1.1. Sample

The research question was designed using the PCC strategy, where P stands for “Participants,” C for “Concept,” and C for “Context.” The “Participants” - preschool-aged children’s parents, the “Concept” - Sleep Hygiene and Parental Empowerment, and the “Context” - all contexts involving parents of preschool-aged children, leading to the following research question: What is the available scientific evidence on strategies that promote parental empowerment in the sleep hygiene habits of preschool-aged children? The search had no time limit up to the date of data extraction and included sources in Portuguese, English, and Spanish that met the eligibility criteria:

(1) Population - all articles addressing parents of children aged three to six years (preschool age) without any pathology that could influence sleep (^{Festas et al., 2020});

(2) Concept - sleep hygiene is characterized by a set of consistently applied, age-appropriate rules and routines (LIahuno et al., 2021; ^{Stasio et al., 2020}; Mindell & Williamson, 2017; Ordem dos Enfermeiros, 2023). Regarding parental empowerment, the concept of Empowerment emerges: a process where the family is the resource, and the nurse facilitates decision-making. Empowerment involves providing parents with tools, resources, and an appropriate environment to achieve the desired goals (Ramos, 2020). Thus, enabling parental empowerment, defined by collaborative actions with parents to make them capable of protecting their children’s health, redefining the parental role (^{Haddad & Toney-Butler, 2020}; ^{Hockenberry & Wilson, 2014}). Parental education programs aim to enable parents to care for their children and increase their knowledge about child development, using the most appropriate strategies. Given its importance, this intervention is included in the ‘Plano Nacional de Saúde Infantil e Juvenil’ as a nursing intervention aimed to empower parents (Ramos, 2020; ^{Direção-Geral de Saúde, 2013});

(3) Context - intra-hospital (inpatient and paediatric consultations) and extra-hospital (primary healthcare, school, extracurricular activities) related to Child and Paediatric Health.

1.2. Research Strategy

The research process occurred in three phases: initially, preliminary research was conducted in the CINAHL, MEDLINE, and COCHRANE databases, the ‘Repositório Científico de Acesso Aberto de Portugal’ and in the ‘Biblioteca Virtual da Saúde’ using the initially defined keywords. By analysing titles, abstracts, and indexed terms, other relevant discriminators were identified, defining the Boolean phrase based on the PCC mnemonic (Population/Concept/Context): (“parent* AND “child, preschool” AND (“sleep” OR “sleep habits” OR “sleep hygiene”) AND (“Education” OR “Training Programs” OR “Educational Activities” OR “Literacy programs” OR “Empowerment”). The Boolean phrase used the operators (OR), (AND), and (*) to include all variations of the same word.

Subsequently, the Boolean phrase was adapted to each database and grey literature, and the references of the articles were analysed to identify any additional sources that might not have been included. Results were exported using a reference manager - Endnote®. Duplicated references were excluded, and the articles were then analysed and selected.

1.3. Data Collection Instruments

Independently, two researchers analysed the studies by title, abstract, and full text, based on the defined eligibility criteria. In cases of disagreement, a third researcher decided on the study’s inclusion. To address the review question, data extraction was performed using a table developed in the protocol, based on Joanna Briggs Institute guidelines (Joanna Briggs Institute, 2015), recording the most relevant study characteristics and the main evidence found.

School Health Education Programs on Sleep

A promising approach to promoting sleep habits is implementing educational programs in school settings (Llaguno et al., 2020). Schools are privileged spaces where collaboration between health professionals, school staff, and families allows for health promotion through curriculum inclusion (Trindade & Ramos, 2020; ^{Wing et al., 2015}).

These educational interventions can be led by teachers in the classroom after receiving training provided by nurses (^{Schneider et al., 2022}). Programs like those described by ^{Bonuck et al. (2022}) and ^{Wilson et al. (2014}) typically last around two weeks, with 40-minute interactive sessions that use playful materials such as books, teddy bears, and music. These activities can involve parents and raise children's awareness of the importance of sleep routines. The use of educational materials facilitates understanding and sparks children's interest, contributing to improved sleep habits for the entire family (Llaguno et al., 2020).

