What is the hypothesis and the research question of the study?

Background: Fatigue associated with shiftwork can threaten the safety and health of nurses and the patients in their care. Napping during night shift breaks has been shown to be an effective strategy to decrease fatigue and enhance performance in a variety of work environments, but appears to have mixed support within health care. Purpose: The purpose of this study was to explore critical care unit managers' perceptions of and experiences with their nursing staff's napping practices on night shift, including their perceptions of the benefits and barriers to napping/not napping in terms of patient safety and nurses'personal health and safety. Methods: A survey design was used. Forty-seven Canadian critical care unit managers who were members of the Canadian Association of Critical Care Nurses responded to the web-based survey. Data analysis involved calculation of frequencies and percentages for demographic data, use of the Friedman rank test for comparison of managers' perceptions, and content analysis for responses to open-ended questions. Results: The findings of this study offer valuable insights into the complexities and confticts perceived by managers with respect to napping on night shift breaks by nursing staff. Staff and patient health and safety issues, work and break expectations and experiences, and strengths and deficits related to organizational napping resources and policy are considerations that will be instrumental in the development of effective napping strategies and guidelines.

I n 2010, the Canadian Nurses Association (CNA) and the Registered Nurses Association of Ontario (RNAO) issued a report titled Nurse Fatigue and Patient Safety, suggesting their findings represented "a clarion call... about the rising levels of nurse fatigue" (p. 1). Evidence has shown that shiftwork, particularly the combination of day and night shifts, contributes to nurses' fatigue (Admi, Tzischinsky, Epstein, Herer, & Lavie, 2008; Akerstedt & Wright, 2009; Berger & Hobbs, 2006; Hartenbaum, Van Cauter, & Zee, 2011; Kilpatrick & Lavoie-Tremblay, 2006; Muecke, 2005). Napping on night shift is a strategy used in environments outside of health care to assist workers to cope with shiftwork and improve work performance (Purnell, Feyer, & Herbison, 2002; Signal, Gander, Anderson, & Brash, 2009; Takeyama, Kubo, & Itani, 2005). This practice, however, remains controversial in nursing (Alspach, 2008; Humm, 2008). Managers are recognized as pivotal change agents within the health care system and are in a strategic position to influence work environments through policy development and system innovations to decrease nurses' fatigue and promote a culture of safety (Caruso & Hitchcock, 2010). At present, we have limited knowledge of nurse managers' perspectives on napping during breaks on night shifts. The purpose of this study was to explore critical care unit managers' perceptions of and experiences with nursing staff's napping practices on night shift. Napping on night shift breaks A review of published literature from the past 20 years was carried out using PubMed and CINAHL. Evidence is available to support the use of brief naps on night shifts to improve alertness and performance on the job and enhance safety of different types of workers (Asaoka, Fukuda, Murphy, Abe, & Inoue, 30 DYNAMICS CANADIAN ASSOCIATION OF CRITICAL CARE NURSES 2012; Bonnefond et al., 2001; Purnell et al., 2002; Ruggiero & Redeker, 2013; Signal et al, 2009; Takeyama et al, 2005). Significant variability was found across reports in terms of the duration and timing of naps during the night shift, with most naps lasting between 20 and 120 minutes and falling somewhere between midnight and four a.m. Sleep inertia, defined as "the state of impaired cognition, grogginess, and disorientation commonly experienced on awakening from sleep" (Wertz, Ronda, Czeisler, & Wright, 2006, p. 163), is identified as a safety concern in some napping studies (Kubo et al., 2010; Takahashi, Arito, & Fukuda, 1999; Takeyama et al., 2004). Two small studies have examined nurses' napping behaviours on night shifts. A group of eight intensive care unit (ICU) nurses in France kept a sleep diary for one month (Daurat & Foret, 2004). Four of the nurses napped at work, recording naps on 75% of their night shifts, with an average nap length of 150 minutes. The researchers concluded that whether or not the nurses napped on night shift appeared to be determined by circadian influences. In a study exploring emergency department (n = 9) and intensive care (n = 4) nurses' experiences with napping during breaks on night shift (Fallis, McMlan, & Edwards, 2011), 10 of 13 nurses reported regularly napping on breaks. Although performance or practice outcomes were not measured, nurses identified benefits of feeling energized or refreshed after a brief nap. Takahashi et al. (1999) examined the effects of timing and length of nurses' naps on 16-hour night shifts on subjective symptoms. Nineteen of 20 nurses in the study napped on their night shifts, with a mean nap length of 1.5 hours. Compared to pre-nap levels, sleepiness, fatigue, and dullness increased directly after the nap, with post-nap fatigue lasting longer, as the length of the nap increased, especially beyond 1.5 hours. Smith-Coggins et al. (2006) carried out a randomized control trial with emergency department physicians (n = 25) and nurses (n = 24) to assess the impact of a 40-minute night shift nap at 3:00 a.m. on cognitive and motor performance and on a simulated drive home after working 12 hours. The 26 participants in the nap group had fewer performance lapses, reported less fatigue and sleepiness, reported more vigor and exhibited less signs of sleepiness during a driving simulation than the non-nap group. Night-shift naps have also been examined in the context of a broader program to address nurses' fatigue. Scott, Hofmeister, Rogness, and Rogers (2010a) evaluated the feasibility of implementing a fatigue countermeasures program, including the use of strategic napping during breaks, for medical-surgical nurses in three hospitals. None of the nurses (n = 47) reported using naps at work in the pre-intervention period; 57 naps at work were reported at four weeks and 13 naps at 12 weeks. Nurses who napped reported that they felt guilty when doing so. In focus groups held with the nurses (n = 46) and their managers (n = 8) to assess the program, managers expressed concerns regarding a lack of organizational support and the inability to locate physical space for napping (Scott, Hofmeister, Rogness, & Rogers, 2010b). Overall, the studies on health care providers reported here involved small samples and varying approaches to napping and the assessment of its benefits (e.g., length and timing of nap, self-reported benefits of napping versus measurement of performance). No study has identified the optimal nap time in critical care settings and more studies are needed to assess the impact of napping on performance in these settings.

Conclusion The critical care nurse managers participating in this survey identified health, safety and patient care issues that support the need for a restorative nap during breaks on night shift, but also identified issues with napping as it is currently practised in their units. In addition, it was evident that barriers currently exist both within organizations and proximal work environments for achieving naps. Managers are in a unique position to provide leadership to promote patient and nurse safety in their units and organizations. To provide this leadership in relation to fatigue prevention and management, nurse managers require education and organizational support. This will assist them to contribute to the development of sound napping policies and guidelines and to work toward the creation of appropriate space for nurses to nap while on breaks.