Analysis

How napping at work can help fight fatigue

Night shifts and long hours can affect sleep and raise the risk of errors. Are naps the answer?

Night shifts and long hours can affect sleep and raise the risk of errors. Are naps the answer?

  • Fatigue leads to errors, research shows, and anyone who has been awake for more than 16 hours is vulnerable to a micro sleep
  • Naps have been shown to help manage fatigue for night shift workers in particular, but some nurses worry about grogginess or sleep problems after napping at work
  • How attitudes to napping at work are changing in the nursing profession, plus how to get the most out of a mid-shift nap

Sleep matters. If it is disordered, interrupted or insufficient, errors and accidents can occur.

Shift workers

...

Night shifts and long hours can affect sleep and raise the risk of errors. Are naps the answer?

  • Fatigue leads to errors, research shows, and anyone who has been awake for more than 16 hours is vulnerable to a ‘micro sleep’
  • Naps have been shown to help manage fatigue for night shift workers in particular, but some nurses worry about grogginess or sleep problems after napping at work
  • How attitudes to napping at work are changing in the nursing profession, plus how to get the most out of a mid-shift nap
Illustration showing a nurse taking a nap while on break at work
Picture: iStock

Sleep matters. If it is disordered, interrupted or insufficient, errors – and accidents – can occur.

Shift workers are especially vulnerable to the detrimental effects of fatigue, according to the Health and Safety Executive (HSE) – and the risk of ‘errors, injuries and accidents’ is greater on night shifts, longer shifts and when there are insufficient breaks.

Fatigue and mistakes are interlinked

A 2019 Nursing Standard survey found as many as one in four nurses have had a car accident or near-miss when driving home tired after a shift.

The survey – undertaken prior to the COVID-19 pandemic – found that, of the 1,955 respondents who told us they drove to work, three quarters reported feeling tired or drowsy on the journey home.

Worryingly, 7% (141) of drivers admitted having fallen asleep at the wheel.

The HSE has concluded that night workers are more likely to be involved in accidents while driving home after a shift than those who work during the day.

Nurse Joanna Kippax, who runs her own insomnia consultancy, says fatigue and mistakes are interlinked.

Anyone who has been awake for more than 16 hours – often the case with night staff – is vulnerable to a ‘micro sleep’, defined as a brief, uncontrollable loss of consciousness.

‘Nurses who take a nap are not being slack. They’re not shirking their responsibilities. This is a patient safety measure’

Joanna Kippax, nurse and certified sleep practitioner

‘You may be unaware of it but your brain will automatically shut off at times,’ Ms Kippax explains. ‘You lose concentration.’

On a busy ward, or if you are driving home after a night shift, that momentary lapse could be critical.

Changing attitudes to napping at work

For nurses working night shifts, short naps may be one way of reducing the risk of unsafe practice and protecting their own health and well-being.

Napping isn’t for everyone though. Some find the experience leaves them with sleep inertia – that woozy feeling just after waking when motor skills and cognitive function seem to operate at half speed.

Others may be discouraged from napping by a workplace culture that perceives a doze even during an authorised break as ‘sleeping on the job’.

40 minutes’ break

should be sanctioned and ‘appropriate facilities’ provided if napping at work is allowed for shift workers

Source: Health and Safety Executive guidance

Then there are practical reasons why napping may be difficult, including overburdened hospital facilities offering no suitable space for staff in need of a restorative nap.

Ms Kippax says that changing attitudes are key to ensuring that night nurses who want to can take a nap.

‘It’s about changing the culture so that naps are expected rather than a luxury. Nurses who take a nap are not being slack. They’re not shirking their responsibilities. This is a patient safety measure.’

Night shift naps of 15-20 minutes ‘can improve alertness’

With medical staff, that shift in attitude has already occurred, she suggests.

The Association of Anaesthetists, for example, has a Fight Fatigue campaign that makes clear ‘a rested doctor is safer’.

A campaign poster asserts that on night shifts a nap of 15-20 minutes ‘can improve alertness’.

Joanna Kippax: ‘It’s about changing the culture so that naps are expected’

But for a variety of reasons, including staff shortages, which may limit proper breaks, nursing seems slower to adopt napping as a measure to protect both patient and staff safety.

