Badge of honor or recipe for disaster? The importance of adequate sleep for nurses.

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Sentimental Women Need Not Apply (Garey & Hott, 1988), a film on the history of nursing, opens with a wartime scene of a nursing instructor admonishing her weary, awaking student with the following words: "A nurse is never too tired, nor too sick, nor too cold, nor too hungry. ... You'll smile because they (patients) need you." This view that "good nurses" deprive themselves of even the basic necessities of life, such as sleep, to care for their patients is pervasive within the nursing profession and establishes a dangerous and unhealthy environment for patients and nurses.

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The importance of Sleep

ONS member and researcher Grace E. Dean, PhD, RN, assistant professor in the State University of New York, University at Buffalo, School of Nursing worked on a study that examined the sleep habits of nurses while under the mentorship of Ann Rogers at the University of Pennsylvania.

"The staff nurses we studied frequently obtained less sleep than the seven to eight hours required by most adults," Dean says. "If nurses continually deprive themselves of adequate sleep, they are susceptible to developing chronic sleep debt and deficits in their ability to care for patients."

ONS member and researcher Ann M. Berger, PhD, RN, AOCN [R], FAAN, is a professor and Dorothy Hodges Olson Endowed Chair in Nursing at the University of Nebraska Medical Center, College of Nursing. In a review of the literature with colleague Barbara Hobbs, Berger cited research showing that only 39% of nurses working the day/evening shift slept seven or more hours per night (Berger & Hobbs, 2006). Less than 30% of nurses working rotating day/night or permanent night shift slept seven hours or more (Gold et al., 1992). In other words, based on this research, approximately 70% of staff nurses who work permanent night or rotating day/night shifts may be deprived of adequate sleep.

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"There are many strategies nurses can use when working permanent night and rotating shifts to ensure that they obtain adequate sleep," Berger says. "However, there is significant room for additional research in areas such as better understanding of lifestyle changes for optimal function among shift workers, the use of melatonin to promote adaptation to shift work, and the appropriate frequency of shift changes for nurses who rotate between day and night shifts.

"Unfortunately, we know little about whether staff nurses are aware of and use the existing strategies recommended for avoiding sleep deprivation," she adds.

Dean agrees that "greater attention needs to be paid to increasing staff nurse awareness of the role of sleep in personal health and wellness, the risks of sleep restriction, and implementation of strategies to prevent sleep restriction."

Risks from lack of Sleep

Nurses need to know that people who do not get adequate sleep may pose a threat to themselves and the public when they get behind the wheel, Dean says. Scott et al. (2007) found that more than two-thirds of the 895 nurses they studied reported difficulty remaining awake while driving home from their shifts at least once during the study's four-week data collection period. Of those nurses, 281 reported having motor vehicle accidents or near misses during the same period. "Drowsy driving" was increased in this study when nurses worked more than 12.5 hours in a shift, slept fewer than 6.33 hours preceding a shift, struggled to stay awake or fell asleep during a shift, or worked a night shift.

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Contrary to the opinion of the nurse in Sentimental Women Need Not Apply, nurses also can be too tired to provide safe and effective care for their patients--regardless of whether the nurse is smiling.

"Staff nurses who restrict their sleep pose a threat to hospitalized patients in at least two ways," Dean says. The number of errors made by nurses increases when nurses work more than 12 hours in a shift or more than 40 hours per week (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). In addition, "Staff nurses play a vital role in discovering and correcting medical errors and those of other health professionals," Dean explains. "Nurses may be the first and sometimes last line of defense in preventing errors before they reach the patient."

She adds that "when sleep is acutely or chronically restricted, neurobehavioral deficits increase, especially for tasks that require attention, memory, and cognitive and psychomotor speed. Since nursing and the detection of others' potential errors requires all of these abilities, often simultaneously, it is critical for nurses to obtain adequate amounts of sleep in order to provide safe and effective patient care." Ways to Get Your Eight Hours

Of the many strategies recommended for nurses to achieve seven to nine hours of sleep, regardless of shift, Berger emphasizes that one of the most important is for nurses who work permanent or rotating day/night shifts to leave the hospital when their shifts end.

