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Patient Safety Tip of the Week
Power Napping
One of our most frequent topics over the
years has been the role of healthcare worker fatigue in patient safety. So, we
were surprised to see we had not done a column on this important topic for over
2 years!
Fortunately, AACN (American Association of
Critical-Care Nurses) just did an excellent podcast on nursing fatigue (AACN
2025). Our many columns on
fatigue in nurses (and other healthcare workers) have discussed the impact of
fatigue on both patient safety and the personal safety of nurses. The podcast
participants cited numerous examples of nurses falling asleep at traffic lights
on their way home, waking up several lanes over on the road on the way home,
missing their exits, or having actual car accidents. Though they note such most
often happens to nurses working night shifts and often new grads,
they note that no nurse is immune to fatigue and its impacts on patients and
the nurses themselves.
They discuss the impact of 12-hour shifts
and back-to-back shifts as contributors. Many nurses dont take breaks because
they are so concerned about their patients or their workloads prevent them from
taking breaks. But they acknowledge that its not just the work environment
that contributes to fatigue. Family responsibilities often prevent nurses from
getting the healthful sleep they need.
The podcast goes on to focus on the role of power
naps and changing the culture to understand that naps may be very appropriate. Its
been over 10 years since the American Nurses Association (ANA) position
statement recommended naps as a strategy to combat fatigue. Yet few hospitals
have implemented formal programs to carry out that strategy.
Barriers to implementation of napping
programs have included:
·
Inadequate space for quiet, secure, undisturbed
naps.
·
Lack administration support
·
Individual nurse
preference
·
Unit culture may make naps seem impossible,
undesirable, or unprofessional
·
Concerns for patients
·
Fear that patients or families will look
negatively upon nurses taking naps
They discuss 2 important studies that had successful
implementation of napping programs. Geiger-Brown and colleagues published on one
hospital's successful initiative to implement napping for night shift nurses (Geiger-Brown 2021). A
pre-implementation survey showed:
·
among nurses who drove, 91.3% of nurses had
frequent drowsy driving experiences (at least once per week)
·
more than half of nurses nodded off or fell
asleep at least once per month while at work (other than sanctioned naps)
·
two-thirds feared making an error because of
sleepiness
·
more than half felt sleepy during change of
shift report or charting
·
nearly all participants
had observed a coworker fall asleep while at work (other than sanctioned naps)
and felt concern about a coworker who appeared to be
impaired by fatigue
The napping initiative recommended that
nurses be allowed to take a brief (30 minutes or less) planned nap at a unit-designated
specific location, before 4:00 AM., and only when staffing and acuity permitted
this to be done safely. The team developed a tool kit that included napping
guidelines, a checklist of steps to consider when implementing napping on the
night shift, the ANA Position Statement on Addressing Nurse Fatigue to Promote Safety
and Health, a list of frequently asked questions, a link to the NIOSH
educational modules for nurses on shift work and long work hours, and a
statement about measuring the processes and outcomes of implementing napping on
the night shift. Team members reviewed the tool kit materials with unit nurses
and assisted units to implement the napping initiative.
Three-fourths of the units that were
eligible to nap successfully implemented and sustained napping. Subjective
reactions to the napping initiative were mixed. On the positive side, 82% of
participants felt refreshed by the brief nap. More than two thirds of nurses
felt that napping benefited their nursing practice. Many reported being able to
communicate more clearly and efficiently during shift changes, no longer asleep
when charting, feeling more refreshed and able to focus, more energized, more confident
to accomplish tasks without error, less stressed, able to think more quickly,
and able to wind down and regroup.
On the negative side, some nurses felt drowsier
on arising, had headaches, had long sleep latency, or were not
able to think clearly upon awakening if they had been exhausted at the
beginning of the nap. Other nurses reported that the nap opportunity was too
short. Some preferred to use the time to eat rather than sleep. Some also reported
that the sleeping accommodations were uncomfortable. Of
those who were dissatisfied with the space, complaints were of excessive noise,
physical discomfort (sitting up in a chair), lack of a door lock, others using
the room for other purposes, and interruptions while napping. Some would also
nap only if they felt comfortable handing off to someone else or if the unit
was too busy. One-fourth worried about or had sleep inertia symptoms. Sleep
inertia is a temporary state of grogginess, disorientation, and impaired
cognitive function that occurs immediately after waking up.
But perhaps the biggest concern was that the
data showed that drowsy driving was a clear risk and was reduced by only 5%
when measured subjectively post-implementation. Drowsy driving was one of the
main reasons for implementing the napping program.
