Just a year ago, on August 2, 2015, at 8:00 in the morning, a nurse from Johns Hopkins University, driving home after working the night shift, was killed when her car left the road and crashed into a utility pole. Joanna Kaskasian left behind a husband and three children, ages 5, 3, and 11 months.[1] "Drowsy driving," as it's called, is frighteningly common, as nurses who work the night shift are aware. Going to work "well rested" is no guarantee that, at the end of a long, 12-hour shift, the nurse will make it home safely. What makes Joanna Kaskasian's death even more tragic is that it was preventable. My Kingdom for a Bed Any nurse who has ever worked the night shift on a regular basis knows what it means to crave sleep. No matter how much attention and care the night shift–working nurse gives to personal sleep hygiene, a time comes in the early hours of the new day when circulating cortisol levels have hit rock bottom and the nurse would give almost anything for a nap—especially on the first night of a stretch, when the nurse has most likely been awake since morning, trying to live a normal life with the rest of the world. Many nurses could get over this predictable "hump" with a brief, 20- to 30-minute nap. Nurses are somehow expected to ... just keep going and going, without sleep, without breaks, and without complaint. Employee napping has been used successfully in many 24-7 industries, including hospitals, as a strategy to improve safety both on the job and during the drive home.[2] Yet in nursing, the practice of intentional napping has never taken off in a significant way. There is a persistent stigma attached to nurses taking naps, and moreover, most hospitals have written, enforceable policies against sleeping at work. Nurses are somehow expected to be immune to fatigue—they are the "Energizer bunnies" of healthcare who just keep going and going, without sleep, without breaks, and without complaint. A Napping Pilot Project A team of nurse researchers, dismissing the notion that napping is unprofessional, set out to determine whether napping on the night shift was feasible, safe, and effective.[3] They invited six different nursing units from two hospitals to participate in a pilot project in which the units would develop and implement a viable napping protocol, taking into consideration each unit's unique architecture, staffing levels, patient care needs, and nursing culture around breaks. Three of the units never got to the planning stage because the nurse managers vetoed the idea upon hearing it, without presenting it to their staff nurses. Their reasons for declining to participate included insufficient staffing, concerns about nurses not waking up for rapid-response duty, a lack of suitable napping space, and general biases against nurses sleeping at work. One unit didn't take formal breaks at all on the night shift, so napping would be superfluous on that unit. Two other units considered participating but ultimately were unable to overcome barriers to napping. In the end, only one of the six units invited to participate was able to implement the napping pilot project. So, what happened on this single napping unit? The nursing staff collaborated on a plan for napping, devised a suitable napping space, planned for patient care coverage, and worked out other details. For 3 months, the nursing staff implemented their napping protocol. To gauge its safety and effectiveness, nurses who napped completed a "sleepiness scale" before napping and a short survey afterwards. A total of 153 nap surveys were available for analysis. Pre-nap sleepiness averaged a "6" (on a scale of 1-10, in which 10 represents the highest level of sleepiness). Nurses fell asleep for more than half of the naps (43% slept "lightly" and 14% "deeply") and average nap duration was 31 minutes. Only 1.3% of napping nurses felt "very groggy" upon waking, although 20.3% admitted to feeling "a little groggy." After 52.6% of the naps, nurses felt "alert and refreshed" and overall gave a score of 7.3 out of 10 points on the "helpfulness of napping" scale (in which 10 represents "most helpful"). Many nurses commented that napping reduced drowsy driving on the way home. Incidentally, this unit voluntarily continued (and improved upon) the napping protocol after the formal study period ended; it's been in use the past 3 years. And it has also been implemented hospital-wide after the human resources department was convinced to revise the policy against employee sleeping. Viewpoint As this study and previous studies have shown, napping can reduce fatigue on the night shift.[2] Although not universally beneficial, some nurses find napping enormously helpful. So then why have so few nursing units and hospitals adopted formal napping protocols for nurses who choose to nap? Minor issues aside, the primary reason is quite simple: Nurse managers and other administrators don't support it and many won't allow it. Many of these administrators, who go home at the end of the day, eat dinner with their families, watch a little TV, tuck themselves into bed, and are deeply asleep when their night-shift nurses are struggling to stay awake on the unit, threaten to fire any nurse who "sleeps on the job." It was difficult to read this research report without becoming disheartened by the report of negative attitudes of nursing administrators toward napping, as well as the barriers thrown up by these individuals to make it impossible for nurses to take the very reasonable and safe step of planned napping during their night-shift breaks. Physicians have been napping in the hospital at night for eons, and jokes about "bed-head hair" aside, few people complain about sleep inertia when physicians race from deep sleep to a code. From a patient-safety perspective, how is it possible to consider the few moments of grogginess that nurses might experience upon waking from a nap more dangerous than hours of fatigue and sleepiness experienced by the same nurse struggling to remain alert and provide safe care throughout the shift? A nurse manager trying to staff a unit may have few qualms about asking nurses to work long stretches of 12-hour night shifts, to rotate from night to day and back to night in the course of a week, or to pull an extra last-minute night shift with no sleep beforehand. These things happen every day. What is increasingly difficult to understand is why hospital administrators and managers who require these kinds of work schedules then turn around and place all of the responsibility for nurses being awake, alert, and error-free (often break-free as well) back on the nurses. It is a peculiar form of torture unique to the nursing profession. It is a peculiar form of torture unique to the nursing profession. Nursing culture has for far too long accepted a warped reality that nurses don't need fully relieved breaks away from patient-care duties, even for a mere 30 minutes. Hospitals have long been unwilling to support this financially and have cut staffing margins to the bone, leaving no coverage for breaks. If nurses want breaks at all, they must cover each other's patients, a practice that sounds simple but isn't always feasible or safe. Working 12 hours without a break, especially at night, is ignored as a safety issue, and it has been going on for so long that nurses simply accept not having real breaks as "just part of the job." Is it enough to just say, "You knew what you were getting into when you became a nurse"? In other words, "If you are tired at work, it's your problem" seems to be the message. Fatigue might be part of the job, but it doesn't have to be. "From years and years of evidence, we know nurses are sleep-deprived and that it affects both their job performance and their ability to drive home safely," explained lead investigator, Dr Jeanne Geiger-Brown, dean of the School of Health Professions at Stevenson University. "This is not trivial. This is a real problem and—as demonstrated by the death of the Johns Hopkins nurse—a fatal problem in some cases. We need to pay more attention to it." One strategy is an organized, planned, intentional napping program. "Napping is not that difficult to implement," added Dr Geiger-Brown. "People have to be willing to take a chance on it and make some minor changes. Nurses will still have to come to work well rested because they can't be assured of being able to nap on any given shift. But the fears about nurses napping while patients are being neglected are ungrounded. Nurses would not jeopardize patient care to nap." What will it take to implement napping in other units and hospitals? "In the pilot hospital, nurses have been the ones who have moved this forward, not the administration," said Dr Geiger-Brown. So it looks like it will be up to nurses to use their shared governance rights to overcome barriers to napping and design napping protocols that will be effective and safe. Source
