
every contact point between the adolescent and a responsible adult.
Many factors contributing to an adolescent’s capability to manage stress-
ful triggers in his or her environment contribute to their repertoire of biopsy-
chosocial behaviors. Numerous studies have addressed adolescent stress and
a variety of coping strategies. In Clarke’s (2006) meta-analysis of interper-
sonal stress and psychosocial health among children and adolescents, the
analysis of 40 studies found that youth “engaged in active coping strategies
had fewer problems and higher social competence” when “compared to those
who used active coping in uncontrollable stressors” (p. 11). Another study
Lynch et al. 5

showed it is possible to teach young people skills to work with mental stress,
everyday life, and other stressors. The investigators purported that through
the most stressful part of the school year—that is, testing students—they had
reduced stress and better outcomes (Kuyken et al., 2013).
Several studies have found a gender difference related to stress. It was
found that for adolescents, a difference in perceived stress was tied to two
areas: relationships with peers (girls more so than boys) and romantic rela-
tionships (boys more so than girls) (Seiffge-Krenke, Aunola, & Nurmi, 2009;
Zhang, Yan, Zhao, & Yuan, 2015). Batada, Chandra, and King (2006) found
a gender difference in ways adolescents cope with stress. Girls were more
likely to prefer active coping styles than boys. An example of active coping
was seeking out support and information (Batada et al., 2006; Rodriguez-
Naranjo & Cano, 2016). In a similar study by Brown, Nobiling, Teufel, and
Birch (2011), adolescent girls admitted to distress about the future, worrying
about social problems such as fitting in and social acceptance, especially as
tied to their appearance. Boys frequently identified distress about the future,
but, as consistent with previous research, were less likely to talk about it
(Brown et al., 2011; Brown, Teufel, Birch, & Kancherla, 2006).
Adolescents’ daily schedule usually involves structured activities, such as
school, homework, as well as after-school events. Unstructured time includes
watching television, playing video games, and/or socializing with friends.
American teens spend 50% more waking hours participating in after-school
activities and unstructured time than East Asian or European teens (Noland,
Price, Dake, & Telljohann, 2009). However, adolescents who engage in three
or more activities were more likely to be stressed.
Noland et al. (2009) found that the majority of adolescents they studied
did not get enough sleep. Hildenbrand, Daly, Nicholls, Brooks-Holliday, and
Kloss (2013) also found adolescents who reported less sleep on weeknights
resulted in tiredness during the day, difficulty paying attention, lower grades,
and increased stress. Short and Louca (2015) determined adolescent mood
worsened following sleep deprivation, with females having elevated anxiety
and depressed mood following just one night without sleep.
In a meta-analysis of school programs to address stress management in
children and adolescents, Kraag, Zeegers, Kok, Hosman, and Abu-Saad
(2006) found that school programs offering stress management or coping
skills support were effective in enhancing coping and reducing stress.
Utilizing a primary prevention program approach in schools, stress manage-
ment training focusing on mental health was effective for the students; these
programs show promise for adolescent stress management (Kraag et al.,
2006). Obviously, the prevalence of stress and sleeplessness can have an
impact on adolescents and their school performance and interaction with
6 Clinical Nursing Research 00(0)

Figure 2. SleepWing™.

others (McCalla et al., 2012). If schools can find an efficacious way to

decrease these behavioral concerns, the beneficial effects of the learning
environment will be supported.

Purpose of Study
The purpose of this study was to examine the beneficial effects of the
EnergyPod™ and the SleepWing™ (Figure 2) on indicators of distress such
as anxiety, anger, depression, and fatigue levels. These indicators were
recorded using the Profile of Mood States–Short Form (POMS-SF) question-
naire. Recognizing not all schools would be able to obtain an EnergyPod™
due to cost or space requirements, the researchers were able to secure a por-
table device called the SleepWing™. The efficacy of the SleepWing™ com-
pared with the EnergyPod™ in decreasing psychological distress and
agitation in adolescents in the high school setting was explored in this study.

Hypotheses
Hypothesis 1: The major hypothesis was that participants in this study
would show an improvement in their mood after being in the EnergyPod™
or the SleepWing™ for 20 minutes.
Hypothesis 2: The second was that there would be a difference in Total
Mood Disturbance (TMD) scores between participants who used the
EnergyPod™ or the SleepWing™.
Lynch et al. 7

Hypothesis 3: There will be a change in blood pressure and pulse rate in

anxious/agitated adolescents after using the EnergyPod™ or the
SleepWing™ for 20 minutes.

