Patient Safety Tip of the Week
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
We’ve read with great interest all the recent news articles about air traffic controllers falling asleep on the job and have been appalled that the response of the authroities has been to fire them all. When you see the same problem pop up at multiple sites you have a system problem. This is not much different than the concentrated KCl issue in healthcare. The initial response years ago when nurses inadvertently administered fatal doses of concentrated KCl was to fire them. That response, of course, removed the one person likely never to make that mistake again and ignored the presence of a widespread system problem, i.e. that we were putting the patients (and nurses) in jeopardy by making concentrated KCl so readily available in the hospital.
So while the air traffic control system struggles to save face rather than address the root causes, we need to ask ourselves whether similar issues exist in healthcare. Of course they do. In both industries, 24x7 coverage is required and workers are often called upon to deal with emergent situations at all times of day or night. Moreover, the general background on night shifts in most industries (usually less noise, less light, less activity, etc.) probably has a soporific effect. Hence, the ability to remain vigilant and capable of quick decision making is both critical and problematic.
In our November 9,
2010 Patient Safety Tip of the Week “12-Hour
Nursing Shifts and Patient Safety” we did discuss some of the issues
related to working long shifts, varying shifts, consecutive shifts, and night
shifts. In that Tip we referred to an excellent 3-part series this year
“Is It Time to Pull the Plug on 12-Hour Shifts?” by Geiger-Brown and
colleagues. Part
3 of that series contained some great suggestions for protecting nurses
working the night shifts (use of “buddy” systems, planned “power naps”,
avoiding certain types of tasks during the body’s circadian nadir around 2-4 AM,
and encouraging nurses to speak up when they are tired).
Now a new study (Fallis 2011) provides a very timely discussion about napping on the night shift. Fallis and colleagues provide a detailed discussion about the literature on fatigue and threats to both patient and personal safety in nurses (and other healthcare workers) on the night shift and the literature on the effects of napping on night shifts in multiple industries. They then did focused interviews with 13 experienced nurses working the night shift in the emergency room or ICU setting in a community hospital in Canada. Ten of the 13 described themselves are “regular” nappers on the night shift (meaning that they often took brief naps on scheduled breaks if circumstances permitted). Three major themes evolved: the environmental scan, the impact of napping, and the consequences of not napping. The environmental scan was an analysis of all the variables taken into consideration in making a decision as to whether a nap was feasible. Those included things like how busy the unit was, what the mix of experienced vs. inexperienced nurses was, who was available for relieving them, and whether anyone was working a double shift.
The impact of napping could be positive or negative.
Most of the regular nappers noted a positive impact, such as awakening
refreshed and able to think more clearly. But naps are not for everyone. One of
the downsides of naps is occasionally awakening and temporarily feeling
disoriented and slow to respond or the phenomenon of “sleep inertia”. Almost a
quarter of the interviewees in the Fallis study mentioned this and it was the
primary reason that several of them had become “non-nappers”.
The consequences of
not napping included slowed mental processes and “foggy thinking”. Nurses
found themselves having to check things multiple times. They gave examples of
missing arrhythmias on telemonitoring screens because of decreased vigilance.
Many found the period between 4AM and 6AM to be most vulnerable. (Note that
almost all studies on fatigue and sleepiness on the night shift do identify a
roughly two-hour period where concentration abilities are at their worst but
the exact time of that nadir differs from study to study).
Prior studies in nursing have revealed a strong correlation
between lack of sleep and errors that have the potential to adversely affect
patient care (Dorrian
2006). That Australian study concluded that less sleep may lead to
the increased likelihood of making an error, and importantly, the decreased
likelihood of catching someone else's error.
Drowsiness, fatigue, and sleep deprivation also have an
impact on personal health of nurses. The issue of nurses having accidents while
driving home from work drowsy is fairly well known (Scott 2007,
Dorrian
2006). While that applies to drowsiness after any shift, it is more
prevalent after night shifts. Working while tired also predisposes to more
needle sticks, stress levels, and other health issues.
Putting systems in place to allow napping on the night shift
is not easy. First, you have to provide adequate “relief” staffing to ensure
full coverage of your units at all times. You already must do this for other
breaks (meal breaks, bathroom breaks, etc.) that nurses need on any shift. Most
nurses will tell you they often work shifts with no breaks at all because of
staffing shortages or mismatches between staffing and patient acuity. Second,
you need to provide an appropriate physical environment conducive to taking a
brief nap (quiet and comfortable, free from interruptions, yet close enough for
the nurse to be aroused to respond to patient care emergencies). Third, you
need to have in place a system of prioritization in which naps would be allowed
only if all preset criteria are met. And lastly you need to have in place a
management culture that recognizes the problem as real and is supportive of
efforts to address the problem rather than approach it in a punitive manner.
