867714

research-article2019
WHSXXX10.1177/2165079919867714Workplace Health & SafetyWorkplace Health & Safety

vol. XX  ■  no. X Workplace Health & Safety

Brief Research Report

Nursing Students’ Sleep Patterns and Perceptions of

Safe Practice During Their Entrée to Shift Work
Lois James, PhD1 , Patricia Butterfield, PhD, RN1, and Erica Tuell, CHES1

Abstract: Background: The transition into shift work sticks, and errors, such as medication miscalculation; and
represents a critical and challenging time point in a nurse’s degrade long-term health (Satterfield & Van Dongen, 2013;
career. The purpose of this study was to describe nursing Williamson & Lombardi, 2011). Within the health care system,
students’ sleep patterns and perceptions of safe practice between 24% and 45% of nurses report sleep disturbances
during their first semester of clinical rotations. Method: (Waage et al., 2014) that have been associated with patient
Repeated measures pertaining to the sleep patterns of medication errors and occupational health risks for nursing staff
19 full-time junior undergraduate nursing students were (Asaoka et al, 2013; Rogers, 2008; Shao, Chou, Yeh, & Tzeng,
measured before, during, and after their first clinical rotations. 2010). A considerable body of research has focused on the
Sleep was measured using wrist activity monitors and sleep relationship between sleep, shift work, and long-term health
diaries for seven consecutive days at each time period. outcomes in practicing nurses. An example is the Nurses’ Health
Students’ “self-efficacy” or belief in their ability to provide Study that began in 1976 with an initial focus on cancer, in
safe practice was measured for (a) patient care (preventing which more than 238,000 U.S. nurses had participated
adverse events to patients) and (b) occupational health (Hankinson, 2015). Findings from this study revealed
(preventing occupational injuries to themselves) using associations between night shift work and multiple risks for
Bandura’s self-efficacy scales. Associations between students’ chronic disease such as obesity, cancer, hypertension, and
sleep, sleepiness, and their perceptions of safe practice cardiovascular mortality (Gangwisch, Feskanich, Malaspina,
were explored. Results: Nursing students’ self-efficacy scores Shen, & Forman, 2013; Gu et al., 2015; Ramin et al., 2015).
regarding patient care (preventing adverse events) improved Occupational health studies addressing sleep and safe
across the three time periods (from 80% before clinical practice around patient care provide a complementary
rotation, to 84% during clinical rotation, to 87% after clinical perspective to those addressing health risks to nurses. For
rotation). Although lower overall, students’ self-efficacy scores example, a study on nursing error rates found that night shift
regarding occupational health (preventing occupational nurses were over 40% more likely to make errors than day shift
injuries to themselves) also improved across the three time nurses (Niu et al., 2013). Given that medical errors are currently
periods (from 71% before clinical rotation, to 76% during the third leading cause of death in the United States, sleep
clinical rotation, to 77% after clinical rotation). Furthermore, restriction and fatigue among nurses are clearly of major
increased sleepiness significantly predicted lower self- concern, so much so that the American Nursing Association
efficacy scores for both patient care and occupational health. (ANA, 2014) has stressed the importance of reducing fatigue
Conclusion/Application to Practice: Sleepiness can impair and sleepiness in nurses to help address this national problem.
nursing students’ confidence in their ability to practice safely. Similarly, The Joint Commission—a U.S.-based, independent,
health care accrediting organization that focuses on enhancing
quality of care and patient safety—identified drowsiness,
Keywords: nursing, shift work, sleep, safe practice, self- fatigue, and sleep deprivation as hazards for both patient safety
efficacy, total worker health and health care workers’ personal safety and well-being (The
Joint Commission Sentinel Event Alert, 2011). There is
Introduction compelling evidence that health risks to both workers and
Shift work and associated sleep loss can impair cognitive patients increase when nurses’ sleep patterns are outside the
performance; promote workplace accidents, such as needle norm.