"Too many nurses stay on the floor to assist the day shift, catch up with colleagues, or do last-minute tasks after their shift has officially ended," Berger says. "These habits extend the nurse's shift to 13 or 14 hours, which limits time for relaxation before bedtime and the ability to obtain seven to nine hours of sleep before waking and preparing for the next shift."

Berger also stresses the importance of nurses who work permanent night or rotating shifts not to jump back to sleeping all night during off times.

"Rather, nurses should continue to sleep over the same four-hour 'anchor' period (e.g., 9 am-1 pm) regardless of whether they are working and adjust their off-day sleep schedule so that they obtain eight hours of sleep from 5 am-1 pm, for example."

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Finally, Berger recommends that an important strategy is for nurses to nap before leaving for a 7 pm shift so that no more than 18 hours elapse before going to bed again.

Both Berger and Dean recommend that workplaces reexamine their policies to provide opportunities for nurses to be adequately rested. The 12-hour shift is the most common schedule among U.S. hospitals (Scott et al., 2007). "We need to rethink the 12-hour shift based on our research findings," Dean says.

As the length of a shift is examined, so too should the frequency of shift work rotations for nurses who rotate between day and night shifts, Berger says. She recommends that employers reduce the number of shift rotations from weekly to monthly and provide opportunities for naps during the shift.

Finally, Dean recommends that researchers "develop and test countermeasures to reduce staff nurse fatigue, such as the timing of caffeine ingestion and the use of a 20- to 30-minute nap on nurses' reaction time."

As long as patients continue to need around-the-clock care, nurses will be at their side. However, as the nursing workforce is stretched further and further by the nursing shortage and the struggling economy, it will be increasingly important for nurses to heed the advice of researchers like Berger and Dean, refuse to accept sleep deprivation as a badge of honor, and advocate for their own health and the well-being of their patients by ensuring that they practice strategies that enable them to obtain adequate sleep.

Berger, A.M., & Hobbs, B.B. (2006). Impact of shift work on the health and safety of nurses and patients. Clinical Journal of Oncology Nursing, 10(4), 465-471.

Garey, D., & Hott, L.R. (Directors). (1988). Sentimental women need not apply [Motion picture]. United States: Florentine Films (Los Angeles, CA, Direct Cinema Ltd.).

Gold, D.R., Rogacz, S., Bock, N., Tosteson, T.D., Baum, T.M., Speizer, F.E., et al. (1992). Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. American Journal of Public Health, 82(7), 1011-1014.

Rogers, A.E., Hwang, W.T., Scott, L.D., Aiken, L.H., & Dinges, D.F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212.

Scott, L.D., Hwang, W.T., Rogers, A.E., Nysse, T., Dean, G.E., & Dinges, D.F. (2007). The relationship between nurse work schedules, sleep duration, and drowsy driving. Sleep, 30(12), 1801-1807.

Contributing Editor Robin M. Lally, PhD, RN, BA, AOCN [R], CNS, is a research assistant professor in the School of Nursing at the State University of New York at Buffalo.

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Tips for Improving Sleep

* Go to bed at a regular time (e.g., 4:30 am, 8:30 am) if you work nights.

* Hang a sign on the bedroom door noting "day sleeper" as a reminder to family.

* Establish a regular wake-up time (e.g., 12:30 pm, 4:30 pm).

* Design the bedroom so it is suitable for day sleep by using black-out curtains.

* Maintain the room's temperature from 65[degrees]F-70[degrees]F.

* Reduce all potentially disturbing noises in the bedroom (e.g., telephone, clock, pets) and wear earplugs or use white noise (e.g., wave machines, box fans) to block out environmental noises.

* Avoid food, alcohol, and drinks that are high in caffeine at least six hours before going to bed.

* Limit fluid intake to 8 oz just before going to bed.

Berger, A.M., & Hobbs, B.B. (2006). Impact of shift work on the health and safety of nurses and patients. Clinical Journal of Oncology Nursing, 10(4), 465-471.

Morin, C.M., & Espie, C.A. (Eds.). (2003). Insomnia: A clinical guide to assessment and treatment. New York: Kluwer Academic.

Szuba, M.P., Kloss, J.E., & Dinges, D.F. (Eds.). (2003). Insomnia: Principles and management. New York: Cambridge University Press.