Identify whether the study design is experimental or observational. Support your identification with examples from the study.

Background:Nurses who work the night shift often experience high levels of sleepiness. Napping has been adopted as an effective countermeasure to sleepiness and fatigue in other safety-sensitive industries, but has not had widespread acceptance in nursing.

Purpose:To assess the barriers to successful implementation of night-shift naps and to describe the nap experiences of night-shift nurses who took naps.

Methods:In this two-hospital pilot implementation project, napping on the night shift was offered to six nursing units for which the executive nursing leadership had given approval. Unit nurse managers' approval was sought, and where granted, further explanation was given to the unit's staff nurses. A nap experience form, which included the Karolinska Sleepiness Scale, was used to assess pre-nap sleepiness level, nap duration and perceived sleep experience, post-nap sleep inertia, and the perceived helpfulness of the nap. Nurse managers and staff nurses were also interviewed at the end of the three-month study period.

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.

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.