DOI: 10.1177/2165079919867714. From 1Washington State University. Address correspondence to: Lois James, PhD, 412 E. Spokane Falls Blvd, Spokane, WA 99201, USA; email: lois_james@
https://doi.org/

wsu.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2019 The Author(s)

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Workplace Health & Safety Mon 2019

sleep, sleepiness, and confidence in their ability to provide safe

Applying Research to Practice patient care.
This study addresses a gap in the total worker health
Method
(TWH) research by examining a critical period in the
professional development of nurses and can inform the Study Design
development of future occupational interventions. Of Using a repeated measures design, the sleep quantity and
particular importance are interventions targeted toward quality of 19 full-time nursing students were monitored before,
reducing nursing student sleepiness and promoting during, and after their first clinical rotations in the second
resilience to shift work, stress, and sleep restriction. Our semester of their junior year. Sleep quantity (calculated based
research adds to the body of research literature informing on minutes of sleep per 24 hours) and quality (calculated based
promotion of patient care and occupational health safe on degree of movement during sleep) were measured
practice, and maximizing the health, safety, and objectively using wrist activity monitors (actigraphy), and
productivity of the nursing workforce. sleepiness was measured using sleep diaries for seven
consecutive days at each time period. During these same time
periods, perceptions of patient care safe practice (preventing
Although the risks of sleep restriction and fatigue for nurses adverse events to patients) and occupational health safe practice
and their patients have been a topic of great interest, very little (preventing occupational injuries to self) were measured using
research has focused on nursing students as they prepare to Bandura’s self-efficacy scales.
face the rigors of the health care workforce. More than 150,000
new nursing graduates join the U.S. workforce each year Theoretical Framework
(Health Services and Resources Administration, 2015). This Social ecological theory formed the foundation for the
workforce has approximately 2.9 million workers and serves a research; key concepts were organized according to the
critical function in the health care system and society at large Ecological Model of Disaster Management, a nested systems
(Hankinson, 2015). During their education, nursing students model developed by Beaton, Butterfield and colleagues to
make an abrupt transition from traditional classes into clinical frame different levels of organizational response during public
rotations and shift work, a challenging time where fears of health emergencies (Beaton et al., 2008). This model informed
medical errors and adverse patient events abound. Qualitative the study due to its focus on the individual within the
research has shown that nursing students fear being negligent, organizational context, making it a holistic way to view nursing
administering incorrect medications, or mislabeling something students’ occupational health and subsequent patient care
(Noland & Carmack, 2014). Another qualitative study exploring consequences. For the current study, the model was adapted to
nursing students’ fears as they transitioned to the workforce focus on levels of concepts addressing student health (e.g.,
found that their anxiety about making mistakes impaired their sleep patterns), student attributes (e.g., household situation
ability to sleep, resulting in a negative spiral of stress, sleep influencing sleep patterns), organizations (e.g., university,
disturbance, and more stress (Postma, Tuell, James, Graves, & hospital), and organizational attributes (e.g., shift expectations).
Butterfield, 2017). Postma and colleagues reported the following This adaptation of the model focused on personal and
quotations from nursing students who characterized this cycle: organizational antecedents of safe nursing practices. In this case,
“. . . I think for a lot of us it felt like drinking out of a fire hose safe-practice self-efficacy in patient care (preventing adverse
. . . Then that adds to the isolation, and the anxiety, and—the events to patients) and occupational health (preventing
stress. . . and then you don’t sleep” (p. 3); “You may fall asleep, occupational injuries to themselves) was used as a proxy for
but then you’re sleeping, and then all of a sudden, you’re safe clinical practice
like—You’re having a dream that you’re just messing up
something in clinical, which I’ve done” (p. 3). Participants
Despite some qualitative research on this topic, the extent A convenience sample of 19 nursing students were recruited
to which nursing students’ sleep affects their ability to provide into the study. Inclusion criteria were full-time student status
safe clinical practice is unknown. Quantitative associations and assigned to clinical rotations as part of their junior year. The
among sleep, sleep problems, and safe practice in student clinical rotations were designed to expose students to shift work
nurses have yet to be fully explored. The goal of this study was and allow them to gain valuable insight into the nursing
to address this gap in the research literature by monitoring workforce. Clinical rotations included three shifts per week, and
nursing students’ sleep patterns (quantity and quality) and shifts ranged from 6 to 8 hours. Students were assigned to day,
sleepiness during their first semester of day and night shift evening, or night shifts. Some students remained on the same
clinical rotations, a critical juncture in their professional shift throughout their clinical rotations, and others experienced
development. During this same time frame, we also measured more than one shift type. Recruitment procedures included
students’ safe-practice self-efficacy (both for patient care and providing a 10-minute in-class briefing to junior year students,
for occupational health) to investigate associations between as well as posting fliers and social media alerts. Students were

