Running head: INTEGRATED REVIEW 1

Integrative Review

Madelyn McLain

Bon Secours Memorial College of Nursing

Dr. Turner

NUR 4122: Nursing Research

October 8, 2017

I pledge…
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Abstract

Purpose: The purpose of this integrative review is to examine literature looking at the effect of a

nap on night shift nurses.

Background: Past research has indicated that the benefit of a nap on night shift could help to

combat fatigue on night shift. Night shift nurses are at risk for fatigue that could affect job

performance and patient safety.

PICO Question: In nurses who work night shift, what is the effect of a nap on fatigue?

Design/search methods: This was an integrative review in which research was collected from

three online article databases. Search words used included nap, napping, night shift, nurses, and

nursing. Five articles were chosen based on search criteria, including reference to the PICOT

question.

Results/findings: The findings and results of the reviewed five research articles were mixed on

the positive benefits of napping on night shift. Variables impacting the implementation of a nap

policy include the environment and management support.

Limitations: Limitations to this review include the researchers limited experience writing

integrative review and the limited amount of articles found on this topic of research.

Implications for practice: An implication for future practice is that with implementation of a

nap, nurses would be more alert, experience less fatigue and would lead to safer patient care.

Recommendations for future research: More research is needed to support the implementation

of a nap on night shift.

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Integrative Literature Review

The purpose of this integrative review is to examine literature looking at the effect of a

nap on night shift nurses. It is well known that those who work nights are prone to extreme

fatigue. According to the National Sleep Foundation night shift workers are at an increased risk

for excessive sleepiness and when experienced in the workplace can lead to “poor concentration,

absenteeism, accidents, errors, injuries, and fatalities” (National Sleep Foundation, 2018). This is

especially serious when considering the direct patient care nurses provide.

While past research has indicated that the benefit of a nap on night shift could help to

combat fatigue on night shift, this researcher was not able to find a lot of current research being

done on this topic. In a statement issued by the American Nurse Association on nurse fatigue

they recommended using naps in accordance with workplace policies (America Nurse

Association, 2014). Even with the support of research and nursing standards stating a nap could

benefit night shift nurses, there is a lot of resistance and stigma associated with the

implementation in hospitals. The PICOT question being addressed by this researcher is in nurses

who work night shift, what is the effect of a nap on fatigue?

Designs & Methods

This integrative review focuses on five research articles. The search for research articles

was conducted through three search engines, Academic Search Complete, EBSCO’s Nursing

Center Reference Plus, and PubMed databases. The key search words used to locate articles were

nap, napping, night shift, nurses, and nursing. Academic Search Complete yielded 26 articles,

EBSCO’s Nursing Center Reference Plus yielded nine articles, and PubMed yielded 22 articles.

The articles were then filtered by publication date between 2011 and 2018. Other inclusion

criteria included full english text as well as peer reviewed and published studies.
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After meeting the qualifications mentioned, the researcher narrowed the articles down to

those relevant to the researcher’s PICOT question, “In nurses who work night shift, what is the

effect of a nap on fatigue?”. Articles not looking at nap interventions in night shift nurses were

disqualified. The five articles included in this review include four qualitative studies (Brown et

al., 2016; Chang et al., 2015; Fallis, McMillan, & Edwards, 2011; Neville,Velmer, Brown, &

Robol, 2017) and one systematic review of literature (Ruggiero & Redeker, 2014).

Findings & Results

The findings and results of the reviewed five research articles were mixed on the positive

benefits of napping on night shift (Brown et al., 2016; Chang et al., 2015; Fallis, McMillan, &

Edwards, 2011; Neville,Velmer, Brown, & Robol, 2017; Ruggiero, & Redeker, 2014). A more

extensive review of the five research articles can be found in the appendix. Included below is a

brief summary of each article.

