We’ve read with great interest all the recent news articles about air traffic controllers falling asleep on the job and have been appalled that the response of the authroities has been to fire them all. When you see the same problem pop up at multiple sites you have a system problem. This is not much different than the concentrated KCl issue in healthcare. The initial response years ago when nurses inadvertently administered fatal doses of concentrated KCl was to fire them. That response, of course, removed the one person likely never to make that mistake again and ignored the presence of a widespread system problem, i.e. that we were putting the patients (and nurses) in jeopardy by making concentrated KCl so readily available in the hospital.
So while the air traffic control system struggles to save face rather than address the root causes, we need to ask ourselves whether similar issues exist in healthcare. Of course they do. In both industries, 24x7 coverage is required and workers are often called upon to deal with emergent situations at all times of day or night. Moreover, the general background on night shifts in most industries (usually less noise, less light, less activity, etc.) probably has a soporific effect. Hence, the ability to remain vigilant and capable of quick decision making is both critical and problematic.
In our November 9, 2010 Patient Safety Tip of the Week “In that Tip we referred to an excellent 3-part series this year “Is It Time to Pull the Plug on 12-Hour Shifts?” by Geiger-Brown and colleagues. ” we did discuss some of the issues related to working long shifts, varying shifts, consecutive shifts, and night shifts. Part 3 of that series contained some great suggestions for protecting nurses working the night shifts (use of “buddy” systems, planned “power naps”, avoiding certain types of tasks during the body’s circadian nadir around 2-4 AM, and encouraging nurses to speak up when they are tired).
Now a new study (Fallis) provides a very timely discussion about napping on the night shift. Fallis and colleagues provide a detailed discussion about the literature on fatigue and threats to both patient and personal safety in nurses (and other healthcare workers) on the night shift and the literature on the effects of napping on night shifts in multiple industries. They then did focused interviews with 13 experienced nurses working the night shift in the emergency room or ICU setting in a community hospital in Canada. Ten of the 13 described themselves are “regular” nappers on the night shift (meaning that they often took brief naps on scheduled breaks if circumstances permitted). Three major themes evolved: the environmental scan, the impact of napping, and the consequences of not napping. The environmental scan was an analysis of all the variables taken into consideration in making a decision as to whether a nap was feasible. Those included things like how busy the unit was, what the mix of experienced vs. inexperienced nurses was, who was available for relieving them, and whether anyone was working a double shift.
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 consequences of not napping included slowed mental processes and “foggy thinking”. Nurses found themselves having to check things multiple times. They gave examples of missing arrhythmias on telemonitoring screens because of decreased vigilance. Many found the period between 4AM and 6AM to be most vulnerable. (Note that almost all studies on fatigue and sleepiness on the night shift do identify a roughly two-hour period where concentration abilities are at their worst but the exact time of that nadir differs from study to study).
Prior studies in nursing have revealed a strong correlation
between lack of sleep and errors that have the potential to adversely affect
patient care (
Drowsiness, fatigue, and sleep deprivation also have an impact on personal health of nurses. The issue of nurses having accidents while driving home from work drowsy is fairly well known (, ). While that applies to drowsiness after any shift, it is more prevalent after night shifts. Working while tired also predisposes to more needle sticks, stress levels, and other health issues.
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 may 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”. Given the news media responses in the recent air traffic controller cases, it is clear that raising public awareness about the dangers of fatigue and the benefits of napping under appropriate circumstances is very important.
So is there an objective evidence base to suggest that naps become a feature embedded into nursing (or other healthcare worker) shifts? Actually there was a randomized controlled trial of naps on the night shift for both physicians and nurses working in the ER (). In that study, physicians (residents) and nurses who worked at least 3 consecutive night shifts in the ER were randomized to a nap group or a control no-nap group. The intervention was a scheduled 40-minute nap around 3AM (the actual monitored time napping was about 25 minutes). A battery of cognitive and performance tests were administered at 4AM and 7:30AM and then a driving simulation was done at 8AM. Those in the nap group had fewer performance lapses at 7:30AM and took less time to insert an IV. They also reported less fatigue and sleepiness and more vigor. On the driving simulation they did not perform better overall than the non-nap group, though they showed less dangerous driving tendencies and fewer behavioral signs of tiredness during the simulation. Interestingly, in view of the comments about sleep inertia in the Fallis study mentioned above, those in the nap group performed more poorly on a memory test administered at 4AM (immediately after the nap). So this study strongly supports the concept of the restorative nap during the night shift even though actual impact on patient outcomes was not measured or assessed.
Naps may be pertinent outside the night shift as well. Those of us who treat patients with migraine have long recognized the benefit of allowing someone in the midst of a migraine to take a brief nap. We often see migraineurs who would have been unproductive on the job for an entire workday able to waken from a short nap refreshed and able to return to productive work.
Sleeping air traffic controllers may be fodder for Jay Leno’s late night television jokes but let’s not let those jokes deter us from taking a hard look at a real problem in not just air traffic control but in healthcare as well. If we fail to openly address this real issue, it will continue to be a problem that continues in a manner not in the best interest of patient or personal safety.
Further studies should be encouraged to measure the actual impact of such naps on patient care and to answer other key questions (what is the best time for the nap? optimal duration of the nap? optimal “wake up” period after the nap? etc.). Remember, any positive impact of such a napping program would have to be balanced against any potential negative impact you’d introduce by requiring coverage of patients for an hour or so by physicians and nurses unfamiliar with those patients. But rather than snicker at people “napping on the job” we need to get serious about a problem potentially detrimental to the care of our patients and the well-being of our staffs.
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
Dorrian J, Lamond N, van den Heuvel C, et al. A Pilot Study of the Safety Implications of Australian Nurses' Sleep and Work Hours. Chronobiology International 2006; 23(6): 1149–1163
Scott LD, Hwang W-T, Rogers AE, et al. The Relationship between Nurse Work Schedules, Sleep Duration, and Drowsy Driving. Sleep 2007; 30(12): 1801-1807
Smith-Coggins R, Howard SK, Mac DT, et al. Improving Alertness and Performance in Emergency Department Physicians and Nurses: The Use of Planned Naps. Ann Emerg Med 2006; 48: 596-604