Moreover, maintaining a partnership with parents proves beneficial and enriching for achieving better outcomes in paediatrics. The ‘Enfermeiro Especialista em Saúde Infantil e Pediátrica’ (EESIP) is the health professional who accompanies the child and family during a crucial phase, making it essential to recognize their needs and intervene based on Anne Casey's Partnership-in-Care Model, which considers parents active partners in their child's care (^{Monteiro & Cerqueira, 2020}). By providing family-centered care, the EESIP acknowledges the family's crucial role, considering all its specificities (^{Salustino et al., 2022}). Thus, a partnership can be established between the nurse, child, and parents to achieve maximum quality of life and well-being for the child (^{Hockenberry & Wilson, 2014}). This relationship is based on appropriate, effective, and bidirectional communication, where care negotiation is key (the EESIP recognizes the needs, beliefs, desires, and capabilities of the child and family and reaches an agreement regarding the care provided and each participant's role) (^{Nobre et al., 2023}).

It is important to create teaching opportunities for parents within child care. In the School Health Education field, involving parents in training activities enhances their knowledge and skills related to sleep hygiene routines, enabling empowerment and self-efficacy perception, aiming to prevent long-term sleep issues (Direção-Geral de Saúde, 2015; ^{Kitsaras et al., 2018}; ^{Bonuck et al., 2022}; ^{Wilson et al., 2014}; Llaguno et al., 2020).

To promote parental empowerment in managing children's sleep routines, programs like those by ^{Bonuck et al. (2022}) and ^{Wilson et al. (2014}) include a 40-minute interactive workshop to enhance parents’ knowledge about sleep and its importance for child development. The workshop covers recommended sleep durations by age and strategies to establish and maintain proper sleep routines. Wilson et al. (2014) also propose providing a guide with tips and strategies to help parents manage children’s sleep routines.

Health education programs aimed at parents facilitate knowledge acquisition, promoting the management of children's sleep routines. This helps create a home environment that supports healthy sleep habits, contributing to children’s well-being and development (^{Kitsaras et al., 2018}). Besides workshops, more personalized interventions like one-on-one or small group discussions are essential for addressing parents’ specific needs. These formats provide a safe space for parents to ask questions and understand which strategies are most suitable for their children (^{Bonuck et al., 2022}).

For these programs to be implemented in schools, teacher training is essential. Given the complexity of the topic, it is important to offer opportunities for teachers to develop teamwork and communication skills, enabling them to understand children's fears, concerns, and beliefs (^{Direção-Geral de Saúde, 2015}). In ^{Wilson et al.'s (2014}) program, a 45-minute interactive workshop is proposed for teachers covering several topics: the importance of sleep, recommended sleep hours by age, and effective strategies for establishing and maintaining good sleep routines. The session allows teachers to clarify doubts and share opinions, helping them feel confident addressing this topic with children. Throughout the program, teachers have access to tools to motivate children and support learning (educational posters, teddy bears, books, calendars, etc.) (Wilson et al., 2014).

The results suggest that a combined approach with classroom educational programs for children, workshops with individualized support for parents, alongside workshops for teachers, can be effective interventions for children and empower parents. Nurses, as educators and health facilitators, play a crucial role in implementing these interventions through a partnership with parents and teachers, contributing to children's and families’ overall well-being (^{Silva et al., 2018}).

For such program to be successful, it must be planned according to the population's needs, assessed, and monitored to ensure the goals are being met. ^{Wilson et al. (2014}) developed a questionnaire and sleep diary for parents to complete before program implementation, aiming to identify difficulties, routines, and sleep habits to adjust interventions. Completing these tools during and after the program helps assess results, track progress, and adjust activities to ensure success (Wilson et al., 2014).

Other studies, such as ^{Owens et al. (2011}), highlight the importance of promoting healthy sleep not just for children but for the whole family. They emphasize using educational opportunities, such as museum visits, to creatively and playfully educate parents about sleep habits.