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assured that decisions to participate (or not) would in no way incomplete (e.g., due to lack of compliance wearing the
affect their grades or academic standing. No members of the Readiband).1 Student health, student context (e.g., whether they
research team were in a teaching or evaluation role for junior slept with a bed partner), organization, and organizational
year students. The study was approved by the Washington State context data (e.g., housing situation, children, evening vs. night
University’s Internal Review Board (IRB) prior to participant shift) associated with sleep were also collected.
recruitment. The primary outcome measure was safe-practice self-
efficacy. This concept was measured by having students
Study Measures and Procedures indicate (on a scale from 0 to 100, where 0 = cannot do at
Data were collected for seven consecutive days at three all, 50 = moderately certain I can do, and 100 = highly
time points: Week 1 of the semester (prior to clinical certain I can do) the degree of confidence they had in (a)
rotations), Week 7 of the semester (during rotations), and safe patient care (preventing adverse events to patients) and
Week 14 of the semester (following rotations, but prior to final (b) occupational health (preventing injuries to themselves). In
exams). Thus, the data collection period took place over the total, 24 items were included. Fifteen of these addressed
course of 14 weeks. The primary study measure/independent patient care (e.g., “administer injections”) and nine addressed
variables were sleep quantity, sleep quality, and subjective occupational health (e.g., “use safe lifting practices”). Scores
sleepiness. Sleep quantity and quality were measured were converted to percentages (maximum 100%) for ease of
physiologically using wrist actigraphy, specifically using the interpretation. We did not select a cutoff point to determine
Readiband V3™ actigraph by Fatigue Science. Actigraphy has “confident” versus “not confident” in ability to provide safe
been validated for the estimation of sleep quantity and quality practice. The research team has previous experience using
across age groups (Driller, McQuillan, & O’Donnell, 2016). Bandura’s (2001) Guide for Constructing Self-Efficacy Scales,
Actigraphy data were scored as “sleep” when the algorithms and the 24 items we selected were based on those developed
detect minimal activity over a period of time. Data are by Ryan and colleagues (2013). Internal reliability for these
recorded for each day the Readiband is worn and are items is high (Cronbach’s α = .94 for patient care self-efficacy
represented as a graph from midnight to midnight. The items and .83 for occupational health self-efficacy items).
software converted these data into information about sleep Students were e-mailed the safe-practice self-efficacy scales to
through the use of scientifically validated algorithms. The complete each day.
more activity recorded, the lower the quantity and quality of
sleep during that time. Sleep quantity was expressed as Analytical Approach
minutes of sleep across a 24-hour period. Sleep quality was Descriptive statistics (means and standard deviations for
expressed as a percentage that was calculated as the inverse of continuous variables, sample sizes, and frequencies for
the percentage of movement recorded during sleep. For categorical variables) were examined. Sleep quantity (minutes
example, if 25% of a participant’s sleep was disturbed through of sleep per 24 hours), sleep quality (expressed as a
movement, their sleep quality measurement for that night percentage of time in bed actually sleeping, based on
would be 75% that was not disturbed. We further calculated actigraphy algorithms measuring movement during sleep),
the average sleep quantity (minutes of sleep) and quality
and subjective sleepiness (measured by sleep diary responses)
(percentage undisturbed sleep) over the seven-night period at
were then tested for their ability to predict students’ self-
each time point (prior, during, and after clinical rotations).
efficacy (expressed as a percentage from 0% to 100%)
Clinical comparison of Readiband sleep scoring versus
addressing (a) adverse events involving patients and (b)
polysomnographic sleep scoring indicated an accuracy rate of
occupational injuries to themselves. Student context (e.g.,
92% (de Souza et al., 2003). Students were instructed to keep
the actigraph on for the seven consecutive days during each sleeping with a bed partner) and organizational context (e.g.,
data collection period. These devices are waterproof and Food shift type) were also examined in the model. Generalized
and Drug Administration (FDA) approved for research use in linear multilevel modeling (MLM) with fixed effects was used
hospital settings. to account for repeated observations across participants
Subjective sleepiness was measured via sleep diaries that overtime to reduce the likelihood of a Type I error and to
participants filled out for the seven consecutive days of each account for potential clustering of data. This statistical
study measurement period. Subjective sleepiness was measured technique provides equivalent output to a linear regression
by asking students whether (on average) they felt sleepy or alert analysis, while estimating fixed effects to account for the
throughout the day. Additional questions were asked in the possible violation of the assumption of independence among
sleep diaries such as the following: “What time did you go to data points. Significance levels were set at .05. SPSS 24.0.0.0
bed?” “How long did it take you to fall asleep?” “How many software was used for all analyses.
times did you wake up in the night?” “What time did you wake
up?” Although this information was all collected with a greater Results
degree of reliability from wrist actigraphy, these data were Table 1 depicts that in our sample of 19 students, most of
important for instances when wrist actigraphy data were them were female (84%) and Caucasian (95%). The average age