In a qualitative study conducted by Fallis, McMillan, & Edwards (2011) the authors

researched critical care nurses’ experiences with napping on night shift during a six month

period. A convenience sample of 13 nurses were interviewed and asked 15 open response

questions on their personal experiences with napping (Fallis, McMillan, & Edwards, 2011) . The

interviews were recorded and then transcribed and analyzed using ethnograph software (Fallis,

McMillan, & Edwards, 2011). The authors found that the nurses performed an environmental

scan when determining when to take a nap. The environmental scan consisted of assessing the

business of the floor, how many nurses were working, and if there was anyone appropriate to

watch their patients while they took a nap. The priority of the environmental scan was ensuring

patient safety while the nurses took their nap (Fallis, McMillan, & Edwards, 2011).
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In a qualitative study by Brown et al. (2016) researchers implemented a napping policy at

two mid-Atlantic hospitals and looked at barriers to nap implementation and perceptions of naps

by the nurses who took them. While six units were selected, only two implemented a nap policy

and from those two units 150 30 min naps were polled. After nurses took naps they filled out a

single page nap experience form that used the Karolinska Sleepiness Scale to examine pre nap

sleepiness, nap length, perceived sleep experience, post nap sleep inertia, and overall helpfulness

of the nap. Data was then analyzed based on the measurement used and graphs were produced to

display proportions of data. The researchers found that the nurses overall reported naps to be

helpful and especially fight fatigue faced when driving home, but that barriers to nap

implementation remain high.

In a qualitative study by Chang et al. (2015) researchers investigated the implementation

of a 30 minute nap on eight hour night shifts and its benefit to worker performance and night

shift fatigue. The sample was 63 nurses from an acute ward of a Kaohsiung Municipal Kai-

Syuan Psychiatric Hospital in southern Taiwan. The sample was then randomly divided into

three groups of 21 nurses with one group comprising of nurses working day shift, one of night

shift nurses who did nap, and a group working night shift without napping. Methods of

collecting data included multiple tests looking at performance results and the Stanford Sleepiness

Scale which measures fatigue. Data was analyzed by looking at variables and examining them

using a chi-square test. The study found that the day shift sample had better cognitive results

then the night shift samples and that the impact of fatigue can affect worker performance on

night shift. The researchers were not able to fully determine if the implementation of a nap was

beneficial in decreasing fatigue.

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Neville,Velmer, Brown, and Robol (2017) conducted a comparative descriptive study

looking at the implementation of a nap on night shift and its effect on fatigue experienced by

nurses. A convenience sample of 68 practicing nurses enrolled at Kean University school of

nursing, all who worked night shift, completed an anonymous survey. The survey used the global

fatigue scale to measure mild, moderate, and severe fatigue on night shift and the impact napping

had on fatigue. The data was analyzed and the mean scores and standard deviations of the global

fatigue scale were computed and the Cronbach’s reliability coefficient was .96. The researchers

found that those who rotated shifts reported higher level of fatigue and only a few of the

participants reported nap policies at their workplaces. Those who took naps reported higher

levels of fatigue, but the researchers were unable to determine that they wouldn’t not be

beneficial.

In a narrative systematic review of literature by Ruggiero, & Redeker (2014) researchers

looked at studies that looked at fatigue and performance results following the implementation of

a nap on night shift, and how that would affect future practice. Thirteen studies met the search

criteria set by the researchers, one was an experimental study/randomized control trial and 12

were quasi-experimental. The variables studied were sleep before, during, and after nap

opportunities, effect of naps on daytime sleepiness, sleep related deficits and effects of nap

taken. The data was analyzed through an investigator developed form comparing the studies

different variables studied, findings and conclusions. The researchers concluded that planned

naps hold benefits for night shift nurses that include decreased sleepiness and decreased

performance deficits.

Discussion
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The five articles discuss are mixed in their results on nap implementation on night shift.

The majority support a reduction in fatigue when a nap is implemented. This researcher has

organized the review according to the following themes: environmental variables, impact of

napping and management support. The following themes will be discussed in relevance to the

PICOT question and how they will affect future practice.

Environmental Variables

The environment was a determining factor in several of the articles in allowing nurses the

opportunity to take a nap. Environmental variables included things like staffing numbers, acuity

of patients, how busy the unit was, and whether breaks were able to be covered by other nurses

(Fallis, McMillan, & Edwards, 2011). In health care settings with high stress, time restrictions

and limited resources, most nurses will forgo the opportunity to nap (Ruggiero, & Redeker,

2014). Successful nap implementation was supported by a specific planned environment

variables, These included a set aside private space where nurses could nap without distraction as

well as planned breaks at the beginning of the shift with assigned nurse coverage (Brown et al.,

2016). The implications for future practice show that a supportive environment that includes a

well staffed nursing shift and an area designated for napping, supports nurses ability to nap on

night shift. This theme directly related to the PICOT question, because it allows nurses the

opportunity to schedule naps when there is a friendly and supportive environment and this will

be a critical step to nap implementation in the future.

