Prompt: For this milestone assignment, address the following in regard to the article you have selected for the final project:
State the results of the research, describing how the researchers determined whether or not the results are statistically significant.
Describe the differences in the results between the groups in the study and support your description with examples from the study.
Explain the limitations presented by the study population and sample size used. Support your explanation with examples from the study.
Discuss the advantages and disadvantages of the type of statistical analysis used. Support your discussion with examples from the study.
Identify the limitations of the study design used and explain why those limitations exist.
Nurses who work the night shift often expe rience high levels of sleepiness as a normal biological consequence of working during a dip in the circadian rhythm (2 AM to 6 AM).1 Other factors, such as sleep disturbances or sleep loss as sociated with working 12hour shifts or frequent overtime, can also play a role.2 And the nighttime work environment typically has periods character ized by lower stimulation (dimmer lighting, quiet, and less bustle), which can raise the propensity for sleep in nurses who are already sleep deprived.
Nightshift sleepiness produces three problems: reduced alertness and possible involuntary sleep, which have been associated with increased risk of patient care errors3, 4; increased risk of jobrelated injuries and accidents, including motor vehicle ac cidents on the drive home58; and increased risk of longterm health impairments, which are associ ated with lost workdays and increased health care costs.6, 9, 10
It’s clear that nightshift sleepiness among nurses warrants serious attention. Research indicates that scheduled naps during night shifts can be an effective countermeasure, decreasing sleepiness, increasing both alertness and total sleep time, and improving response accuracy.11 This article describes the results of a napping implementation project that was con ducted in two hospitals. Its purpose was twofold: to assess the barriers to successful implementation of nightshift naps, and to describe the nap experiences of nightshift nurses.
BACKGROUND
Researchers began studying nightshift sleepiness in the 1950s; and physiologic evidence of involun tary sleep in train engineers, truck drivers, and in dustrial workers, among others, has been reported in the literature since the 1980s.12 Sleep scientists have been writing about the benefits of napping to reduce nightshift sleepiness since the 1970s.1215 In a recent systematic review of experimental and quasi experimental studies of napping, Ruggiero and Re deker concluded that “planned naps hold promise as the means to improve sleepiness and sleeprelated performance deficits among shift workers. It may be feasible to implement nap programs in current workplace studies.”11 Indeed, in certain industries in which safety is a concern, such as the transportation industry, napping has been adopted as an effective countermeasure to sleepiness and fatigue.16, 17
The 2004 report Keeping Patients Safe: Transform- ing the Work Environment of Nurses from the Insti tute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, En gineering, and Medicine) discussed the benefits of providing nurses with nap opportunities in order to maintain a safer work environment.17 Napping was promoted as a safety practice in an evidencebased
ABSTRACT
Background: Nurses who work the night shift often experience high levels of sleepiness. Napping has been adopted as an effective countermeasure to sleepiness and fatigue in other safety-sensitive industries, but has not had widespread acceptance in nursing.
Purpose: To assess the barriers to successful implementation of night-shift naps and to describe the nap experiences of night-shift nurses who took naps.
Methods: In this two-hospital pilot implementation project, napping on the night shift was offered to six nursing units for which the executive nursing leadership had given approval. Unit nurse managers’ ap- proval was sought, and where granted, further explanation was given to the unit’s staff nurses. A nap expe- rience form, which included the Karolinska Sleepiness Scale, was used to assess pre-nap sleepiness level, nap duration and perceived sleep experience, post-nap sleep inertia, and the perceived helpfulness of the nap. Nurse managers and staff nurses were also interviewed at the end of the three-month study period.
Results: Successful implementation occurred on only one of the six units, with partial success seen on a sec- ond unit. Barriers primarily occurred at the point of seeking the unit nurse managers’ approval. On the suc- cessful unit, 153 30-minutes naps were taken during the study period. A high level of sleepiness was present at the beginning of 44% of the naps. For more than half the naps, nurses reported achieving either light (43%) or deep (14%) sleep. Sleep inertia was rare. The average score of helpfulness of napping was high (7.3 on a 1-to-10 scale). Nurses who napped reported being less drowsy while driving home after their shift.
Conclusion: These data suggest that when barriers to napping are overcome, napping on the night shift is feasible and can reduce nurses’ workplace sleepiness and drowsy driving on the way home. Addressing nurse managers’ perceptions of and concerns about napping may be essential to successful implementation.
Keywords: adverse event, drowsy driving, fatigue, medication error, occupational health, occupational safety, patient safety, shift work, sleepiness, workplace safety, work schedule tolerance
handbook for nurses published in 2008 by the Agency for Healthcare Research and Quality, whose mission it is to produce and disseminate evidence that will make health care safer.2 The Joint Commission, concerned about the effects of health care worker fatigue on pa tient safety, issued a Sentinel Event Alert in 2011 rec ommending that all health care organizations work “to help mitigate the risks of fatigue.”18 Noting that “the only way to counteract the severe consequences of sleepiness is to sleep,” the document included nap ping as one component of a fatigue management plan. And the American Nurses Association (ANA) updated its position statement on nurse fatigue in September 2014, adding a recommendation that RNs “use naps (in accordance with workplace policies)” as one of several “evidencebased fatigue countermeasures.”19
The two-process model of sleep. Conceptually,
the benefits of napping can best be understood by considering the twoprocess model of sleep, first de scribed by Borbély.20 This model holds that sleep is regulated by two interactive processes: sleep–wake homeostasis and circadian rhythm. The homeostatic drive to sleep, often called sleep pressure, increases with every hour awake and reduces rapidly at next sleep onset. The circadian drive for wakefulness, often called waking pressure, follows a more nuanced pat tern: it increases at daybreak, dips in early afternoon
between 1 PM and 3 PM, increases to a peak level be tween 7 PM and 9 PM, and then decreases during the night, reaching its lowest point between 2 AM and 6 AM.21 In nightshift workers the natural interaction of these forces is disrupted, such that, in the middle of the night, high sleep pressure exists unopposed by waking pressure, resulting in a high level of sleepiness.
‘The only way to counteract the severe consequences of sleepiness is to sleep.’
Normal sleep involves two sleep states—non– rapid eye movement (NREM) and rapid eye move ment (REM)—and four sleep stages, ranging from a transition stage (NREM stage 1) and light sleep (NREM stage 2) to deep sleep (NREM stage 3 and
REM stage 4), with the sleeper cycling through all four stages several times a sleep period. During short naps (20 to 30 minutes), the sleeper will usually experience stage 1 or 2 sleep only, since stage 3 sleep typically occurs after about 30 to 45 minutes of sleep time. Thus a short nap can reduce sleep pressure without inducing sleep inertia (the groggy feeling that some people feel when awakened from deep sleep22).
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