Researchers have found that a significant proportion of nurses and nursing students suffer from sleep abnormalities and related medical issues, as well as lower grades in those with significant lack of sleep (Dumer & Dinges, 2005; Lockley, Barger, Ayas, Rothchild, Czelsler, & Landrigan, 2007; Stickgold, 2005). Further, a study performed by Wagstaff and Lie (2011) found that work periods greater than eight consecutive hours carry an increased risk of occupational accidents that accumulates so that the increased risk of accidents after working twelve hours is two times the risk of accidents after working eight hours. Finally, shift work resulting in sleep deprivation in other healthcare workers, such as interns and residents, has been shown to be a crucial factor in contributing to medical error (Baldwin & Daugherty, 2004; Landrigan, Rothschild, Cronin, Kaushal, Burdick, Katz, Lilly, Stone, Lockley, Bates, & Czeisler, 2004; Mansukhani, Kolla, Surani, Varon, & Ramar, 2012).
While the literature presents a persuasive picture of the need for sleep and the impact sleep deprivation can have on individuals, students, and healthcare practitioners, a dearth of literature surrounding, specifically, nursing students, sleep deprivation, and associated impact of sleepiness on health and safety exists. Arguably, this lack of research on sleep habits and sleep deprivation calls for research studies, such as the one on which we report, as well as ways to address this phenomenon. Consequently, nurse educators, nurse leaders, and nursing students have a responsibility to collaborate and cultivate strategies to help students improve sleep habits and, thereby, enhance safer, healthier work environments.
A convenience sample of 328 pre-licensure nursing students from a Mid-western university was sought for the study. Internal Review Board (IRB) approval was obtained. The questionnaire and all study materials were sent to all undergraduate nursing students who had been or were currently enrolled in a nursing course with a clinical component via university email accounts, and an online survey method administered study instruments. This research was a quantitative survey pilot study that was used to determine the need for a more in-depth, comprehensive larger study.
The questionnaire was titled, Sleep Deprivation of Nursing Students, and included five sections with a total of twenty-one questions. Section (A) included six questions related to student demographics. Section (B) addressed aspects of personal sleep habits with two questions. Section (C) included four questions and addressed automobile and motor vehicle use after working and program clinical experiences. Section (D) included one multi-part question addressing students’ expenditure of spare time. Section (E), with a total of ten questions, addressed work safety and program clinical experiences.
An invitation letter to participate in the study and a consent form was included in the survey packet sent to all study participants via email. No incentives for completing the study were identified or provided in the survey packet. Three email reminders were sent to the survey sample during the six-week study completion period.
Data was analyzed using descriptive statistics. Of the convenience sample (n=328), 179 completed the study for a 54% response rate. While participants reported a need for 8 or more hours of sleep to feel rested, most obtained less than 6 hours of sleep prior to class or clinical experiences, potentially negatively impacting learning in the classroom and safety in the clinical setting. The majority of participants indicated that they self-medicated to stay awake and to induce sleep, consuming caffeine/stimulants or sleeping pills, depending on the perceived need. Clinical hours ranged from 7-12 hours per week, with nearly one third of respondents having 12 or more clinical hours per week.
More than half of participants were employed 8-12 hours per week and worked 7 to greater than 12 consecutive days combining employment and clinical schedules in spite of the known increase in error rates and decrease in decision making and critical reasoning after 12 hours of employment or clinical experience. Factoring in drive time to number of work hours, consecutive days between jobs, clinical experiences, and clinical hours showed the risk of accident or falling to sleep is greatly increased. More than half of participants reported fatigue after clinical experiences and when driving after work or clinical experiences. Most of participants were awake 18-19 hours out of a 24-hour day. In spite of this, though, nearly all of participants believed they engaged in safe practice at work and clinical experience and that 12 hour shifts or longer did not impact safety or decrease ability to learn.
The majority of nursing students in this study did not recognize the impact of sleep deficit and 12 hour employment or clinical experiences on learning capacity, error rates, decision making and critical thinking. Over 30 years of research has shown the negative effects of sleep deprivation, circadian misalignment and human performance in physicians and nurses. There is little, if any, investigation to date into the effects of those same variables on nursing students. Post-study, these researchers conclude that educators are responsible for recognizing that sleep, employment, and clinical variables affect safety and clinical judgment and for teaching students about the negative impact of sleep deprivation on health and safety. Additionally, educators must collaborate with nursing students and nurse leaders to determine if limits on work and clinical experiences are needed and to develop strategies that promote healthy sleep habits. Lastly, educators must be role models for balancing family/social/work life so that students can see how a healthy balance positively affects health and attitude, thereby positively impacting home and work environments.