Patient Safety Tip of the Week
September 6, 2016 Napping Debate
Rekindled
We’ve done numerous columns on the role of healthcare worker
fatigue both on patient outcomes and worker personal health. One of the issues
we’ve often discussed is the role of naps in mitigating these adverse effects
of fatigue. Prior studies in nursing have revealed a strong correlation between
lack of sleep and errors that have the potential to adversely affect patient
care (Dorrian
2006). That Australian study concluded that less sleep may lead to
the increased likelihood of making an error, and importantly, the decreased
likelihood of catching someone else's error. 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 (Scott
2007, Dorrian 2006). 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.
Back in 2010 when we did our first column addressing the
12-hour nursing shift (see our November
9, 2010 Patient Safety Tip of the Week “12-Hour
Nursing Shifts and Patient Safety”) we discussed the use of “power
naps” that were part of the excellent 3-part series “Is It Time to
Pull the Plug on 12-Hour Shifts?” by Geiger-Brown and Trinkoff
(Geiger-Brown
2010). In our April 26, 2011
Patient Safety Tip of the Week “Sleeping
Air Traffic Controllers: What About Healthcare?” we really delved into the
issue of why naps, which are well accepted in other industries that operate in
long shifts, are not more widely accepted in healthcare.
The issue of napping has been rekindled in a Medscape
article following the unfortunate death of a Johns Hopkins nurse in an
automobile accident following working a night shift (Stokowski 20016). The
accident was likely due to drowsy driving.
Napping is an
evidence-based intervention shown to reduce worker fatigue in a number of
industries. The Joint Commission even refers to napping as a strategy in its Sentinel
Event Alert on Healthcare Worker Fatigue and Patient Safety (TJC 2011) as
discussed in our January 2012 What's New
in the Patient Safety World column “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety”.
In our April 26,
2011 Patient Safety Tip of the Week “Sleeping
Air Traffic Controllers: What About Healthcare?” we discussed a
study (Fallis 2011)
that included 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).
Tiredness on the night shift is particularly problematic for
a number of reasons. As noted by Gieger-Brown and
colleagues (Geiger-Brown
2016) there is a normal low point in the circadian drive for wakefulness
between 2AM and 6AM. Add to that several soporific factors on the night shift
such as dim lighting, relative quiet, reduced patient activity and less overall
activity.
But there is surprisingly scant high quality evidence on the
impact of napping. A randomized controlled trial of naps on the night shift for
both physicians and nurses working in the ER applied a battery of cognitive and
performance tests to 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 (Smith-Coggins
2006). The 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.
A systematic review on the effect of napping in night-shift
workers in multiple industries done in 2014 (Ruggiero 2014)
found such variability in study size and design that they had to do a “narrative”
systematic review. Of the 13 relevant studies only one was a randomized
controlled trial and 12 had quasi-experimental designs. Overall they found that
planned naps during night shifts (or simulated night shifts) reduced nocturnal
sleepiness and improved sleep-related performance deficits in a number of
populations and settings.
A Canadian study reported the attitudes of 47 critical care
nurse managers toward napping and this demonstrated numerous barriers to
implementation of napping as a safety tool (Edwards
2013). While most were aware of the patient safety issues caused by nurse
fatigue and also aware of the worker safety issues (eg.
needle sticks, accidents driving home, etc.) they had numerous concerns about
napping. Most respondents felt that their administrators would disapprove of
napping and most stated their hospital lacked a formal policy on napping or
were unaware of one. Many expressed concern that napping might create patient
care coverage shortages or that coverage would be being provided by nurses who
knew little about their patients. Others noted the lack of suitable facilities
for napping. And many felt that patients or their families would look unfavorably
upon nurses napping. Some also feared “sleep inertia”. The latter is a “groggy”
feeling sometimes perceived when one wakes up from sleep. We discussed an
article on sleep physiology (Amin
2012) in our November 2012 What's New in the Patient Safety World column “The
Mid-Day Nap” which noted short naps are typically not associated with the
phenomenon of “sleep inertia” that is often seen after one wakens from a long
nap.
Another recent study from Geiger-Brown and colleagues highlights
the barriers in implementing power nap programs for nurses (Geiger-Brown
2016). They had planned implementation of a night shift nurse napping
program at 6 units in two hospitals. However, the implementation never got off
the ground in 4 of the units and was waylaid in a 5th unit.
Therefore, it was only actually fully implemented in one of the six units.
Several barriers were encountered but the major one was that nurse managers did
not buy in. They often never even presented the project to their staff nurses.