Additionally, aligning with technological advances, ^{Yoshizaki et al. (2023}) conducted a study offering a smartphone app called ‘Nenni Vani.’ The app provides personalized guidance based on family needs, using notifications and explanatory videos to remind parents of daily routines. The app proved effective in increasing parents’ adherence and motivation (Yoshizaki et al., 2023).

Anticipatory Guidance Programs

Another effective approach is anticipatory guidance, which focuses on child health promotion and fosters an active relationship between nurses and parents. This relationship aims to prepare parents to perform their parenting roles with greater confidence and competence. During the child development, parents often face doubts and challenges. Nurses play a key role by providing information that boosts parents’ sense of self-efficacy and equips them to handle these challenges (^{Burlamaqui et al., 2024}).

Several studies highlight that families actively seek parenting information and appreciate access to educational materials, whether printed or digital (^{Blank, 2003}). In this context, child and family-centred care becomes even more relevant, especially regarding the role of nurses. These professionals strategically use points of contact to recognize family competencies and increase knowledge, particularly concerning sleep hygiene (Trindade & Ramos, 2020). Anticipatory guidance can be integrated into parental education, especially during parenting preparation courses and throughout child development consultations (^{Burlamaqui et al., 2024}). ^{High et al. (1998}) suggest nurses use these opportunities to teach parents about age-appropriate sleep hygiene practices and provide educational materials that facilitate understanding.

Among the various educational strategies, offering age-appropriate children's books to encourage bedtime reading is notable. This practice promotes children's autonomy in falling asleep and reduces nighttime awakenings (^{High et al., 1998}). ^{Halal and Nunes (2018}) support this approach, emphasizing that calming activities like reading should be encouraged 20 to 30 minutes before bedtime, facilitating sleep onset and promoting a more restful environment.

Educational Programs for Sleep Disorders

Nurses intervene early through school health education and anticipatory guidance to promote healthy sleep and prevent issues. When a child struggles with sleep, it impacts not only the child but also the family’s daily life. In such cases, the intervention focuses on resolving the identified sleep disorder (^{Salavessa & Vilariça, 2009}).

Sleep problems, though often underestimated, are common in children and cause significant concern and anxiety among parents (^{Salavessa & Vilariça, 2009}). A key strategy to empower parents is implementing educational programs to manage sleep issues.

During healthcare encounters, nurses collect data to identify sleep-related problems, enabling early and appropriate intervention to minimize short- and long-term impacts (^{Salavessa & Vilariça, 2009}; ^{Torres et al., 2021}).

^{Folgueiras et al. (2017}) propose conducting an initial interview with parents during Child and Youth Health Consultations to collect relevant information (sleep routines, sleep duration, and quality) (^{Torres et al., 2021}). They also recommend using a questionnaire and sleep diary to assess parental difficulties in managing sleep routines and better understand children's specific needs (^{Ogundele & Yemula, 2022}).

Several questionnaires can be used by nurses to assess children’s sleep, with the most common being the Children’s Sleep Habits Questionnaire, validated in Portugal as the Child Sleep Habits Questionnaire. This tool, in its full or shortened version, is used to screen for sleep problems, assess sleep habits, and monitor results (^{Loureiro et al., 2013}). Children’s self-reported sleep diaries can assess individual needs, but due to the cognitive development of preschoolers, understanding and self-assessment can be difficult. Therefore, tools like the Sleep Self Report (validated in Portugal) are best applied from age seven or used with younger children through parental collaboration (Loureiro et al., 2013).

Based on the collected data, ^{Folgueiras et al. (2017}) advocate for tailored educational interventions, encouraging parents to adopt healthy sleep habits to prevent more severe future consequences. Since sleep hygiene strategies are the first line of treatment for paediatric sleep issues, nurses must focus their interventions on educating children, parents, and caregivers (^{Ogundele & Yemula, 2022}). Child and Youth Health Consultations, besides being ideal for data collection and identifying problems, are also ideal for teaching parents, empowering them to manage sleep routines at home (Folgueiras et al., 2017). To complement oral teaching, distributing educational materials (leaflets, posters, videos) or recommending relevant books (e.g., Estivill’s ‘Duérmete Niño’) helps consolidate concepts and increase parents' confidence (Folgueiras et al., 2017; ^{High et al., 1998}). After providing theoretical knowledge, it is important to help parents identify sleep routines best suited to their child’s individual needs. Nurses should then offer specific, personalized advice to support routine management (High et al., 1998).