Alison Steven, professor of research in nursing and health professions education at Northumbria University, has studied risk management strategies for staff fatigue during night shifts.

She says fatigue is a complex concept but studies across various industries, including aviation, nuclear and petrochemical, as well as healthcare, demonstrate the impact that tiredness can have on performance.

The cognitive decline that takes place as we tire can become the equivalent of trying to operate at the legal alcohol limit for driving.

Tiredness affects cognitive ability, as well as capacity for empathy

But fatigue has other effects too.

‘We know from the body of work out there that not only does your cognitive ability decline, your potential for empathetic responses to patients or clients can also be impaired,’ Professor Steven says.

In other words, tiredness threatens safety but it also can also diminish core nursing skills.

20 minutes’ break

away from the workstation is required for staff working longer than six hours

Source: Gov.uk

So can naps help? The improvement project Professor Steven was involved in, funded by the Health Foundation, aimed to help staff on a maternity unit at Newcastle upon Tyne Hospitals NHS Foundation Trust manage night shift fatigue.

Focus groups helped distil the main issues that staff across disciplines experienced while working nights.

A mix of views emerged on the benefits or otherwise of taking a nap during a night shift.

‘There were some people who liked napping but there were others who weren’t so keen,’ Professor Steven says.

There was concern among some individuals that a nap could make sleeping more difficult after their shift. Others were worried that, post-nap and back at work, they would feel groggy.

Nursing Standard’s well-being centre: podcasts, resources and more

Workplaces without the appropriate facilities

The question of where to nap also arose. ‘What do you sleep on?’ asks Professor Steven. ‘A couch? The floor?’

The lack of adequate facilities in many hospitals hints at an enduring stigma attached to taking a nap on a night shift – and perhaps a lack of organisational drive to adopt napping as a safety measure.

Health and Safety Executive guidance says if napping is sanctioned, ‘appropriate facilities should be provided, with scheduled breaks of around 40 minutes’.

These will allow workers ‘sufficient time to have a short nap, refresh themselves and regain alertness before resuming work’, the guidance states.

Professor Steven says: ‘For a long time there has been a feeling or culture in nursing and other professions that sleeping or napping on a night shift is not acceptable, not “the done thing”.’

But she suggests that view is receding. ‘We have become much more aware of the impact of fatigue on the individual but also of its impact on your practice.’

Nurses and midwives in the focus groups held as part of Professor Steven’s study also reported near-misses behind the wheel. ‘Blink and you’re up on the kerb,’ she says. ‘It’s absolutely terrifying.’

A junior doctor tries out the sleep pod in the trust’s trial
A junior doctor tries out the sleep pod in the trust’s trial

Staff sleep pods or reclining chairs: testing the benefits

Is it feasible to take a nap during a night shift?

Staff at the Hereford County Hospital, part of Wye Valley NHS Trust, are finding out.

The trust trialled reclining chairs and a futuristic-looking sleep pod complete with a lid that can be lowered for privacy and extra darkness.

Trust associate medical director for education Jayne Clarke says the junior doctors involved in the trial preferred the reclining chairs.

‘A number of reasons were given but the main one was that the chair was more comfortable.

‘The sleep pod was fine, it wasn’t uncomfortable. But if you were a larger person it was a bit snug.’

The doctors also found that with the lid of the pod down they felt a little vulnerable or exposed.

‘They couldn’t see out but people could see their bodies, whereas with the reclining chair you could open half an eye if you heard somebody in the room.’

The pod also took up a lot more space than a chair.

An option for staff members working nights

Dr Clarke says COVID-19 delayed the extension of the scheme to other professions, but a ‘wonderfully dark’ room has now been found near to the hospital restaurant that will house six reclining chairs for use by any staff member working nights.

Director of nursing Lucy Flanagan supports the scheme, says Dr Clarke, and was keen for nurses and other night staff to have access to the chairs during breaks.

The initial trial was restricted to medics because funding came via the government’s Enhancing Junior Doctors’ Working Lives programme. But an allocation from the foundation established by NHS fundraiser Captain Sir Tom Moore allowed the scheme to be extended to all staff.

Other trusts in England have also been trialling sleep pods, with some doctors and nurses using them before they drive home after night shifts.

