Power nap: Why sleeping on the job boosts safety

'Strategic naps' improve alertness

Encouraging nurses to sleep on the job may be one of the safest steps you can take.

That may seem paradoxical, since of course you don't want employees to be asleep when they should be taking care of patients. But a "strategic nap," taken during a scheduled break, can combat fatigue and improve alertness, sleep experts say.

In fact, the VA Palo Alto (CA) Health Care System has implemented the Strategic Nap Program to improve alertness, a pilot program that is being expanded to other VA hospitals around the country. "Sleeping at work is just odd," acknowledges Steven K. Howard, MD, staff physician and director of the Patient Safety Center of Inquiry at the VA Palo Alto. "But if it's done the correct way, it can actually lead to safer care."

While it may be challenging to convince employers to implement a nap program ("You have to educate people and put the positive spin on it," says Howard), the problems caused by lack of sleep are well-known. In fact, after 17 hours of wakefulness, performance drops and is equivalent to a 0.05 blood alcohol level, or about two drinks.1

In 2003, an Institute of Medicine panel emphasized the impact of fatigue on nurses who work night shifts or extended shifts. It cited a study that showed impaired performance after 12-hour shifts and recommended limits on nursing hours.2

"[T]here is no evidence to suggest that any amount of training, motivation, or professionalism is able to overcome the performance deficits associated with fatigue, sleep loss, and the sleepiness associated with circadian variations in alertness," the IOM panel concluded.

But restructuring the nursing work environment is controversial and complex. Hospitals can take immediate steps to improve alertness by creating a culture that enables "strategic naps," says Mark Rosekind, PhD, president and chief scientist at Alertness Solutions in Cupertino, CA.

Light exposure, caffeine, and physical activity are among the strategies for improving wakefulness, says Rosekind, an internationally known sleep expert who previously headed the Fatigue Countermeasures Program at the National Aeronautic and Space Administration (NASA) Ames Research Center. But strategic napping should be incorporated into a culture of safety, he says. In one study, when pilots on transpacific flights of nine hours duration took naps averaging 26 minutes, they had a boost in performance of up to 34%.3

Naps ranging from 15 minutes to 40 minutes are most effective, says Rosekind. Longer naps may allow someone to go into deep sleep, leaving them groggy and temporarily disoriented when they awaken and possibly disrupting their nighttime sleep, he says.

"A strategic nap is one of the most effective strategies to boost alertness and performance," says Rosekind.

'Our job is vigilance'

Howard became personally aware of the impact of sleep deprivation when he was a medical resident in anesthesiology. Like other residents, he just tried to tough it out.

Fatigue is especially problematic in anesthesia, Howard's field, because of the need to monitor the dosages given to patients for hours during surgery. "Our job is one of vigilance," says Howard, who is associate professor of Anesthesia at the Stanford University School of Medicine in Palo Alto. "Alertness is extremely important and sometimes challenging."

Howard began working with the VA's National Patient Safety Center to address the issue. He led a randomized, controlled study of 49 medical residents and nurses who worked at least three consecutive night shifts in the emergency department. On the third night, a randomly selected group had a 40-minute nap in a darkened room (with a bed and linens) between 3 a.m. and 4 a.m.

Faster reactions, fewer lapses

Performance tests at 7:30 a.m., after the third night shift, showed that the napping group had "faster reaction times and fewer vigilance lapses," Howard and his colleagues reported. The nurses and physicians also reported that they felt less sleepy. However, the nap group had fewer correct answers on a memory recall test at 4 a.m., when they awoke. The differences had disappeared when they were retested at 6:30 a.m. The nappers also were able to perform a catheter insertion more quickly than the non-napping group.4

Armed with data from that and other studies that showed improved performance after a short nap, Howard worked with hospital leadership to develop the Strategic Nap Program. It does not require any additional staff; employees are encouraged to take a nap during a scheduled break, such as a lunch or dinner break.

It wasn't difficult to find a place for napping. Some break rooms had a couch. A library was furnished with a reclining chair. A meditation room was vacant at night. Whatever the solution, the space needs to be very convenient because employees won't leave their work area to find a place to nap, Howard says.

When Howard evaluated the nap program, he found that employees on the night shift were more likely to use it than those on the day shift. Nurses reported feeling more alert after the naps. And education was critical, he says. "People tended to utilize the strategy more after we taught them about it and sanctioned it," he says.

Howard acknowledges that there are other issues that affect sleep and wakefulness. Employees may have a second job, or family responsibilities, or untreated sleep problems. But the Strategic Nap Program highlights the importance of being rested — and may begin to change the paradigm, he says.

"We know people are impaired because they're sleep-deprived. That's accepted in health care," he says. "Clearly it's not accepted to come to work if you've been drinking or on drugs. But we come to work impaired all the time."

Insomniacs have more errors

In fact, sleep problems are common among nurses. Rosekind surveyed 2,082 nurses and found that more than one quarter (27%) suffered from insomnia — difficulty falling asleep, staying asleep, or both — but only about 30% had sought medical treatment.

Those with sleep problems reported more medical dispensing errors and "charting deviations from standard practice." They also were significantly more likely to report having trouble staying awake at work.

The findings show the importance of educating nurses about sleep and insomnia, encouraging them to receive treatment for sleep problems, and implementing alertness strategies, says Rosekind, who previously directed the Center for Human Sleep Research at the Stanford University Sleep Center.

"When you help people manage their schedules, help them understand about sleep, they will be safer, healthier, and more productive on the job," he says.

Rosekind recognizes that transforming attitudes about sleep will take time. "In our culture today, we really care about what we eat, how we exercise. Sleep is not even in the ballpark yet, and it's just as important," he says.

(Editor's note: For more information on the VA's Strategic Nap Program, contact Steve Howard, MD, at showard@stanford.edu. More information on Alertness Solutions is available from www.alertness-solutions.com.)


1. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388:235-235.

2. Page A. (Editor). Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press, Institute of Medicine; 2004. Available at http://www.nap.edu/books/0309090679/html/.

3. Rosekind MR, Smith RM, Miller DL, et al. Alertness Management: Strategic naps in operational settings. J Sleep Res 1995; 4:62-66.

4. Smith-Coggins R, Howard SK, Mac DT, et al. Improving alertness and performance in emergency department physicians and nurses: The use of planned naps. Ann Emerg Med 2006; 48:596-604, 604.e1-3.