Impact of Napping

All five articles discussed the impact of napping on night shift nurses with the general

consensus being that a nap on night shift greatly reduces fatigue (Brown et al., 2016; Chang et

al., 2015; Fallis, McMillan, & Edwards, 2011; Neville,Velmer, Brown, & Robol, 2017;
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Ruggiero, & Redeker, 2014). A planned naps of 30 to40 minutes in duration on night shift is

shown to reduce fatigue and improve nurse performance (Ruggiero & Redeker, 2014). Another

benefit of implemented naps was reducing fatigue experienced on the drive home and promoting

the wellness and safety of the nurse (Brown et al., 2016). Most nurses who napped reported

increased energy which led to clearer judgment and safer patient care (Chang et al., 2015; Fallis,

McMillan, & Edwards, 2011). An implication in this research is that with the implementation of

a nap nurses would be more alert, experiencing less fatigue, leading to safer patient care. While

most reported naps to be helpful in reducing fatigue and increasing energy levels, some reported

sleep inertia and increased fatigue levels. The negative experiences reported by nurses were

mostly related to sleep inertia, causing disorientation and confusion when waking from a nap

(Fallis, McMillan, & Edwards, 2011; Neville,Velmer, Brown, & Robol, 2017). Other negative

effects reported included increased fatigued when napping, but could however be due to

increased responsibilities outside of the workplace factoring to the increased fatigue levels

(Neville,Velmer, Brown, & Robol, 2017). The implications of the negative effects of napping

show that more research needs to be done to reduce sleep inertia and increased fatigue. This

theme is directly related to the PICOT question since it addresses decreasing levels of fatigue

through napping. Napping is shown to decrease levels of fatigue in most nurses to support this in

practice more research needs to be done.

Management Support

The implementation of a nap on night shift as discussed above has revealed positive

benefits on fatigue. The key to ensuring nap implementation is successful is directly related to

the support of nursing management. This relates to the PICOT question, because the biggest

barrier to nap implementation identified in four of the articles was lack of support from nursing
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management (Brown et al., 2016; Fallis, McMillan, & Edwards, 2011; Neville,Velmer, Brown,

& Robol, 2017; Ruggiero, & Redeker, 2014). When management concerns arise about nap

implementation, the concerns should be addressed in shared nursing governance and work

together to find solutions. The implications for future practice show that nurse managers play a

major role in deciding if nap implication will be successful, by creating a quiet area for naps and

to encourage and support night shift nurses who decide to nap during their shift.

Limitations

The limitations of this integrative review should be mentioned by this researcher. This

integrative review was completed by a senior semester student at Bon Secours Memorial College

of Nursing for a senior research class. This student had no previous experience in writing an

integrative review. The student also was under time constraints in gathering article and

compiling the paper.

This was not an exhaustive review on all the literature and is only limited to the five

articles found. The review was also limited to articles written in the last seven years. The

individual articles had additional limitations including limited sample sizes and convenient

sampling methods which should also caution the reader. The methodology of two of the studies

included open interviews which could cause bias to the studies and a limitation to this studies

results. All the limitations mentioned should be taken into account when taking into

consideration these results.

Conclusion

The articles included in this integrative review overall support the implementation of a nap

on night shift decrease nursing fatigue (Brown et al., 2016; Chang et al., 2015; Fallis, McMillan,

& Edwards, 2011; Neville,Velmer, Brown, & Robol, 2017; Ruggiero, & Redeker, 2014). The
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overall conclusion is that the impact of napping was extremely subjective and personal to the

individual nurses and were affected by the nurse’s work environment, management support of

nap implementation, and individual physiological responses of a nap (Brown et al., 2016; Chang

et al., 2015; Fallis, McMillan, & Edwards, 2011; Neville,Velmer, Brown, & Robol, 2017;

Ruggiero, & Redeker, 2014).

In relation to the PICOT question being researched, in nurses who work night shift, what is

the effect of a nap on fatigue? The literature is mixed with most of it supporting decreased levels

of fatigue in nurses on night shift. More research will need to be done to support the

implementation of these findings.

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References

American Nurses Association. (2014). Addressing nurse fatigue to promote safety and health:

Joint responsibilities of registered nurses and employers to reduce risks. Retrieved from

http://www.nursingworld.org/MainMenuCategories/ WorkplaceSafety/Healthy-Work-

Environment/WorkEnvironment/NurseFatigue/Addressing-Nurse-FatigueANA-Position-

Statement.pdf

Brown, J. G., Sagherian, K., Zhu, S., Wieroniey, M., Blair, L., Warren, J.,Szeles, R. (2016).