Method
The study design was a cluster-randomized equivalency trial. This method
was used to compare two different interventions (energy pod and the sleep
wing) to compare intervention outcome. By definition, an equivalency trial is
the statistical test that aims at demonstrating that there are no relevant differ-
ences between the two treatments. A key element of cluster randomization is
that inferences are frequently applied at the individual level despite random-
ization being at the group level.
The study was approved by the university institutional review board and
the review boards for the four high schools in this study. Written permission
was obtained from Multi-Health Systems Incorporated to use POMS-SF tool
for this study.
The authors had no conflict of interest associated to the SleepWing™ or
the EnergyPod™, no monetary interest, association or ownership with the
manufacturer MetroNaps, or any other financial gain to any entity. The uni-
versity institutional review board and the administration of two school dis-
tricts in Southern New Mexico approved the study.

Sample
All adolescents presenting for care at four SBHCs located in Southern New
Mexico from March 1, 2012, to May 4, 2012, who were identified by the nurse
practitioners with agitation, anxiety, fatigue, irritability, and/or stress were offered
an opportunity to participate in this study. The exclusion criteria were adolescents
who could not read or write in English. Adolescents who agree to participate in
this study were referred to the clinic coordinator for random assignment based on
the study intervention, the SleepWing™ or the EnergyPod™. A local computer
was used to run a randomization software, which provided a list of two groups,
Group A (EnergyPod™) and Group B (SleepWing™). One hundred students
between the ages of 14 and 19 agreed to participate in the study.

Setting
The students were seen in the school-based health clinics of four high schools
in boarder communities of a southwest state of the United States. Each site
used in the study was a high school based SBHC that supports the health care
of adolescent students. Four SBHC sites were used for a total of 100
8 Clinical Nursing Research 00(0)

participants. These sites were supported by Adolescent Services, which is a

dedicated interdisciplinary, interagency consortium. Adolescent Services is a
nonprofit organization, who employ nurse practitioners and health care disci-
plines to support adolescents’ physical and emotional well-being at the SBHC.

Tools/Interventions
The POMS-SF™ is a questionnaire designed to assess current mood states
(Lin, Hsaio, & Wang, 2014; McNair, Lorr, & Droppleman, 1992). POMS™
investigations have shown it to be “predictive and construct validity of the 6
POMS™ subscales measuring anxiety, depression, anger, confusion, vigor,
and fatigue, and the POMS™ TMD score in different patient and subject
populations” (Wyrwich & Yu, 2011, p. 1111). Furthermore the POMS™ has
“demonstrated validity to evaluate patient change over time to therapeutic
interventions, especially short-term treatments, and has differentiated the
effects of experimental manipulations of mood in normal and cancer patients”
(Wyrwich & Yu, 2011, p. 1111).
The POMS-SF™, developed by Shacham in 1983, consists of 30 descrip-
tive objective items developed to measure six aspects of mood (anxiety–ten-
sion); assess as subjective, state, and somatic experience of anxiety
(depression–dejection); assess feelings of inadequacy, isolation, guilt, futil-
ity, and sadness (anger–hostility); examine overt hostility and irritability
(confusion–bewilderment); assess efficiency of clarity of thinking (vigor–
activity); examine well-being enthusiasm, liveliness, energy, and optimism
(fatigue–inertia); and assess feelings of weariness and friendship (McNair
et al., 1992; Shacham, 1983; Souissi et al., 2012; Wyrwich & Yu, 2011).
Responses to a 5-point scale, each item range from (0 = not at all to 4 =
extremely), with higher scores indicating more negative mood. To generate
the POMS™ TMD score, the Vigor subscale score, created from responses to
positively worded items (e.g., lively, active), is subtracted from the sum of
the five other subscale scores to yield a TMD score ranging from 32 (best
possible TMD score) to 200 (worst possible TMD score) (DiLorenzo,
Bovbjerg, Montgomery, Valdimarsdottir, & Jacobsen, 1999; McNair et al.,
1992; Souissi et al., 2012; Wyrwich & Yu, 2011).
The POMS-SF™ was used in studies, such as Rodrigue, Widows, and Baz
(2006), which measured the current mood status of the caregiver of lung
transplant patient. Furthermore, the POMS-SF™ has been used in yoga,
sports, and physical education psychology studies of adolescent samples
(Noggle, Steiner, Minami, & Khalsa, 2012). In Lefaiver, Keough, Letizia,
and Lanuza (2009), the POMS-SF™ was used to measure the “psychology
affects of moods of caregivers and lung transplant candidates” (p. 144). Other
Lynch et al. 9

studies, such as Hills, Paice, Cameron, and Shott (2005) and Giesbrecht,
Smeets, Merckelbach, and Jelicic (2007), used the POMS™ to study persis-
tent mood reactions to current life situations. In another study, the POMS was
used with adolescents to measure mood across time following one night with-
out sleep (Short & Louca, 2015).

