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Wake-up Call for Nurses


Work schedules and levels of sleepiness among medical residents long have been a source of concern. A pilot study in the May-June issue of the Journal of Hospital Medicine shows nurses—especially those in high-stress specialties like intensive care—also could benefit from an extra 40 winks.

Lead author Salim Surani, MD, of the Baylor College of Medicine, and colleagues compared sleepiness in 10 intensive care unit (ICU) nurses to those of 10 floor nurses, all of whom worked night shifts beginning at 7 p.m. and ending at 7 a.m.

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Find this study (“Sleepiness in Critical Care Nurses: Results of a Pilot Study”) in the May-June Journal of Hospital Medicine.

Sleepiness was assessed in three ways. On the morning after the third or fourth shift, each nurse underwent a modified version of the Multiple Sleep Latency Test (MSLT), which measured the time it took for them to fall asleep during two nap periods, one at 7:15 a.m., another at 8:30 a.m. Sleep latency less than five minutes is considered severely pathological. Before the MSLT, they filled out the Epworth Sleepiness Scale (ESS), a questionnaire designed to explore the subject’s chances of falling asleep under six different scenarios. The ESS is considered a well-standardized and validated measure of subjective sleepiness, with a score more than eight considered abnormal.

Some hospitals provide shuttle buses to transport night-shift workers to and from work. Dr. Subramanian

Some hospitals provide shuttle buses to transport night-shift workers to and from work.

Finally, for the week leading up to the day of the test, the nurses maintained a sleep diary, recording their bedtimes, wake times, daytime naps, nocturnal awakenings, and comments about their feelings of sleepiness. Each participant received a $25 gift certificate at the completion of the study.

ICU nurses were chosen because they typically “must make extremely critical judgments; they must be alert enough to recognize abnormalities in their patients and react quickly enough when something goes wrong,” coauthor Shyamsunder Subramanian, MD, says. These demands take their toll, as some studies show ICU nurse burnout rates as high as 33%, leading the investigators to hypothesize that ICU nurses also would report feeling sleepier and having poorer sleep quality than floor nurses.

The results bore out the hypothesis. Among ICU nurses, the mean ESS score was 8.7, compared with a mean of 5.6 for the floor nurses (p=0.042). All in all, seven of the 10 ICU nurses had a score more than eight, compared with only two of the 10 floor nurses (p<0.005).

Similarly, the mean MSLT for the first nap period was 4.7 minutes for the ICU nurses and 10.9 minutes for the floor nurses (p=0.025), with nine of the 10 ICU nurses falling asleep in less than five minutes, compared with two of the floor nurses (p<0.005). ICU nurses also had a shorter MSLT overall, of 6.1 minutes, versus 10.6 minutes for the floor nurses, but this difference was not statistically significant. There also was no significant difference between the groups in mean nightly sleep time: ICU nurses reported a total 405 minutes, while the floor nurses clocked in at 416 minutes.

There are two probable interpretations of the data, said Dr. Subramanian, director of sleep services at Baylor. Perhaps it is simply too exhausting for people to function at a peak level of alertness, particularly in a demanding specialty like intensive care, for 12 hours. Or it could be burnout was as common among the ICU nurses in this study as it was for their colleagues in other studies, as reflected in their ESS scores, which rival the scores observed in people with depression or chronic illness and suggest a lower quality of everyday sleep. The findings most likely result from a combination of these factors, he notes.

This study is the first to evaluate sleepiness in night-shift nurses using the ESS and the MSLT, but not the first to document at least subjective reports of nurse sleepiness.

This study is the first to evaluate sleepiness in night-shift nurses using the ESS and the MSLT, but not the first to document at least subjective reports of nurse sleepiness, the investigators wrote. The authors of a Japanese survey of 4,407 nurses estimated at least 26% of those respondents suffered from excess sleepiness, and in a survey of 502 American nurses, two-thirds said they struggled to stay awake during their shifts. Dr. Subramanian pointed out that in studies of emergency room doctors and nurses, as well as workers in other intense, high-stress occupations, vigilance dwindles and sleepiness mounts after eight and especially 10 hours.

Dr. Subramanian

This can have serious consequences for patients and healthcare workers alike, he warns.

Excessive sleepiness “correlates very robustly with medical errors, incorrect operation of medical equipment, and falling asleep while driving.” In fact, some hospitals provide shuttle buses to transport night-shift workers to and from work, fearing they may be too exhausted to drive.

The Accreditation Council for Graduate Medical Education (ACGME) has limited work weeks for medical residents to 80 hours and no more than 24 hours’ continuous time on duty, but “that has clearly not worked: ICU residents still are extremely sleepy even when they adhere to the ACGME regulations,” Dr. Subramanian said. He recommended no one shift last longer than eight hours, and that healthcare workers be required to demonstrate they are not sleepy when they report to work.

Dr. Subramanian and his coauthors also found the ICU nurses had a higher mean body mass index than the floor nurses, which might suggest they eat more as a way of coping with higher stress levels. “Most nurses are women, and in addition to working 12-hour shifts, they’re probably taking care of their families,” he explains. “They’re not going home and catching up on their sleep.” TH

Norra MacReady is a medical writer based in California.

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