What’s New in the Patient Safety World
November 2012
The Mid-Day Nap
We’ve done multiple prior columns on the impact of fatigue, shiftwork,
etc. on both patient outcomes and adverse personal events for workers
themselves (see our November 9, 2010
Patient Safety Tip of the Week “12-Hour
Nursing Shifts and Patient Safety” and our April 26, 2011 Patient Safety Tip of the Week
“Sleeping
Air Traffic Controllers: What About Healthcare?”).
In those 2 columns
and our January 2012 What’s New in the Patient Safety World column “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety”
we had extensive discussions about the value of naps and “power naps”
as strategies to minimize the effects of healthcare worker fatigue in those
working long shifts or night shifts.
Now a new study (Amin
2012) has looked at the potential impact of a short mid-day nap on
alertness and cognitive functioning in internal medicine housestaff. They
hooked up the residents to portable sleep monitoring devices as they arrived
for a shift at 8 AM. Slow eye movements (SEM’s), a measure of attention
failure, were recorded throughout the day. At about 1 PM residents returned to
a quiet room where they were given a test measuring cognitive functioning
(Conner’s Continuous Performance Test) and then were either allowed to take a
20-minute (maximum) nap or simply rest without sleeping for 20 minutes. The CPT
test was repeated after the 20-minute period and the residents returned to work
and their SEM’s continued to be recorded until about 4:30 PM. The group that
took the naps had fewer attention failures later in the day and performed
better on the cognitive test than the group that just rested without actually
napping. This was a very small study (29 residents in total) and did not
control for potential confounders like caffeine use or patient load. It also
did not have any measure of patient care or safety. Nevertheless, it does lend
further credence to the concept of the power nap as a strategy to reduce the
potential impact of fatigue in healthcare workers.
The Amin article
also nicely summarizes some of the known and hypothesized physiology of sleep
that may be involved, including mechanisms that might explain why such a short
nap would result in improved alertness and cognition. Short naps also are
typically not associated with the phenomenon of “sleep inertia” that is often
seen after one wakens from a long nap.
So it is fairly clear that multiple different types of healthcare workers can benefit from short naps or power naps. The Joint Commission Sentinel Event Alert on Healthcare Worker Fatigue and Patient Safety reminds us we must provide the proper environment (including ensuring staff are truly going to be allowed to nap without interruptions) for naps or sleep breaks. In two of our prior columns we highlighted the work of Geiger-Brown and colleagues (Geiger-Brown 2010) and Fallis and colleagues (Fallis 2011) related to napping strategies for nurses and noted that putting systems in place to allow napping on the night shift is not easy. First, you have to provide adequate “relief” staffing to ensure full coverage of your units at all times. You already must do this for other breaks (meal breaks, bathroom breaks, etc.) that nurses need on any shift. Most nurses will tell you they often work shifts with no breaks at all because of staffing shortages or mismatches between staffing and patient acuity. Second, you need to provide an appropriate physical environment conducive to taking a brief nap (quiet and comfortable, free from interruptions, yet close enough for the nurse to be aroused to respond to patient care emergencies). Third, you need to have in place a system of prioritization in which naps would be allowed only if all preset criteria are met. And lastly you need to have in place a management culture that recognizes the problem as real and is supportive of efforts to address the problem rather than approach it in a punitive manner.
Many (or most) nurses and physicians also have difficulty napping if they have one or more patients who are unstable. One other barrier mentioned by several nurses in the Fallis study was fear of what the public would think about nurses “napping on the job”. It is clear that raising public awareness about the dangers of fatigue and the benefits of napping under appropriate circumstances is very important.
In the study by Fallis et al. the impact of napping could be positive or negative. Most of the regular nappers noted a positive impact, such as awakening refreshed and able to think more clearly. But naps are not for everyone. One of the downsides of naps is occasionally awakening and temporarily feeling disoriented and slow to respond or the phenomenon of “sleep inertia”. Almost a quarter of the interviewees in the Fallis study mentioned this and it was the primary reason that several of them had become “non-nappers”. The current study by Amin et al. provided some reasonable physiological explanations as to why the 20-minute nap might avoid “sleep inertia”. The Amin study also describes characteristics of the room in which the residents were allowed to sleep and the mechanisms for ensuring they were wakened within the 20-minute timeframe.
We are learning more and more about how to use napping strategies to help minimize healthcare worker fatigue and hopefully improve patient safety and patient care.
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping
Air Traffic Controllers: What About Healthcare?”
February 2011 “Update on 12-hour Nursing Shifts”
September 2011 “Shiftwork
and Patient Safety
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “June
2012 Surgeon Fatigue”
November 2012 “The
Mid-Day Nap”
References:
Amin MM, Graber M,
Ahmad K, et al. The Effects of a Mid-Day Nap on the Neurocognitive Performance
of First-Year Medical Residents: A Controlled Interventional Pilot Study.
Academic Medicine 2012; 87(10): 1428-1433, October 2012.
The Joint
Commission. Sentinel Event Alert. Health care worker fatigue and patient
safety. Issue #48. December 14, 2011
http://www.jointcommission.org/assets/1/18/SEA_48.pdf
Geiger-Brown J. Trinkoff AM. Is It Time to Pull the Plug on
12-Hour Shifts? Part 3. harm reduction strategies if
keeping 12-Hour Shifts. Journal of Nursing
Administration 2010; 40(9): 357-9, 2010
Sep
Fallis, WM, McMillan DE, Edwards MP. Napping During Night Shift: Practices, Preferences, and Perceptions of Critical Care and Emergency Department Nurses
Crit Care Nurse March 31, 2011 vol. 31 no. 2 e1-e11
http://ccn.aacnjournals.org/content/31/2/e1.full
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