Napping on the night shift: A two-hospital implementation project. The American

Journal of Nursing, 116(5), 26–33. http://doi.org/10.1097/01.NAJ.0000482953.88608.80

Chang, Y.S., Wu, Y.H., Lu, M. R., Hsu, C.Y., Liu, C.K., & Hsu, C. (2015). Did a brief nap break

have positive benefits on information processing among nurses working on the first 8-h

night shift? Applied Ergonomics, 48, 104–108.

https://doi.org/10.1016/j.apergo.2014.11.005

Fallis, W. M., McMillan, D. E., & Edwards, M. P. (2011). Napping during night shift: Practices,

preferences, and perceptions of critical care and emergency department nurses. Retrieved

September 24, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/21459861

National Sleep Foundation. (2018). Shift Work and Sleep. Retrieved October 15, 2018, from

https://www.sleepfoundation.org/sleep-topics/shift-work-and-sleep

Neville, K., Velmer, G., Brown, S., & Robol, N. (2017). A pilot study to examine the

relationship between napping and fatigue in nurses practicing on the night shift. Journal

of Nursing Administration, 47(11), 581–586.

https://doi.org/10.1097/NNA.0000000000000546
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Ruggiero, J. S., & Redeker, N. S. (2014). Effects of napping on sleepiness and sleep-related

performance deficits in night-shift workers: A systematic review. Retrieved October 9,

2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079545/

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Appendix

Article #1

APA Citation for Fallis, W. M., McMillan, D. E., & Edwards, M. P. (2011, April). Napping during
Article night shift: Practices, preferences, and perceptions of critical care and emergency
department nurses. Retrieved September 24, 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/21459861
Author(s) -
Qualifications ● Wendy M. Fallis is the founding director of the Clinical Institute of
Applied Research and Education at Victoria General Hospital and is an
adjunct professor in the Faculty of Nursing at the University of
Manitoba in Winnipeg, Manitoba,
● Canada.Diana E. McMillan is an associate professor
● Marie P. Edwards is an assistant professor in the Faculty of Nursing at
the University of Manitoba in Winnipeg

Background/Problem ● The purpose of this study was to provide an in-depth description of critical
Statement care nurses’ practices, preferences, and perceptions of napping/not napping
when working night shift in either an emergency department or an
intensive care unit (ICU).
● The benefits and drawbacks and the impact of napping/not napping on
both patients’ and nurses’ personal health and safety were sought.
Conceptual/theoretical ● this is a qualitative study and does not have a theoretical framework, they
Framework are developing theory.

Design/Method ● Qualitative descriptive study

If appropriate, ● Convenience sample of critical care nurses
Philosophical ● Feedback from night shift nurses on the affect napping had on them during
Underpinnings their shift.

Sample/ Setting/Ethical ● Interviews were conducted during a 6-month period with 13 registered
Considerations nurses who worked either in the emergency department (9 participants) or
the ICU (4 participants).
● Study was undertaken in an accredited acute care community hospital
located in central Canada. The hospital has an active 8-bed mixed ICU,
and an emergency department with more than 30000 visits per year.
● Approval was received from the University of Manitoba research ethics
board and access to the facility was granted.
● nurses were recruited through verbal invitations at staff meetings and
written invitations left in mailboxes.
● Written, informed consent was obtained before interviews.
● Participants were offered a small honorarium (Can$35) to offset costs
associated with the interview such as travel, parking, and child care.
Major Variables ● The Environmental Scan -a number of variables are taken into
Studied (and their consideration when determining when (or if) breaks or naps will be taken.
INTEGRATED REVIEW 14

definition), if ● Impact of Napping: Energized or Disoriented - Most nurses felt refreshed

appropriate after a nap, but few nurses avoided napping because of significant
challenges with sleep inertia
● Consequences of Not Napping: Foggy Thinking - slowed mental
processing, uncertainty, irritability, and energy loss were described by
nurses who wanted but were unable to nap during the shift.
Measurement Tool/Data ● 60- to 90-minute audio-taped, semistructured interview with each
Collection Method participant who volunteered to take part in the study was undertaken by 1
of the researchers (M.P.E.) at a mutually convenient time and place.
● Interview guide of 15 questions was used and were subsequently
transcribed verbatim by a transcriptionist; transcribed interviews were
checked for accuracy by the researcher undertaking the interviews.