Is napping viewed as unacceptable?

So where does the perception that napping is not acceptable originate? Does it percolate down from the top?

Not necessarily. Managers and senior nurses are often well aware of the risks to safety posed by fatigued staff.

In 2019, for example, Nursing Standard reported on efforts by Gloucestershire Hospitals NHS Foundation Trust to encourage staff on long shifts to take naps as a ‘safety initiative’.

Chief nurse and director of quality Steve Hams said the trust wanted nurses to see napping during breaks as ‘perfectly acceptable’.

Professor Steven agrees that it is often assumed that senior nurses are against the idea of their nurses taking naps, but she adds: ‘The extent to which that is true, I do not know. Sometimes these perceptions become received wisdom.’

While some may continue to question the value of a snooze during a designated break, she suggests there is a ‘great groundswell of people saying, “Actually, we get what’s going on here”.’

The point about fatigue rendering nurses less empathetic is also revealing, Professor Steven says.

Insights from her study suggest that a senior nurse or manager who might once have been surprised by a complaint about a staff member’s attitude, regarding such behaviour to be out of character for the individual, may now see it ‘through the prism of fatigue’, she says.

Digging deeper into the evidence around the benefits associated with night shift napping reveals little by way of counterargument, providing your nap meets certain criteria (see box below).

Making it count: how to nap well

Nurse and certified sleep practitioner Joanna Kippax suggests that if you are able to take a nap during a night shift, it’s a good idea to have a caffeine-based drink shortly beforehand.

‘That will take 20 minutes to get into your system and then you can have a 15-20-minute snooze. By that time, the caffeine will be kicking in and you’ll feel much more alert.’

‘If you nap for too long, you’re going to go into a deep sleep cycle. That’s when you wake up quite groggy and out of it, and obviously that’s dangerous’

A nurse napping while on break in a staff area
Picture: Neil O’Connor

And don’t nap for more than half an hour, she advises.

‘If you nap for too long, you’re going to go into a deep sleep cycle. That’s when you wake up quite groggy and out of it, and obviously that’s dangerous.’

When during a night shift is it best to take a nap?

‘If you can, take it between 1 and 3am,’ says Ms Kippax. ‘It’s preferable to avoid taking it around 4am because that’s when you’re likely to fall into your deepest sleep and feel pretty exhausted when you wake up.

‘It may also affect your daytime sleep if you leave it too late.’

A snooze during the afternoon before a night shift may also be beneficial.

‘That will ease your level of tiredness,’ Ms Kippax says.

What the research says about fatigue and napping

A study in the United States found naps helped reduce sleepiness in nurses and that sleep inertia was rare. Participants also reported feeling less drowsy on their drive home.

Research published in 2019 in the Journal of Advanced Nursing looked at night shift naps among 109 female nurses. The authors concluded: ‘A scheduled nap provides an effective countermeasure against the negative consequences of night-time shift work in female nurses above and beyond interpersonal differences.’

7%

of nurse drivers who responded to a 2019 Nursing Standard survey admitted to having fallen asleep at the wheel after a shift

Source: Nursing Standard

The US-based Sleep Foundation highlights health-survey data indicating that black people experience more sleep problems than white people.

Reasons for the disparity are uncertain but possible causes include people of colour being more likely to work night shifts or irregular hours. This finding suggests that some groups of nurses might find particular benefit from interventions designed to make night work less injurious to their well-being.

Rest, Rehydrate, Refuel initiative

The RCN’s Rest, Rehydrate, Refuel initiative encourages nurses and their managers to regard breaks not as a luxury but as a way of guarding against fatigue-related incidents.

Part of Professor Steven’s study also involved an educational element, with videos and other resources used to raise awareness of the impact of fatigue.

Like Ms Kippax, she stresses that napping during a night shift is purely an issue of safety and nothing to do with laziness.

‘It’s about moving away from stigmatising it and saying no, this impacts you, your colleagues, your patients or service users and your family.’


Further information

RCN Rest, Hydrate, Refuel initiative

Health and Safety Executive: Managing shift work: health and safety guidance

The Association of Anaesthetists: Fight Fatigue campaign

The Health Foundation: Effective management of staff fatigue during the night shift


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