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periods—from 80% at Time 1 (range = 28%-94%), to 84% at

Table 1.  Demographic Characteristics of the Nursing Time 2 (range = 59%-94%), to 87% at Time 3 (range =
Student Sample (N = 19) 53%-94%). This was a statistically significant difference (F =
33.41; df = 1,62; p < .001), indicating that the overall
Gender %
exposure to clinical rotations improved students’ belief in their
 Male 16 own safe practice regarding safe patient care. This trend was
also observed for self-efficacy regarding occupational health
 Female 84
(preventing injuries to themselves)—from 71% at Time 1
Race, ethnicity (range = 58%-90%), to 76% at Time 2 (range = 55%-90%), to
77% at Time 3 (range = 52%-90%). Although self-efficacy
  Non-Hispanic White 95 scores for occupational health were lower overall than
 Hispanic 5 self-efficacy scores for patient care, the change in scores over
time was statistically significant (F = 30.27; df = 1,56; p <
  Non-Hispanic Black 0 .001), indicating that the exposure to clinical rotations also
Marital status improved students’ belief in their own safe practice regarding
occupational health.
 Single 84 Students assigned to night shift rotations had lower self-
efficacy scores overall than students assigned to day shift
 Married 16
rotations (82% vs. 87%), although this was not a statistically
Children at home significant difference. Feeling sleepy significantly predicted both
lower safe-practice self-efficacy scores (F = 42.55; df = 1,60; p
 Yes 11
< .001) and occupational health self-efficacy scores (F = 3.67;
 No 89 df = 1,58; p < .05). No other contextual variables entered into
the models (e.g., sleeping with a bed partner) were significant.
Age
  Mean years of age (range) 25 (19-44) years
Discussion
This study revealed that students’ safe-practice self-efficacy
regarding both patient care and occupational health improved
significantly with exposure to clinical rotations; however,
occupational health self-efficacy was consistently lower than
of students was 25 years (range = 19-44 years), 16% were patient care self-efficacy. Furthermore, higher levels of self-
married, and 11% lived with children in the home. reported sleepiness were significantly associated with students’
Table 2 shows that, overall, student sleep quantity and quality confidence in their ability to perform safe practice in both the
(measured by actigraphy) did not vary greatly across the data patient care and occupational health domains.
collection periods. During the first round of data collection (prior Of particular interest, sleep quantity itself (per actigraphy)
to clinical rotation), students received on average 427 minutes did not significantly impair self-efficacy scores—in fact,
(SD = 8.4 minutes) or 7.1 hours of sleep per 24 hours, and their participants tended to receive similar sleep across the semester
average sleep quality was 85% (range = 69%-98%). During the (just over 7 hours per night). Per current recommendations, this
second round of data collection (during clinical rotations), falls below the estimated 7.5 to 8.5 guidelines on sufficient
students received on average 434 minutes (SD = 7.0 minutes) or sleep (Hirshkowitz et al., 2015). There are several possible
7.2 hours of sleep per 24 hours, and their average sleep quality explanations for our finding that sleep quantity did not vary, yet
(percentage of undisturbed sleep) was 86% (range = 72%-98%). self-reported sleepiness both increased over the semester and
During the third round of data collection (after clinical rotation, predicted lower self-efficacy scores.
but prior to finals), students received on average 423 minutes First, students consistently received slightly less than
(SD = 8.6 minutes) or 7.1 hours of sleep per 24 hours, and their adequate sleep and thus were likely slightly deprived of sleep
average sleep quality was 85% (range = 70%-95%). throughout the duration of the study. The increase in sleepiness
The number of students reporting being sleepy, however, seen across the study period could speak to a reduced ability to
went from 29% (five students) before rotations, to 32% (six cope with this slight sleep restriction, especially when additional
students) during rotations, to 39% (seven students) after factors such as the stress of clinical rotations are considered. In
rotations, suggesting an increase in self-reported sleepiness other words, students who find it harder to cope with reduced
(collected via sleep diary) during and following clinical sleep and the rigors of clinical exposure (evidenced by higher
rotations. self-reported sleepiness scores) may also be less likely to feel
Nursing students’ self-efficacy scores regarding their ability confident in their ability to provide both safe patient care and
to provide safe patient care (prevent adverse events to practice in a way that promotes safety to themselves. The prior
patients) consistently improved across the three time work of Postma et al. (2017) supports this possibility, as nursing

