1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief


The night shift, that is.


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One hospital has a relaxation room, with a recliner for staff naps.

Figure. Diana J. Mas... - Click to enlarge in new windowFigure. Diana J. Mason, PhD, RN, FAAN, AJN Editor-in-Chief

I hated working nights. (And so did physician Edwin Leap; see Viewpoint, page 13.) Rotating shifts were required at my first job at Walson Army Hospital in Fort Dix, New Jersey. Even if it was a slow night, you weren't allowed to nap. Between 4 AM and 5 AM I could barely keep my eyes open, let alone think clearly and function safely. But no one can see you in the bathroom. I devised the perfect position on the toilet: resting my head on my crossed arms atop my knees. I would alert whomever I was working with that I was about to take a "bathroom break," which was unspoken code for a quick nap. I could usually nap for about 10 minutes or so, although on occasion, my coworker would knock on the door and ask: "Everything okay in there?"&-a signal that I was needed on the unit or a night supervisor had arrived. I would do the same for them during their secret nap times in empty rooms.


More than a decade later, while conducting research on circadian rhythms for my doctoral dissertation, I discovered that nurses were often subjects in studies of shiftwork that documented performance problems experienced by many people who work rotating and night shifts. The studies found that some people should never work nights because they're more vulnerable to deleterious health effects (such as gastrointestinal and cardiac disturbances) when their circadian rhythms are disrupted. Rapid, forward rotations (two days, two evenings, two nights) were easier on workers than backward rotations (such as days to nights or evenings to days). Schedules that used rotating shifts of four days or more were long enough to desynchronize circadian rhythms.


The growing body of evidence on fatigue and errors suggests that we should change our approach to scheduling policies. In the November 2006 issue of the Annals of Emergency Medicine, Smith-Coggins and colleagues examined the use of planned naps in both physicians and nurses, working 12-hour night shifts in the ED of a level-1 trauma center. The 49 subjects were randomly assigned to a 40-minute nap period at 3 AM or no nap. In the nap group, 90% of subjects slept for almost 25 minutes (as measured by polysomnography) and had fewer lapses in performance, felt more vigor, and reported less fatigue and sleepiness than the no-nap group. The nap group had an initial decline in recall memory (at 4 AM) but performed a simulated IV insertion more quickly than the no-nap group. But the nap group didn't do better on a simulated driving test at the end of the shift, indicating that naps aren't a cure-all for the dangers of night work. Errors or near misses were not measured; this would be an important variable to include in future studies.


I had never heard of a hospital that permitted staff naps until last year when I visited a Transforming Care at the Bedside (TCAB) unit at the M. D. Anderson Cancer Center in Houston. (See the December 2007 Editorial for more information on the TCAB project.) The staff created a relaxation room, which included a recliner for staff naps. Before entering, the staff person notes on a clipboard outside the room the time she or he went in and the desired exit time so that anyone can come by and wake the person if needed. Nurses are permitted to save up their break times for an extended nap. The nurse manager told me that their nurse-patient ratio of 1:3 or 1:4 allowed nurses to actually take breaks and use the room.


Some of these options would be more difficult in hospitals that aren't staffed adequately. But maybe hospitals would retain their nurses and preserve the safety of their patients if they were to start using such evidence-based policies and scheduling.