Many (or most) nurses may have difficulty napping if they have
one or more patients who are unstable. One other barrier mentioned by several
nurses in the Fallis study was fear of what the public would think about nurses
“napping on the job”. Given the news media responses in the recent air traffic
controller cases, it is clear that raising public awareness about the dangers
of fatigue and the benefits of napping under appropriate circumstances is very
important.
So is there an objective evidence base to suggest that naps
become a feature embedded into nursing (or other healthcare worker) shifts?
Actually there was a randomized controlled trial of naps on the night shift for
both physicians and nurses working in the ER (Smith-Coggins
2006). In that study, physicians (residents) and nurses who worked
at least 3 consecutive night shifts in the ER were randomized to a nap group or
a control no-nap group. The intervention was a scheduled 40-minute nap around
3AM (the actual monitored time napping was about 25 minutes). A battery of
cognitive and performance tests were administered at 4AM and 7:30AM and then a
driving simulation was done at 8AM. Those in the nap group had fewer
performance lapses at 7:30AM and took less time to insert an IV. They also
reported less fatigue and sleepiness and more vigor. On the driving simulation
they did not perform better overall than the non-nap group, though they showed
less dangerous driving tendencies and fewer behavioral signs of tiredness during
the simulation. Interestingly, in view of the comments about sleep inertia in
the Fallis study mentioned above, those in the nap group performed more poorly
on a memory test administered at 4AM (immediately after the nap). So this study
strongly supports the concept of the restorative nap during the night shift
even though actual impact on patient outcomes was not measured or assessed.
Naps may be pertinent outside the night shift as well. Those
of us who treat patients with migraine have long recognized the benefit of
allowing someone in the midst of a migraine to take a brief nap. We often see
migraineurs who would have been unproductive on the job for an entire workday
able to waken from a short nap refreshed and able to return to productive work.
Sleeping air traffic controllers may be fodder for Jay
Leno’s late night television jokes but let’s not let those jokes deter us from
taking a hard look at a real problem in not just air traffic control but in healthcare
as well. If we fail to openly address this real issue, it will continue to be a
problem that continues in a manner not in the best interest of patient or
personal safety.
Further studies should be encouraged to measure the actual
impact of such naps on patient care and to answer other key questions (what is
the best time for the nap? optimal duration of the nap? optimal “wake up”
period after the nap? etc.). Remember, any positive impact of such a napping
program would have to be balanced against any potential negative impact you’d
introduce by requiring coverage of patients for an hour or so by physicians and
nurses unfamiliar with those patients. But rather than snicker at people
“napping on the job” we need to get serious about a problem potentially
detrimental to the care of our patients and the well-being of our staffs.
References:
Geiger-Brown J. Trinkoff AM. Is It Time to Pull the Plug on
12-Hour Shifts? Part 3. harm reduction strategies if
keeping 12-Hour Shifts. Journal of Nursing
Administration 2010; 40(9): 357-9, 2010
Sep
Fallis, WM, McMillan DE, Edwards MP. Napping During Night
Shift: Practices, Preferences, and Perceptions of Critical Care and Emergency
Department Nurses
Crit Care Nurse
March 31, 2011 vol. 31 no. 2 e1-e11
http://ccn.aacnjournals.org/content/31/2/e1.full
Dorrian J, Lamond N, van den Heuvel C, et al. A Pilot Study
of the Safety Implications of Australian Nurses' Sleep and Work Hours.
Chronobiology International 2006; 23(6): 1149–1163
http://informahealthcare.com/doi/abs/10.1080/07420520601059615
Scott LD, Hwang W-T, Rogers AE, et al. The Relationship
between Nurse Work Schedules, Sleep Duration, and Drowsy Driving. Sleep 2007;
30(12): 1801-1807
http://www.journalsleep.org/ViewAbstract.aspx?pid=27018
Smith-Coggins R, Howard SK, Mac DT, et al. Improving Alertness and Performance
in Emergency Department Physicians and Nurses: The Use of Planned Naps. Ann
Emerg Med 2006; 48: 596-604
http://www.annemergmed.com/article/S0196-0644%2806%2900239-3/abstract
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