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Table 2.  Patient Care and Occupational Health Self-Efficacy Across Time 1 (Preclinical Rotation), Time 2 (During-Clinical Rotation),
and Time 3 (Postclinical Rotation)

p
Time 1 (Week 1 of 15) Time 2 (Week 7 of 15) Time 3 (Week 14 of 15) value
Patient care self- M = 80% (range = 28-94) M = 84% (range = 59-94) M = 87% (range = 53-94) .001
efficacya
Occupational health M = 71% (range = 58-90) M = 76% (range = 55-90) M = 77% (range = 52-90) .001
self-efficacyb
Sleep quantityc 7.1 hours (SD = 8 minutes) 7.2 hours (SD = 7 minutes) 7.1 hours (SD = 9 minutes) .43

Sleep qualityd 85% (range = 69-98) 86% (range = 72-98) 85% (range = 70-95) .58
Sleepiness ratingse
 Sleepy 5 (29%) 6 (32%) 7 (39%)
.15
 Alert 14 (71%) 13 (68%) 12 (61%)
a
Measured using Bandura’s patient care self-efficacy scales—where participants rate their degree of confidence in ability to prevent adverse events
to patients, on a scale from 0 to 100 (0 = no confidence, 100 = complete confidence).
b
Measured using Bandura’s occupational health self-efficacy scales—where participants rate their degree of confidence in ability to prevent injury to
themselves, on a scale from 0 to 100 (0 = no confidence, 100 = complete confidence).
c
Sleep quantity measured using wrist actigraphy to estimate minutes asleep within a 24-hour period.
d
Sleep quality measured using wrist actigraphy to estimate percentage of time in bed that the participant had undisturbed sleep (calculated using
algorithms based on amount of movement).
e
Number of participants reporting being sleepy versus alert.

students reported anxiety about coping with both sleep for occupational health nurses working in the health care
restriction and the uncertainty of shift work. system. It is arguably easier to increase mental resilience to
A second potential explanation for the fact that students’ sleep restriction and stress than it is to increase total sleep time
sleep remained consistent over time and yet their sleepiness and reduce stressors. For example, shift work will always result
increased could be related to the timing of sleep. A proportion in less than optimal sleep—especially for evening and night
of the sample (37%) were assigned to evening and night shifts, shift workers (James et al., 2017). Educating nursing students on
requiring their sleep timing to be disrupted. Resulting circadian how to optimize their sleep and promote sleep hygiene is of
misalignment can result in sleepiness, even if sleep itself is not course important, but perhaps equally important is teaching
affected (Niu et al., 2013). That students assigned to night shifts them about sleepiness countermeasures such as light exposure,
tended to have lower self-efficacy scores (although not caffeine management, exercise, and hydration. Similarly, the
significantly so) lends some support to this possibility. nursing profession will always face stressors, particularly for
Another finding that requires discussion is that nursing new nurses. Reducing the number of stressors new nurses are
student self-efficacy regarding occupational health was exposed to is likely less feasible than promoting nurses’ belief
consistently lower than their self-efficacy regarding patient care. in their ability to handle those stressors. As such, interventions
It is possible that this is an indicator of priority for nurses, and education that seek to (a) provide fatigue and sleepiness
whereby they are more concerned about the safety of the countermeasures and (b) promote resilience to stress may result
patient than their own well-being. Nurse self-care is critical in safer nursing practice—both in patient care and in
however, both for the safety of nurses and for their provision of occupational health.
high-quality care to the patients. This speaks to a disconnect This education could happen within nursing colleges or in
often speculated about within the nursing profession, where the hospital setting. Qualitative research on nursing students
occupational health can be considered less important than preparing to enter the workforce suggests that students
patient care (Hankinson, 2015). would be highly receptive to education on fatigue/sleepiness
countermeasures and sleep hygiene promotion (Postma et al.,
Implications for Occupational Health Nursing Practice 2017). Within the hospital setting, several options for this
Our findings have implications for interventions designed to type of education exist, including the National Institute of
prepare nursing students for safe entrée to the workforce and Occupational Safety and Health (NIOSH) training “NIOSH