Results show that nurses' involvement in sleep disorder education programs empowers parents to effectively manage sleep routines at home, improving children's quality of life.

Parental Education Program Based on the Theory of Self-Efficacy (^{Bandura, 1986})

According to the assumptions of the Transactional Model (2010), the behaviours adopted by parents regarding their children’s sleep influence the quality of the child’s sleep, and vice versa. In this way, another effective strategy for empowering parents on this topic is the use of Parental Education Programs Based on the Theory of Self-Efficacy (^{Bandura, 1986}; ^{Silva et al., 2018}).

Children’s sleep affects various areas of their growth and development, making it a crucial area of intervention, particularly in paediatric age groups (Liahuno et al., 2021). Given the complexity of the topic, it is observed that although sleep is an important area, it is still a subject that is rarely addressed (^{Honaker & Meltzer, 2016}).

Through sleep hygiene, parents can influence the initiation and maintenance of their children’s sleep. With the aim of preventing, identifying, and managing sleep problems, nurses play a fundamental role by contributing to parental education and empowerment through interventions that enhance their knowledge and skills in this area (^{Silva et al., 2018}).

Regarding the role of parents in managing sleep hygiene routines, it is essential to explore the concept of parental empowerment. This is defined as the process through which parents adopt an active role in caring for their children, seeking solutions to problems, and strengthening the positive aspects of family dynamics (^{Oliveira et al., 2020}). Parental empowerment is intrinsically linked to parental self-efficacy, which refers to the parents’ perception of their role and their capabilities to carry out parenting responsibilities (Bandura, 1997; ^{Dumka et al., 2010}).

Parental self-efficacy is influenced by the balance between parental knowledge and their ability to act. The greater the self-efficacy, the more likely parents are to overcome challenges and achieve their goals. This concept is characterized by the recognition, on the part of parents, of their competence to influence their children’s behaviour and to promote adjustment appropriate to their development (^{Cotrim & Neto, 2021}).

Studies show that high levels of parental self-efficacy are associated with more positive and effective parenting practices, which in turn support empowerment (^{Glatz & Buchanan, 2023}). Thus, it becomes evident that strengthening self-efficacy should be a focus of nurses, particularly in supporting the development of strategies that aim to improve parent-child interactions and facilitate the management of family routines.

Parental education plays a crucial role in promoting healthy sleep habits in children, making it essential that parents recognize the challenges and are willing to learn and improve their skills. In this context, parental self-efficacy emerges as a key factor for the successful management of sleep hygiene routines. Studies show that higher levels of self-efficacy in parents are associated with a reduction in children's screen time, resulting in a significant improvement in sleep quality (^{Lin et al., 2020}).

To foster parental empowerment, strategies that promote increased parental self-efficacy are recommended. ^{Lin et al. (2020}) propose a parental education program for parents of preschool-aged children. This program consists of weekly sessions of approximately 50 minutes, held over eight weeks. During these sessions, parents could share knowledge and experiences through participatory activities, aimed at equipping them to properly manage their children's sleep hygiene routines, including reducing screen time.

To complement the sessions, a pocket-sized booklet is provided with a summary of the most relevant guidelines. This practical resource offers parents a quick and accessible reference tool, reinforcing their self-confidence and supporting the proper management of their children’s sleep (^{Lin et al., 2020}).

Additionally, the sessions include activities such as roleplay and discussion groups, which allow parents to reflect on the challenges they face. These activities promote knowledge acquisition and foster a greater perception of parental self-efficacy. As a result, parents become better prepared to implement consistent and appropriate routines at home, contributing to healthier sleep and, consequently, to a better quality of life for their children.