EnergyPod™.  The EnergyPod™ (MetroNaps, Inc.) is the world’s first chair

designed specifically for napping. Based on years of research, the Energy-
Pod™ is an innovative and elegant solution to the modern problem of where
to take a brief nap at work. The sphere design provides a semiprivate environ-
ment with privacy from a visor for additional seclusion. The EnergyPod™
unit has a built in timer and music player. After the 20-min rest, the unit effec-
tively wakes the user in a gentle manner with a programmable combination of
lights and vibration. This device has been utilized in a number of settings from
hospital on-call rooms to pilot resting areas. It has been found to improve the
functioning of medical residents when compared with mid-day naps (Amin
et al., 2012). The EnergyPod™ has been used in the SBHC since 2009.

SleepWing™. Similar in approach to the EnergyPod™, the SleepWing™

(MetroNaps, Inc.) is designed as a sophisticated alarm clock and usage moni-
tor specifically for short-term rest facilities. The SleepWing™ has an air-
plane wing-like design, combined with an alarm clock with a status indicator
and usage tracker. The SleepWing™ device is much smaller than the Energy-
Pod™ and considerably less costly. The SleepWing™ was used with a cot
available in the SBHC. Students would lay down on the cot and headphones
were applied. After 20 min of rest, the unit would wake them in a gentle
vibrating manner.

SBHC training.  The primary investigator (PI) of the study contacted each site
and provided training to both the coordinators and the health care providers
about the study, the protocol, and the reporting of the participation. Collab-
orative partners in the study picked up the sealed completed data envelopes
on a weekly basis during the time of the study. All data were delivered to the
study PI prior to data analysis.
Each study sight was provided with 25 packets for adolescent participants
who were to be included in the study. The packets contained a Demographic
Information Form, two consent forms (one for record keeping and the other
for the participant to keep), two copies of the POMS™ survey tool (pre- and
postintervention), and an envelope with a subject study number and a random
assignment to either the EnergyPod™ (A) or the SleepWing™ (B)
intervention.
10 Clinical Nursing Research 00(0)

Study Protocol
The students who came to the SBHC were screened using the usual protocol,
then seen by the licensed health care provider. The provider evaluated the
student and determined whether the stress intervention would be helpful and
then notified the clinic coordinator of a potential participant for inclusion in
the stress intervention study. The coordinator asked the students whether they
had participated in the study at a prior time, and if they said no, then the study
was explained and they were asked to participate. If the students had partici-
pated at a prior time, they were thanked for their time but not included a
second time in the study. The students could then be referred to either stress
reduction device but not included in the data collection.
The student that was eligible and wished to be included in the study was
asked to sign the consent. Parental consent was waved for this study while
ensuring that the adolescent signed an informed consent after the study was
explained. Children and adolescents are considered protected under Federal
Regulation 45 Code of Federal Regulations (CFR) Form 46. New Mexico
Law 32A-6A-15 gives children 14 years of age or older capacity to consent
for the following services:

A child fourteen years of age or older is presumed to have capacity to consent

to treatment (individual psychotherapy, group psychotherapy, guidance
counseling, case management, behavior therapy, family therapy, counseling,
substance abuse treatment or other forms of verbal treatment that do not include
aversive interventions).

The coordinator then completed the Demographic Information Form and

recorded the identification number correlated with adolescent participant’s
blood pressure and heart rate. Names of the students were not written on the
demographic sheet; however, there was a master list with names and correlat-
ing identification numbers. Once the consent was signed and vital signs were
documented, the intervention envelope was opened and the participant and
coordinator were informed of the intervention device to which the adolescent
was assigned. The study number and intervention (A or B) along with the
coordinator initials were then entered on the Demographic Information Form.
At that time, the adolescent participant was asked to complete the POMS™
and identify it as the “pre” survey tool. Their study identification number was
also written on the POMS™. The “pre” POMS™ was used to assess their
mood prior to the intervention.
If the participant was randomized to Intervention Group A, they were
placed in the EnergyPod™ for 20 min. If the participant was in Intervention
Group B, they were placed on the cot with the SleepWing™ for 20 min. After
Lynch et al. 11