Data Analysis ● Ethnograph software was used to help organize and manage the interview
data.

Findings/Discussion ● This study noted that 10 of the 13 nurses noted improvements in mood,
energy level, and response time when the work environment allowed them
to nap. Even a short 20-minute nap was viewed by some nurses as
restorative, allowing them to better attend to their job and improve their
work performance.
● Participants in our study identified impairments in cognitive functioning
and decision making when naps were desired but not possible.
● When tired before a nap, nurses in this study reported the increased need to
be vigilant when making decisions.
● Participants in our study described regularly scanning the environment to
ensure safe patient care could be provided before decisions were made to
go for a break of a nap.
Appraisal/Worth to ● The findings of this qualitative study illustrate some of the benefits and
practice concerns associated with napping on breaks during night shift.
● The unstable nature of patients’ conditions, staffing issues, worry, and a
non supportive napping environment combined to contribute to an inability
to take a nap, or the inability to achieve a restful nap.

Article #2

APA Citation for Brown, J. G., Sagherian, K., Zhu, S., Wieroniey, M., Blair, L., Warren, J.,Szeles,
Article R. (2016). Napping on the Night Shift: A Two-Hospital Implementation Project.
The American Journal of Nursing, 116(5), 26–33.
http://doi.org/10.1097/01.NAJ.0000482953.88608.80
Author(s) - Jeanne Geiger- Brown -Associate professor, University of Maryland School of
Qualifications Nursing, Baltimore, MD
Knar Sagherian - PhD student, University of Maryland School of Nursing,
Baltimore, MD
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Shijun Zhu - Assistant professor, University of Maryland School of Nursing,

Baltimore, MD
Margaret Wieroniey - Pediatric intensive care nurse, Childrens National Medical
Center, Washington, D.C
Lori Blair - Nursing administrative manager, Central Staffing Operations,
Children’s National Medical Center, Washington, D.C
Joan Warren - Director of nursing research and Magnet, MedStar Franklin Square
Medical Center, Baltimore, MD
Pamela Hinds - The William and Joanne Conway Chair in Nursing Research;
Director, Department of Nursing Research and Quality Outcomes; Associate
Director, Center for Translational Science, Children’s National Health System;
Professor, Department of Pediatrics, The George Washington University,
Washington, D.C
Rose Szeles8 -Director of nursing, hematology, oncology and bone marrow
transplant programs, Childrens National Health System, Washington, D.C
Corresponding author: Dr. Geiger-Brown, University of Maryland School of
Nursing
Background/Problem ● Nurses who work the night shift often experience high levels of sleepiness.
Statement 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.
● “This article describes the results of a napping implementation project that
was conducted in two hospitals. Its purpose was twofold: to assess the
barriers to successful implementation of night-shift naps, and to describe
the nap experiences of night-shift nurses.”
Conceptual/theoretical ● this is a qualitative study and does not have a theoretical framework
Framework ● literature review was conducted to see the effects of nap on the nurses
fatigue level.
Design/Method ● Qualitative
If appropriate, ● In this two-hospital pilot implementation project, napping on the night
Philosophical shift was offered to six nursing units for which the executive nursing
Underpinnings leadership had given approval. Unit nurse managers' approval was sought,
and where granted, further explanation was given to the unit's staff nurses.
● Nurse managers and staff nurses were also interviewed at the end of the
three-month study period.
Sample/ Setting/Ethical ● 2 mid-atlantic hospitals, one a 380 bed community teaching hospital, and
Considerations the other a 313 bed children's hospital. six nursing units were selected,
only implemented on two of the six units. 153 30-min naps were polled
during 3 months. Post survey period only one unit implemented naps.
● approval was obtained from the directors of nursing research, the nursing
research councils, and vice presidents for nursing at each hospital.
● Approval was also obtained from hospital's institutional review board and
from University of Maryland’s IRB.
● no unique identifiers were collected from the survey and researchers stated
thy kept anonymity
INTEGRATED REVIEW 16

