Physician wellness/original researchImproving Alertness and Performance in Emergency Department Physicians and Nurses: The Use of Planned Naps
Introduction
Health care professionals perform rotating shift work to provide patient care 24 hours a day. Not only does this present a serious concern for patient safety but also it places the workers themselves at risk for problems associated with circadian disruption and sleep deprivation.1, 2, 3, 4, 5, 6 It has been well documented that shift workers sleep less, perform less effectively on psychomotor and cognitive tests, make more errors during night shifts, and are at higher risk for driving crashes because of postnight shift drowsiness.7, 8, 9, 10, 11, 12
Adequate sleep before a night shift addresses a core physiological mechanism that underlies performance and alertness, though circadian factors typically reduce the quantity and quality of this day sleep.13 Therefore, planned naps in the workplace might be effective for health care professionals to promote a high level of alertness, attention to detail, and decisionmaking proficiency. Studies have demonstrated that under conditions of prolonged wakefulness, naps can improve performance and alertness.14, 15, 16, 17 Field studies in pilots and truckers have shown that naps mitigate drowsiness and improve performance and alertness.18, 19, 20 In a randomized, prospective study of planned naps as an operational countermeasure in a high-risk industry, long-haul flight crew members who napped had significantly improved performance and alertness, including fewer microsleeps in the last 90 minutes of flight.21 Based on these findings, a proposed Federal Aviation Administration advisory circular outlined the use of planned naps for flight crews. Several international airlines, including British Airways, Air New Zealand, Lufthansa, Quantas, Swissair, and Finnair, have implemented planned cockpit nap procedures, whereas the Federal Aviation Administration continues its consideration for use in the United States.22 However, planned naps have not been adequately tested as a fatigue countermeasure for physicians and nurses.
The goal of this study was to conduct a randomized controlled trial of napping as an intervention in the middle of a night shift for a physician and nurse population to see if there is improvement in their cognitive and psychomotor performance, ability to drive home, and subjective report.
Section snippets
Study Design and Setting
The study design was a randomized, controlled intervention trial conducted at a university emergency department (ED). The ED had 38,802 patient visits during the recruitment period, with 38.2% of visits occurring between 7:30 pm and 7:30 am. The study was approved by the university’s human subjects committee, and written informed consent was obtained for all subjects.
Selection of Participants
Inclusion criteria were resident physicians and nurses working at least 3 consecutive 12-hour night shifts in the ED. Attending
Results
Table 1 shows demographic characteristics of the 2 groups of subjects. There were no differences between NAP and NONE.
There were no differences between the 2 groups with reference to the Sleep Disorders Questionnaire, Shift-work Experiences Questionnaire, or Owl and Lark Questionnaire. All subjects scored within normal limits on the Sleep Disorders Questionnaire and reported no evidence of clinical sleep disorders. As a whole, the groups reported that their optimal sleep would be mean 9.0 (SD
Limitations
The driving simulator was limited as it lacked the usual noises, vibration, and lights of a real environment. Moreover, subjects knew there was no real risk associated with falling asleep. Any potential alertness-enhancing effects of the nap may have been overpowered by the simulator’s relatively soporific nature. As a result, the driving performance may have been reduced to a common poor quality in both groups.
There was no baseline measure of driving performance obtained when the subjects were
Discussion
This study reports the first randomized trial of a nap intervention during the night shift for physicians and nurses. It was accomplished as a field study in the ED of a Level I trauma center. Results showed that a 40-minute nap opportunity allowed health care professionals to maintain their performance, self-reported alertness, and mood through the end of their night shift. However, these improvements did not extend beyond the night shift to ensure the safety of subjects’ simulated drive home.
References (42)
- et al.
Driver risk factors for sleep-related crashes
Accid Anal Prev.
(2003) - et al.
Relationship of day versus night sleep to physician performance and mood
Ann Emerg Med.
(1994) - et al.
The role of driver sleepiness in car crashes: a systematic review of epidemiological studies
Accid Anal Prev.
(2001) - et al.
Some measures to reduce effects of prolonged sleep deprivation
Neurophysiol Clin.
(1995) The effects of two alternative timings of a one-hour nap on early morning performance
Biol Psychol.
(1984)- et al.
Antecedents of fatigue, close calls, and crashes among commercial motor-vehicle drivers
J Safety Res.
(2004) - et al.
The effect of shiftwork on driving to and from work
J Hum Ergol (Tokyo)
(2001) Long workhours and health
Scand J Work Environ Health
(2003)- et al.
A prospective study of sleep duration and coronary heart disease in women
Arch Intern Med.
(2003) - et al.
Overtime work, insufficient sleep, and risk of non-fatal acute myocardial infarction in Japanese men
Occup Environ Med.
(2002)
Impaired driving performance in shiftworkers: the role of the circadian system in a multifactorial model
Alcohol Drugs Driving.
Rotating shiftwork schedules: can we enhance physician adaptation to night shifts?
Acad Emerg Med.
Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses
Am J Public Health
Increasing awareness of sleep hygiene in rotating shift workers: arming law-enforcement officers against impaired performance
Percept Mot Skills
Extended work shifts and the risk of motor vehicle crashes among interns
N Engl J Med.
Crew Factors in Flight Operations VII: Psychophysiological Responses to Overnight Cargo Operations
Minimal sleep to maintain performance
Naps and modafinil as countermeasures for the effects of sleep deprivation on cognitive performance
Aviat Space Environ Med.
Crew Factors in Flight Operations IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations
Truck driver fatigue risk assessment and management: a multinational survey
Ergonomics
Alertness management: strategic naps in operational settings
J Sleep Res.
Cited by (158)
Athletic performance; effects of sleep loss
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second EditionNapping during the night shift in prehospital emergency medical services—a narrative review
2024, Journal of Public Health and Emergency
Supervising editor: Debra E. Houry, MD, MPH
Author contributions: RS-C, SKH, MRR, and DMG conceived the study and designed the trial. RS-C, SKH, DTM, CW, SK, and JL supervised the conduct of the trial and data collection. RS-C, SKH, DTM, CW, SK, and JL undertook recruitment of participating subjects and managed the data, including quality control. YS, RB, and DMG provided statistical advice on study design and analyzed the data. RSC drafted the manuscript, and all authors contributed substantially to its revision. RSC takes responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Publication dates: Available online May 2, 2006.