Many were concerned about short staffing. One was concerned that nurses would
not be available to respond to rapid response team calls. Lack of adequate
space for napping was another concern. Interestingly, on some units nurses
never took extended breaks at all, even though they may be working 12-hour
shifts. But the one unit that implemented the napping program did so very
successfully. Over the 3-month pilot project naps averaged 31 minutes and on
over half the naps nurses noted actual sleep occurred. Nurses noted an average
score of 6.1 (scale 1 to 9 with 9 being the most sleepy) on a sleepiness scale
prior to napping (with 44% having scores between 7 and 9). After napping 56% of
nurses felt “alert and refreshed” and sleep inertia was relatively rare. And,
though not formally measured, many nurses noted that napping had eliminated
drowsy driving on their way home after work.
Several key factors aided that successful implementation.
The nursing director met with the supervisors and charge nurses prior to implementation
and discussed potential barriers and concerns. Staff nurses were then engaged
and had input. An appropriate space for napping that ensured complete privacy
was provided. Nap breaks, with plans for patient care coverage for napping
nurses, were planned at the beginning of each shift. Also important was that
several of the nurses had experienced nap programs elsewhere, they already had
a “buddy” system in place to cover patient care, and they had a high level of
trust among each other.
Note that the program was continued on the one unit after
the pilot study was completed and several other units expressed interest in
implementing a napping program. Some also felt that other nurses now wanted to “float”
to this unit after they heard about the napping program. The napping protocol
was modified to include an additional 5 minutes before and after the 30 minutes
of actual sleep time.
The optimal timing of naps remains unclear. The systematic
review by Ruggiero and Redeker (Ruggiero 2014)
noted that further studies are needed to determine the optimal timing of naps
in order to minimize the possible hazards associated with sleep inertia.
So here are the key lessons learned for implementing a
napping program:
- Get buy-in from hospital
and nursing administration
- Make sure your nurse
managers are on board
- Emphasize that napping
programs are evidence-based and promote both patient safety and worker
safety
- Make sure your staff
nurses have input into program development
- Nurses must be willing to
take completely relieved breaks
- Having a “buddy” system
in place can help nurses feel comfortable that their patients will be well
cared for during their break or nap break
- Provide space and
location that will allow uninterrupted napping
- Keep the actual napping
period short (30 minutes or less) but consider allowing an additional 5
minutes before and after the nap
- Incorporate napping plans
at the beginning of each shift, including planned patient care coverage
for nurses on nap break
- Measure sleepiness/alertness
results on a formal scale of some sort and provide feedback on the results
- Measure rates of adverse patient
care occurrences on units before and after implementation of napping
programs
- Solicit feedback from
staff on their perception of the program
Many nurses remain concerned about what their patients or
patient families may think about nurses napping. To that we recommend you have
a prepared script with which to respond if questioned. That script should
mention the adverse impact of healthcare worker fatigue on patient care, that
napping has been shown to be an effective means of reducing fatigue, that The
Joint Commission actually recommends napping programs, and use the analogy of
how the aviation industry sets work hour limits to reduce pilot fatigue and
allows naps for pilots on long flights.
The time has come to break down the many barriers that have
prevented implementation of napping programs. The safety of our patients and
the personal safety and health of our nurses demands that we step up to the
plate and address this important issue. It would be very helpful to have a
study that shows both a reduction in patient safety events and worker health
events after implementation of a program with an analysis of the financial
savings that might be accrued from such a program. However, hospitals shouldn’t
have to wait for such study to begin implementation of napping programs.
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”
References:
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
http://informahealthcare.com/doi/abs/10.1080/07420520601059615
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
http://www.journalsleep.org/ViewAbstract.aspx?pid=27018
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): 357-359,
2010 Sep
Stokowski LA. Should Night-Shift Nurses Nap at Work?
Medscape Nurses Viewpoints 2016; August 05, 2016
http://www.medscape.com/viewarticle/866836
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
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
Geiger-Brown J, Sagherian K, Zhu
S, et al. CE: Original research: napping on the night
shift: a two-hospital
implementation project. Am J Nurs 2016; 116: 26-33
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
http://www.annemergmed.com/article/S0196-0644%2806%2900239-3/abstract
Ruggiero JS, Redeker NS. Effects
of napping on sleepiness and sleep-related performance deficits in night-shift
workers: a systematic review. Biol Res Nurs 2014; 16: 134-142
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079545/
Edwards MP, McMillan DE, Fallis WM. Napping during breaks on night shift:
critical care nurse managers’ perceptions. Dynamics (now the Canadian Journal
of Critical Care Nursing) 2013; 24(4): 30-35
http://chemshark.com/nursing/wp-content/uploads/2014/07/NursingNappingNightShift.pdf
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.
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