Major Variables ● timing and duration of nap

Studied (and their ● sleepiness level immediately before the nap
definition), if ● sleep ability during the nap
appropriate ● sleep inertia upon arising
● perceived helpfulness of nap
Measurement Tool/Data ● a single page nap experience form was completed by nurses each time a
Collection Method nap was taken.
● 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.
● answers to questions were assessed using numeric scale to indicate levels
of sleepiness, four point ordinal scale to assess sleep ability during the nap
and sleep inertia, and a visual analog scale to rate perceived helpfulness of
nap.
Data Analysis ● data were described based on the level of measurement and graphs were
produced to display the relative proportions of the variables.
Findings/Discussion ● study showed barriers to napping implementation remain high
● “findings showed that nurses found naps to be helpful, Not directly assess
drowsiness while driving it was mentioned by nurses that napping helped
them stay awake on the drive home.”
Appraisal/Worth to ● first implication: napping is unlikely to be successful unless staff nurses
practice are willing to take completely relieved breaks, and can be assured when
they do coverage will be adequate and quality of patient care won’t suffer
● second implication: napping is evidence based practice that has potential to
improve workplace safety.
● third implication: napping is one component of hospitals employee health
and safety management programs.

Article #3

APA Citation for Chang, Y.S., Wu, Y.H., Lu, M. R., Hsu, C.Y., Liu, C.K., & Hsu, C. (2015). Did a
Article brief nap break have positive benefits on information processing among nurses
working on the first 8-h night shift? Applied Ergonomics, 48, 104–108.
https://doi.org/10.1016/j.apergo.2014.11.005
Author(s) - Yu-SanChang - Graduate Institute of Medicine, College of Medicine, Kaohsiung
Qualifications Medical University, faculty of nursing department Meiho University.
Yu-HsuanWu - Kaohsiung Municipal Kai-Syuan Psychiatric Hospital
Mei RouLu - Kaohsiung Municipal Kai-Syuan Psychiatric Hospital
Chung-Yao Hsu - Department of Neurology, Kaohsiung Medical University
Hospital
Ching-Kun Liu - Kaohsiung Medical University Hospital
ChinHsu - Department of Physiology, Kaohsiung Medical University
INTEGRATED REVIEW 17

Background/Problem ● It is therefore of interest to investigate whether the implementation of naps

Statement into the first night shift of 8-h night shift work has positive benefits on
performance.

Conceptual/theoretical ● no theoretical framework- qualitative study, building theory.

Framework

Design/Method ● The subjects were randomly assigned into three groups: nurses who
If appropriate, worked on daytime shift (n ¼ 21), on the first night of a night shift without
Philosophical taking a 30-min nap (n ¼ 21), and with taking (n ¼ 21), respectively
Underpinnings ● “The subjects in the night shift groups arrived at the hospital about 7:00
p.m. The room used for the subjects to take their prophylactic nap between
7 and 11 p.m. or 30-min nap between 2 and 3 a.m. was a distance away
from patient rooms and staff activity. The subjects were able to lie in a
quiet, dark bedroom. Participants were awoken by an alarm when the nap
ended.”
Sample/ Setting/Ethical ● Sample: 63 nurses from the acute ward of Kaohsiung Municipal Kai-Syuan
Considerations Psychiatric Hospital, which is the largest psychiatric center in southern
Taiwan
● Written informed consent was obtained from all subjects prior to
participation in the study,
● Approval of the Ethics Committee of Kaohsiung Municipal Kai-Syuan
Psychiatric Hospital.
Major Variables ● total sleep time
Studied (and their ● Impact of napping
definition), if ● Impact of not napping
appropriate

Measurement Tool/Data ● 3 a.m.e4 a.m. was selected of night shift groups to assess maximum
Collection Method fatigue and disturbance on performance
● the “State-Trait Anxiety Inventory (STAI) (Spielberger et al., 1983) -
STAI is a self-reported measure for state and trait anxiety. Each inventory
contains 20 self-reported items. All items are rated on a 4-point scale
(range 20e80 points) with a higher score indicating a higher anxiety”
● “Stanford Sleepiness Scale (SSS) (Hoddes et al., 1973) - The SSS is a 7-
point self rating scale developed for quantifying progressive steps in
sleepiness, from 1 (alert) to 7 (no longer fighting sleep). A score above 3
was defined as being no longer alert in this study”
● “Wisconsin Card Sorting Test (WCST) (Heaton et al., 1993) - The
computerized WCST, which is loosely considered a measure of frontal
lobe ability, consists of four stimulus cards and 128 response cards that
depict figures of varying forms, colors, and numbers of figures. Research
subject matches each consecutive card from the deck with one of the four
stimulus cards that she thinks it matches”
● “Taiwan University Attention Test (TUAT) (Ko, 1977)- The TUAT
involves attention processing as with the DSST and SST, which requires
INTEGRATED REVIEW 18

the examinee to cross out two target characters from a random list of 780
letters, numbers and symbols printed on an A4 sheet of paper as fast and as
accurately as possible.”
● Digit Symbol Substitution Test (DSST)
● Symbol Searching Test (SST) (Wechsler,1981)

