Identify the data collected as quantitative or categorical. Support your identification with examples from the study.

METHODS

Setting.This pilot study of a napping implementation project was one component of a study of fatigue risk management implementation initiatives in two mid-Atlantic hospitals. One is a 380-bed community teaching hospital, and the other a 313-bed children's hospital. Both hospitals have received Magnet recognition from the American Nurses Credentialing Center. Procedures.Initial study approval was obtained from the directors of nursing research, the nursing research councils, and the vice presidents for nursing at each hospital. Approval was also obtained from each hospital's institutional review board (IRB) and from the University of Maryland's IRB. Six nursing units were then selected collaboratively by the nursing research directors and executive nursing leadership. Unit selection took place between October 2011 and May 2012. The selected units included medical-surgical, critical care, and ED units.

The process of engaging the units was the same in both settings. Between January and October 2012, the principal investigator (JGB) met with each nurse manager and her designates (nurse educators, senior nurses, or a staff nurse designated as the project "point person"), and provided information about the risks of sleepiness on the night shift, the scientific evidence supporting napping, and methods to avoid post-nap sleep inertia. Each unit was encouraged to develop its own evidence-based method of implementing napping (seeTable 1,7, 22, 24, 25, 30-35). Nurse managers often delegated implementation to their senior nursing staff. When requested, the principal investigator introduced the study to nurses verbally during change of shift meetings. Data collection with staff nurses took place between February 2012 and May 2013. Nurse managers were interviewed at the end of the data collection period, and night-shift nurses were also interviewed as a group on the unit where napping was successful. These interviews took place during February 2014, and written notes were taken.

Measures.A single-page nap experience form was used by napping nurses to document aspects of the nap. Nurses were asked to complete the form each time they took a nap. Data gathered included the timing and duration of the nap, sleepiness level immediately before the nap, sleep ability during the nap, sleep inertia upon arising, and helpfulness of the nap. No unique identifiers were collected. The nap experience form incorporated the following tools. Sleepiness levels immediately before napping were assessed using the Karolinska Sleepiness Scale (KSS). This scale rates sleepiness on an ordinal scale ranging from 1 to 9, with 1 representing extremely alert, 5 representing neither alert nor sleepy, and 9 representing very sleepy, great effort to keep awake, fighting sleep. Ratings of 7 to 9 indicate levels of sleepiness that can impair workplace safety. The KSS is widely used in sleep science to describe state of sleepiness,36and has been validated against performance and electroencephalographic variables.37Sleep ability during the nap was assessed using an investigator-developed four-point ordinal scale (1, awake, eyes closed; 2, eyes closed, not sure if I fell asleep; 3, slept lightly; 4, slept deeply). Sleep inertia on arising was measured using an investigator-developed four-point scale (1, very groggy or sluggish; 2, a little groggy or sluggish; 3, alert, not refreshed; 4, alert and refreshed). The perceived helpfulness of the nap was assessed using an investigator-developed visual analog scale in which participants marked a line to rate their nap somewhere between "not at all helpful" (rated 0) and "extremely helpful" (rated 10).In order to ensure participants' anonymity, we did not collect demographic data.

Data analysis.Data were described based on the level of measurement, and graphs were produced to display the relative proportions of the variables.

Results:Successful implementation occurred on only one of the six units, with partial success seen on a second unit. Barriers primarily occurred at the point of seeking the unit nurse managers' approval. On the successful unit, 153 30-minutes naps were taken during the study period. A high level of sleepiness was present at the beginning of 44% of the naps. For more than half the naps, nurses reported achieving either light (43%) or deep (14%) sleep. Sleep inertia was rare. The average score of helpfulness of napping was high (7.3 on a 1-to-10 scale). Nurses who napped reported being less drowsy while driving home after their shift.

Conclusion:These data suggest that when barriers to napping are overcome, napping on the night shift is feasible and can reduce nurses' workplace sleepiness and drowsy driving on the way home. Addressing nurse managers' perceptions of and concerns about napping may be essential to successful implementation.