20 min, the coordinator took the adolescent participant’s blood pressure and
heart rate, recording these vital signs on the Demographic Information Form.
The participant then completed the POMS™ “post” survey tool to identify
whether the intervention had an effect. After the survey tool was completed,
the adolescent was asked, “How are you feeling?” and if the adolescent had a
self-identified improvement, the student was then sent back to class. However,
if there was no self-identified improvement, the adolescent was seen by the
health care provider again for further evaluation.
A log from the PI was kept by the coordinators with the participant’s name
and subject ID number to ensure no duplication of participants. This was kept
in a locked file during the data collection period at the SBHC and was given
to the PI upon completion of data collection and destroyed.

Results
In the AST study, there were a total of 99 students. One student did not com-
plete the postsurvey. Of the 99 students who completed the study, 47 were
assigned to Intervention Group A: the EnergyPod™, and 52 were assigned to
Intervention Group B: the SleepWing™. Of these students, 76 were Hispanic
(77%) and 23 were non-Hispanic (23%). The grade levels were ninth through
12th. Thirteen were ninth graders, 27 were 10th graders, 25 were 11th graders,
30 were 12th graders, and four students’ grade level was unidentified. The
mean age of these students was 17 years, with an age range of 14 to 20 years.
The gender breakdown was 74 females (75%) and 25 males (25%) (Table 1).

Analyses
Using SPSS Version 22 (IBM Corporation), an ANOVA within groups and
between groups was used to determine whether there was a difference in age
or TMD Scores between the four high schools. Chi-square was used to deter-
mine whether ethnicity or gender was different between the four high schools.
Paired-sample t tests were run to compare pre- and postintervention Total
Mood Disorder scores, and subscale scores are provided in Table 2.
A statistically significant difference was found in the total TMD (t = 10.24,
df = 75, p < .0001) and all TMD subscales between preintervention and pos-
tintervention. All participants in the study showed an improvement in their
mood after being in the SleepWing™ or the EnergyPod™ for 20 min.
Secondary outcomes of stress that were used, such as pulse rate and systolic
blood pressure, did not change after the intervention.
The four high schools demonstrated no statistically significant difference
between the schools in gender, ethnicity, and/or age. There was no
12 Clinical Nursing Research 00(0)

Table 1.  Baseline Demographics and Clinical Characteristics.

statistically significant difference between postintervention TMD scores or

any of the TMD subscales on the POMS-SF™ . No significant difference was
noted on the preintervention TMD score (t = –.0288, df = 83, p = .77) or TMD
subscales between participants who used the EnergyPod™ or the
SleepWing™. There was no statistically significance difference in postinter-
vention TMD scores between participants who were placed in the
EnergyPod™ compared with those who placed in the SleepWing™ (t =
–0.568, df = 87, p = .57).

Discussion
Data exist demonstrating an association between sleep and school violence
behaviors (Hildenbrand et al., 2013), as well as improved cognitive function
following a nap using the EnergyPod™ (Amin et al., 2012). The findings in
this study indicate that the EnergyPod™ and the SleepWing™, which pro-
mote a short nap, improve TMD scores, as well as all subscale scores. A
decrease in stress and agitation in adolescents in this study was found, which
supports the anecdotal evidence these schools have been experiencing for
several years.
Current literature suggests that in many cases, this population is being left
out of certain studies that require adolescent ascent and parental consent. An
important part of this study was obtaining institutional review board approval
Lynch et al. 13

Table 2.  Paired-Sample Test.

95% confidence
interval of the
difference Significance
(two-
  Paired differences M SD SE M Lower Upper t df tailed)

Pair 3 PreTense– 4.398 3.794 0.393 3.616 5.179 11.179 92 .000

PostTense
Pair 4 PreDepression– 3.198 3.571 0.364 2.474 3.921 8.775 95 .000
PostDepression
Pair 5 PreAnger– 3.896 4.226 0.431 3.039 4.752 9.032 95 .000
PostAnger
Pair 6 PreVigor– 1.242 3.659 0.384 0.480 2.004 3.238 90 .002
PostVigor
Pair 7 PreFatigue– 4.330 3.461 0.363 3.609 5.050 11.933 90 .000
PostFatigue
Pair 8 PreConfuse– 2.667 3.395 0.352 1.967 3.366 7.574 92 .000
PostConfuse
Pair 9 PreTMD– 18.039 15.364 1.762 14.529 21.550 10.236 75 .000
PostTMD