The second study was from Mission Hospital
in Mission Viejo, California (Drake
2021). A survey done there
showed that 23% of 420 hospital nurses reported high levels of fatigue,
including high levels of acute fatigue after working long shifts, low levels of
recovery between shifts, and high levels of chronic fatigue. Moreover, nurses
with high levels of fatigue reported poorer health and wellness scores and
poorer hospital safety culture scores.
For the study, 19 unit nurses who worked full-time 12-hour night
shifts for at least 6-months and didnt have a primary
sleep disorder were asked to schedule planned naps during break times between 1
AM and 4 AM. All received NIOSH training on sleep hygiene and napping. The
planned nap was a 30-minute scheduled rest period that included 20 minutes of
rest or sleep followed by a 10-minute recovery period to awaken and return to
work. Naps were encouraged, but if nurses didnt sleep, they were asked to rest
quietly. A dedicated room for napping was located in
the middle of the unit behind the nurses station.
Before the study, 54% of participants
reported never napping at work, and 46% reported napping only occasionally.
During the study, nurses scheduled planned naps in 62% of the shifts worked.
Follow-up surveys indicated planned naps were safe, feasible, and associated
with decreased chronic fatigue and sleepiness. After the study ended many
nurses used the designated nap room and other unit nurses began planned naps.
Several nurses who had worked night shifts for many years without naps and had
considered themselves successful at maintaining a good worklife balance felt
empowered to engage in planned naps to improve their sleep health.
They discuss the difference between a typical
nursing unit break room and a designated nap room. Ideally, the planned nap
room should be convenient to the unit and away from
noise and disruption. They also note the importance of completing NIOSH
training and acquiring sleep hygiene education to ensure they understand the
importance of adequate sleep to their health and patient safety.
The article goes on to discuss some
strategies for implementation of a nap policy and tips
to optimize the naps.
Though some might consider the results of these 2 studies to be modest, they are encouraging. Its clear that implementation of a nap policy is not easy. There are many barriers, and sustainability is an issue. But we share the enthusiasm of the podcast participants that power naps offer a common sense opportunity to combat the problem of fatigue that affects both patient care and nurse well-being.
Has your
organization implemented a nap policy?
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
2012 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
November
13, 2012 The 12-Hour Nursing Shift: More Downsides
July
29, 2014 The 12-Hour Nursing Shift: Debate Continues
October
2014 Another Rap on the 12-Hour Nursing Shift
December
2, 2014 ANA Position Statement on Nurse Fatigue
August
2015 Surgical Resident Duty Reform and
Postoperative Outcomes
September
2015 Surgery Previous Night Does Not Impact
Attending Surgeon Next Day
September
29, 2015 More on the 12-Hour Nursing Shift
September
6, 2016 Napping
Debate Rekindled
April
18, 2017 Alarm
Response and Nurse Shift Duration
July
11, 2017 The
12-Hour Shift Takes More Hits
February
13, 2018 Interruptions
in the ED
April
2018 Radiologists
Get Fatigued, Too
August
2018 Burnout
and Medical Errors
September
4, 2018 The
12-Hour Nursing Shift: Another Nail in the Coffin
August 2020 New
Twist on Resident Work Hours and Patient Safety
August 25, 2020 The Off-Hours Effect in
Radiology
September 2020 Daylight
Savings Time Impacts Patient Safety?
January 19, 2021 Technology to Identify
Fatigue?
October 12, 2021 FDA Approval of Concussion
Tool Why Not a Fatigue Detection Tool?
February 2022 Does
Time of Day Matter?
May 2, 2023 ACGME Work Hour Guidelines
Not Good Enough
May 9, 2023 Can Light Reduce
Fatigue-Related Errors?
September 2023 Mandatory
Overtime Restricted for NY Nurses
References:
AACN Voices in Nursing Podcast. Ep. 021:
Nurse Fatigue: Sleep, Safety and Smarter Solutions. October 01, 2025
https://blubrry.com/3715980/148788197/ep-021-nurse-fatigue-sleep-safety-and-smarter-solutions/
Geiger-Brown J, Harlow A, Bagshaw B,
Sagherian K, Hinds PS. Going Beyond Position Statements: One Hospital's
Successful Initiative to Implement Napping for Night Shift Nurses. Workplace
Health Saf 2021; 69(10): 474-483
https://pubmed.ncbi.nlm.nih.gov/34528852/
Drake D, Malcuit M. To Nap or Not to Nap? American
Nurse Journal 2021; October 13, 2021
https://www.myamericannurse.com/to-nap-or-not-to-nap/
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