Data Analysis ● Difference of continuous variables was examined by using oneway

analysis of variance whereas difference of categorical variables was
examined by using chi-square test.
● Scheffe's post hoc test was performed on variables demonstrating
significant differences in group comparisons.
Findings/Discussion ● “Post hoc tests showed that the subjects in the daytime shift group had a
significantly longer mean self reported total sleep time and a higher
number of characters per second on the TUAT compared to those in the
nap and none-nap groups”
● “The subjects in the daytime shift group also had a shorter completion time
on the TUAT compared to those in the nap and none-nap groups”
Appraisal/Worth to ● “However, the night shift groups experienced an approximate 2-h
practice reduction in sleep length compared to the daytime shift group, even there
was no difference in subjective sleepiness among the groups. Performances
on visual attentive tests in night shift groups also were worse than the
daytime shift group. This suggests that people frequently underestimate the
impact of sleep restriction on cognitive functions”
● “The daytime shift group had better performances on visual attentive tests
than did the night shift groups in the present study, which indicated
working on the first night shift being associated with sleep loss, leading to
a decrease in the accuracy of visual attentive tests.”
● “conclusion regarding there is positive benefits on perceptual speed when
implemented a 30-min nap into the first night shift and the ability cannot
compatible with working in the daytime shift even after taking a nap”

Article #4

APA Citation for Neville, K., Velmer, G., Brown, S., & Robol, N. (2017). A pilot study to examine
Article the relationship between napping and fatigue in nurses practicing on the night
shift. Journal of Nursing Administration, 47(11), 581–586.
https://doi.org/10.1097/NNA.0000000000000546
Author(s) - Kathleen Neville , PhD, RN - Professor, School of Nursing, Kean University,
Qualifications Union
Gillian Velmer, MA CCC-SLP - Academic Specialist, Kean University, Union
Shari Brown, MSN, RN - Clinical Coordinator, East Orange General Hospital
Nancy Robol, MSN RN-BC, NJCSN - School Nurse, Bridgewater-Raritan School
District, Bridgewater, New Jersey
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Background/Problem ● “The research question was: In nurses practicing on the night shift, will
Statement there be a difference in fatigue levels between nurses who take a
restorative nap as compared with those who do not?”
Conceptual/theoretical ● no theoretical framework- qualitative study, building theory.
Framework

Design/Method ● comparative descriptive design

If appropriate,
Philosophical
Underpinnings

Sample/ Setting/Ethical ● study was approved by Kean University institutional review board.
Considerations ● A power analysis revealed that a minimum sample size of 68 subjects was
needed.
● A convenience sample of practicing RNs, all of whom were enrolled in the
school of nursing received an e-mail requesting participation.
Major Variables ● global fatigue score, categorized as mild (0-3), moderate,4-6 and severe.(7-
Studied (and their 10) and compared those who napped on night and those who did not nap.
definition), if ● Impact of napping
appropriate ● Management impact

Measurement Tool/Data ● “Subjects completed an anonymous survey consisting of a demographic

Collection Method information sheet and the BFI,14 a 9-item scale with 3 items measuring
rating of fatigue now, usual, and worst fatigue and 6 items assessing daily
life interferences of fatigue in the past 24 hours.”

Data Analysis ● Descriptive statistics were conducted on demographic variables

● Mean Scores and Standard Deviations of the BFI
● “As reflected in the global fatigue score (Table 2), nurses reported
moderate4-6 levels of fatigue. While there were no statistically significant
differences in global fatigue and fatigue now between night-shift nurses
who napped and those who did not nap, findings revealed nurses who
napped had statistically significantly higher usual.”
Findings/Discussion ● Similarly, nurses who rotated shifts were found to have statistically
significantly higher mean scores in worst fatigue levels.
● This suggests that nurses who have more rigorous and taxing schedules
may experience greater fatigue.
● “Only a small percentage of nurses reported a napping policy at their place
of employment, which is consistent with the literature documenting a lack
of policies supporting napping.”
Appraisal/Worth to ● “The development of institutional interventions such as napping policies,
practice ultimately, night-shift nurses should be supported in self-monitoring for
fatigue and adjust their schedules accordingly.
● “Disruption in circadian rhythms dramatically impacts fatigue levels.” It is
important that both employers and nurses are educated on the hazards of
 INTEGRATED REVIEW 20

working while fatigued, as well as the benefits of working when well

rested.”
● “Nurses should be discouraged from the practice of working multiple
consecutive shifts, as well as discouraged from reverse rotations of shifts.”