Note. TMD = Total Mood Disturbance.

without parental consent. Adolescents are considered a vulnerable and pro-

tected population. Parental consent was waived for this study while ensuring
that the adolescent signed an informed consent after the study was explained.
Children and adolescents are considered protected under Federal Regulation
45 CFR Form 46. New Mexico Law 32A-6A-15 gives children 14 years of
age or older capacity to consent for nonaversive mental health treatment.
Therefore, the adolescents in this study were able to choose the noninvasive
intervention for treatment of their agitation, anxiety, and/or distress without
parental consent.

Implications for School Nurses

School nurses often play a central role in the prevention, assessment, referral,
and follow-up care of adolescents experiencing a behavioral emergency.
With the EnergyPod™ or the SleepWing™, school nurses have an interven-
tion, which can help de-escalate students experiencing agitation, anxiety, irri-
tability, stress, as well as fatigue. All students in the study returned to class
after a simple, 20-min session, instead of having the student lay on a cot until
they felt better without resolution of the problem. In this study, the
SleepWing™ was as effective as the EnergyPod™, suggesting that this much
14 Clinical Nursing Research 00(0)

smaller device could be a feasible method of managing emergent behavioral

health problems in school sites with limited space.

Limitations
The AST study was located in SBHCs located in four high schools in south-
ern New Mexico. These schools had a predominantly Hispanic student popu-
lation. This sample may not represent all regions of the United States.
Power analyses indicated a sufficient sample size to detect moderate effect
size of the interventions (Lipsey, 1990), yet it was not powered to examine
intervention and gender differences. A larger sample would have allowed for
examination of the interaction effect of gender, ethnicity, and the intervention
on the outcome variables. Future research in this area will benefit from sam-
ple participants collected at multiple sites in different regions of the country
to improve generalizability.
The authors recognize that the results of the study reflect an immediate
mood response of the EnergyPod™ and the SleepWing™. Further studies
could include a follow-up of the student to evaluate the duration of the mood
response. Stronger causal inferences could be made with a longitudinal
approach. Data collected across time—for example, the initial visit, a few
weeks after the initial visit, and at 3 months—would allow consideration of
patterns of change over time.
The researchers chose not to include a control group due to the school
requirement of necessary interventions with agitated adolescents at these
school sites and the school personnel anecdotal experience with the success
of the EnergyPod™ in de-escalating students. Students were not given the
opportunity to lay in the cot in the nurses office, which is what normally
would occur in typically in the school nurses office in high schools without
this equipment. Future studies may incorporate napping in a cot compared
with using the devices in this study.

Conclusion
The EnergyPod™ and the SleepWing™ were both successful in decreasing
anxiety and stress in this population by offering an objective measure via the
POMS. The SleepWing™, however, offers a lower cost alternative to schools
that lack the funding to purchase the EnergyPod™. In addition, the
SleepWing™ offers a space saving option. Study results were shared with
school nurses, school personnel, and administration.
The students at all four high school sites continue to use the EnergyPod™
daily. Anecdotal reports from the school nurses indicate that teachers and staff
Lynch et al. 15

are using the EnergyPod™ for various issues, including stress reduction and
headache management. In addition, the SleepWing™ has been donated to the
school nurses at three other local high schools not previously in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

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Author Biographies
Stephanie Lynch, PhD, RN, FNP, PMHNP, is an assistant professor in the School of
Nursing in the College of Health and Social Services at New Mexico State University.
She works as the director of the Doctorate of Nursing Practice Program.
Conni DeBlieck, DNP, MSN, RN, is an assistant professor in the School of Nursing
in the College of Health and Social Services at New Mexico State University. She
works as the director of the RN/BSN (Registered Nurse to Bachelor’s of Science in
Nursing) program.
Linda C. Summers, PhD, RN, FNP, PMHNP, is an associate professor in the School
of Nursing in the College of Health and Social Services at New Mexico State
University. She works as the director for the Family Nurse Practitioner Program.
Anita Reinhardt, PhD, RN, is an associate professor in the School of Nursing in the
College of Health and Social Services at New Mexico State University. She works as
the associate director for the Undergraduate Nursing Programs.
Wanda Borges, PhD, RN, ANP, is an associate professor in the School of Nursing
and Health Professions at University of San Francisco. She works as the associate
dean for the Graduate Programs and Community Partnerships.