Background: The American Nurses Association (ANA) position statement addressing nurse fatigue identifies a shared responsibility between nurses and employers to diminish the risk of nurse fatigue, endorse a culture of safety and create balance in work-life settings. ANA recommendations emphasize nurses and employers work together and strategically implement fatigue countermeasures to reduce fatigue and sleepiness in the work place (ANA, 2014). Night shift nurses have significant risk to experience alterations in both waking and sleeping states because of disrupted circadian regulation (Lee, Gay & Alsten, 2014). Fatigue induced impairment may result in medication and medical errors, mislabeled lab samples and calculation errors. Fatigue studies conducted with other 24-hour professionals including law enforcement officers indicate shiftwork has a cumulative and debilitating effect on judgment and decision-making (Violanti, 2012).
Methods: A quasi-experimental descriptive design was used for the purpose of this study to investigate the feasibility and effects of a fatigue risk management strategy that included a planned rest/nap for nightshift registered nurses (RNs) working full-time on a Surgical Intensive Care Unit (SICU). The study team included nurse leaders who reported to the hospital chief nurse officer and the principal investigator was an administrative nursing supervisor. The specific aim of the study was to answer three research questions:
1) What was the rate of nurse participation in the fatigue risk management intervention?
2) Was participation in the planned rest/nap associated with changes in; a) nurse fatigue, b) nurse sleepiness and c) nurse sleep quality?
3) Was participation in the planned rest/nap associated with SICU unit changes in a) medication errors, and b) sleep room logistic difficulties?
Subjects: All SICU RNs working night shift were invited to participate in the study. Study eligibility required RNs to: (a) be an SICU nurse working night shift with an independent assignment for at least six months, (b) be scheduled to work during the study period, (c) not have a diagnosis of a primary sleep disorder, and (d) provide written consent to participate in the study.
Sample: There were 21 respondents during recruitment, 17 nurses met inclusion criteria and were enrolled. One nurse transitioned to day shift at week 6 and was dropped from the study. A total of 16 nurses completed the twelve-week study. Participation in the study was voluntary. Prior to initiation of recruitment, the study received approval from the healthcare system investigational review board (IRB).
Protocol: RN participants were asked to schedule a planned rest/nap during a thirty-minute lunch period in a designated rest/nap room. The rest/nap room was designed and arranged by nursing leaders and members of the study team with financial support from the CNO. Each RN was responsible to begin and end the rest/nap according to the planned scheduled time and return to work alert. Rest/naps schedules were coordinated each shift by RNs with the charge nurse who maintained a form listing tentative break times between the hours of 1- 4 a.m. RNs were encouraged to eat lunch during another fifteen-minute break and were provided with a “Nap Protocol” that clarified expectations of a planned rest/nap and nap room logistics. Taking a nap was not mandatory but sleep was encouraged if possible. If unable to sleep, resting was recommended.
Setting: The study took place at a Magnet designated, level II trauma center in South Orange County, California in a twenty bed SICU.
Data collection: Following informed consent, RNs provided descriptive information and completed three study questionnaires using a survey generator, QualtricsR.
Data entry and analysis: Study forms used a study code assigned to each RN and all data collected was kept confidential. There was no individual identification of RN participant in the data file or analysis of results. Statistical analysis was conducted using IBM Statistical Package for the Social Sciences (version 22). Descriptive statistics were used to describe sample characteristics of RNs. A percentile rest/nap participation was calculated using a summary of rest/nap log reports from each shift worked. An average (mean) was calculated from fatigue and sleep scores using six and twelve week survey responses. Weekly unit medication errors and sleep room logistic difficulties were summarized from pharmacy and study log reports.
Study measures: Each RN completed a planned rest/nap log. Descriptive measures included nurse age, years worked, nursing degree and chronotype and history of napping at work. Pre-test and week-six and week-twelve survey measures included the Pittsburgh Sleep Quality Index (PSQI), The Epworth Sleepiness Scale (ESS), the Occupational Fatigue Exhaustion and Recovery Scale (OFER) and the Chalder Fatigue Scale. Weekly medication error rate reports were provided by the pharmacy to the study team during the twelve-week study. Sleep room logistics difficulties were summarized from the nurse rest/nap logs.
Results: Sixteen nurses, thirteen females and three males completed the twelve-week study. The average age was 37. Highest education was BSN (11), and ADN (5). The range for continuous night shift work years was 2 – 23 years, mean 7.09 (7.36) years. Ten nurses reported chronotype more evening type (owls), and 6 were more morning type (larks). Nine RNs reported never napping at work prior to the study and seven RNs reported only occasionally napping at work prior to the study. Average RN rest/nap participation during the twelve-week study was 62% with a range of 42% - 86%. Of 573 shifts worked, 196 naps were taken and 160 rests were taken. The majority, twelve RNs reported taking a combination of rest and naps. Two RNs took naps only, and two RNs took rests only. Improvements were observed in the average scores of physical fatigue, inter-shift recovery, and sleepiness at six weeks and improvements again at twelve weeks. Improvements in chronic fatigue were observed and week six and stable at week twelve. Mental and acute fatigue scores improved at week six and were worse (increased) at week twelve. Sleep quality did not improve at week six, but did improve at week twelve. There was one “low risk” of harm to the patient medication error reported by pharmacy during the study period. There were four reports by RNs of difficulty with room logistics because the rest/nap room was not available (already scheduled). There were twelve reports the rest/nap room was noisy.
Conclusion: Although many hospital nursing units provide a break room where nurses may rest or eat away from patient care, designated rest/nap rooms are not commonly available to nursing staff. Hospital nurses have many reasons to not rest or nap during the work shift. Many nurses are concerned with lack of administrative support, perceived inability to work twelve hours, a culture that does not tolerate sleep on the job, sleep inertia, and inadequate facilities to promote quiet, clean, undisturbed, secure and private rest/napping. This twelve-week study demonstrated that nurses who previously would never rest or nap were able to rest/nap on most shifts work and report less physical fatigue, less sleepiness, and improved sleep quality. A planned rest/nap intervention was an effective fatigue risk management strategy. The findings in this study support the shared responsibility of fatigue risk management between nursing leadership and clinical nursing staff.
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