Article #5

APA Citation for Article Ruggiero, J. S., & Redeker, N. S. (2014, April). Effects of napping on sleepiness
and sleep-related performance deficits in night-shift workers: A systematic review.
Retrieved October 9, 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079545/
Author(s) - Qualifications Jeanne S. Ruggiero, PhD, RN - College of Nursing, Rutgers, the State University
of New Jersey, Newark, NJ, USA
Nancy S. Redeker, PhD, RN, FAHA, FAAN - Yale University School of Nursing,
New Haven, CT, USA
Background/Problem ● Night-shift workers are prone to sleep deprivation, misalignment of
Statement circadian rhythms, and subsequent sleepiness and sleep-related
performance deficits.
● “a narrative systematic review in which we
addressed the following research questions:
1. What is the methodological quality of the studies of napping and
sleepiness and
sleep-related performance deficits?
2. What are the characteristics of the study populations, nature of the work,
and
workplace settings in studies of night-shift napping?
3. What characteristics of the naps are provided (e.g., length, time of day,
location) in
studies of night-shift napping?
4. What are the effects of night-shift napping on subsequent daytime
sleep?”
● The purpose of the study: “narrative systematic review is to critically
review and synthesize the scientific literature regarding improvements in
sleepiness and sleep-related performance deficits following planned naps
taken during work-shift hours by night workers and to recommend
directions for future research and practice.”
Conceptual/theoretical ● no theoretical framework identified.
Framework

Design/Method ● “A literature search using the Medline, PsychInfo, CINAHL, Cochrane

If appropriate, Library, and Health and Safety Science Abstracts databases and included
Philosophical English-language quasi experimental and experimental studies that
Underpinnings evaluated the effects of a nighttime nap taken during a simulated or actual
night-work shift.”
● narrative systematic review
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Sample/ Setting/Ethical ● 13 studies that met the inclusion criteria and included them in the analyses
Considerations ● Level 1: experimental study/randomized control trial
● 12 are Level II: quasi-experimental
● no ethical considerations are mentioned.
Major Variables Studied ● “Environmental variables: Sleep Before, During, and After Nap
(and their definition), if Opportunities - Pre Experimental Sleep, Nap Opportunities and Settings,
appropriate Effects of Night-Shift Naps on Daytime Sleep”
● Impact of napping - Sleepiness and Sleep-Related Performance Deficits
● Effects of Naps Taken at 00:00 or 01:00 hr, Effects of Naps Taken at
02:00, 02:30, 03:00 Hr, Outcomes of Naps Taken at 04:00
Measurement Tool/Data ● “Investigators used polysomnography (PSG) to measure nap duration,
Collection Method sleep architecture, and post-shift daytime sleep in 11 studies.”
● Karolinska sleepiness scale
● Stanford sleepiness scale
● Fatigue feeling scale

Data Analysis ● “investigator-developed form: the purpose of the study or research

question(s), sample characteristics and sampling procedure, setting,
random/nonrandom assignment and selection, blinding/double blinding,
data collection methods, intervention characteristics, outcome variables
and measures, internal and external validity, statistical methods, results,
and conclusions.”
Findings/Discussion ● “The findings of this review indicate that planned naps during night shifts
or simulated night shifts reduced nocturnal sleepiness and improved sleep-
related performance deficits in a number of populations and settings.”
● “naps as short as 20 min during this time frame had beneficial effects”
● “sleep inertia may have an impact on the outcomes of naps taken during
this time frame - further studies are needed to determine the optimal
timing of naps in order to minimize the possible hazards associated with
sleep inertia.”’
● “Future studies should include larger, randomized controlled trials to
establish the efficacy of napping in improving performance and safety.”
Appraisal/Worth to ● “planned naps hold promise as the means to improve sleepiness and sleep-
practice related performance deficits among shift workers.”
● “it may be feasible to implement nap programs in current workplace
studies.”