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Workplace Health & Safety Mon 2019

training for nurses on shift work and long work hours,” Conflict of Interest
DHHS (NIOSH) Publication No. 2015-115. Preliminary
The author(s) declared no potential conflicts of interest with
research suggests that this training could be effective at
respect to the research, authorship, and/or publication of this
enhancing nurse safety and wellness, which could have
article.
consequent effects on patient care outcomes (Caruso, 2014).
Of particular importance in light of our study findings, the
NIOSH training places just as much importance on
Funding
occupational health as it does on patient care, with key The author(s) disclosed receipt of the following financial
information on taking breaks, safe lifting practices, and so support for the research, authorship, and/or publication of this
on, which can hopefully bring to light the importance of article: This study was funded by NIOSH U19 OH010154,
nurses taking care of themselves with the same commitment Oregon Healthy Workforce Center.
that they take care of their patients.
ORCID iD
Study Strengths and Limitations Lois James https://orcid.org/0000-0002-0278-318X
A strength of the study was the use of biopsychological
sleep measurement via wrist actigraphy. Many studies rely solely Notes
on sleep diaries or other self-reported sleep measures, which 1. In this study, we observed 100% compliance in wearing the
tend to be less accurate (de Souza et al., 2003). Actigraphy is Readiband and did not have any missing physiological data.
currently considered the most reliable method for investigating 2. http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/
workforceprojections/index.html
sleep outside using polysomnography in a laboratory setting
(Driller et al., 2016). Another strength was the longitudinal
design, allowing data collection at critical times during the References
nursing student’s professional formation. In addition, no American Nurses Association. (2014). Addressing nurse fatigue to promote
participant attrition or missing data throughout the study were safety and health: Joint responsibilities of registered nurses and
employers to reduce risks. Silver Spring, MD: Author.
observed. This was particularly beneficial given the small
sample size, which is a limitation of the study. The small Asaoka, S., Aritake, S., Komada, Y., Ozaki, A., Odagiri, Y., Inoue, S., . . .
Inoue, Y. (2013). Factors associated with shift work disorder in nurses
convenience sample precludes generalization to the nursing working with rapid-rotation schedules in Japan: The nurses’ sleep
student population. Future research needs to test larger samples health project. Chronobiology International, 30, 628-636.
to fully explore the impact of sleep and sleepiness on nursing Bandura, A. (2001). Guide for constructing self-efficacy scales. Palo Alto,
student self-efficacy in safe practice. The current study findings CA: Stanford University.
do provide justification, however, for conducting a larger study Beaton, R., Bridges, E., Salazar, M. K., Oberle, M. W., Stergachis, A.,
on this topic. Another limitation, related to the small sample, Thompson, J., . . . Butterfield, P. (2008). Ecological model of disaster
was the lack of diversity (racial, ethnic, and gender) among the management. AAOHN Journal: Official Journal Of The American
students, which also limits the generalizability. Finally, subjective Association Of Occupational Health Nurses, 56(11), 471-478.
sleepiness was measured with a single item, and future research Caruso, C. C. (2014). Negative impacts of shiftwork and long work hours.
should consider a more comprehensive examination of Rehabilitation Nursing, 39, 16-25. doi:10.1002/rnj.107
sleepiness. de Souza, L., Benedito-Silva, A. A., Pires, M. N., Poyares, D., Tufik, S., &
Calil, H. M. (2003). Further validation of actigraphy for sleep studies.
Conclusion Sleep, 26, 81-85.
Driller, M., McQuillan, J., & O’Donnell, S. (2016). Inter-device reliability of
This work begins to address a gap in the total worker an automatic-scoring actigraph for measuring sleep in healthy adults.
health (TWH) research by examining a critical period in the Sleep Science, 9, 198-201.
professional development of nurses and helps to guide Gangwisch, J. E., Feskanich, D., Malaspina, D., Shen, S., & Forman, J. P.
occupational interventions—particularly those targeted (2013). Sleep duration and risk for hypertension in women: Results
toward reducing nursing student sleepiness. Understanding from the nurses’ health study. American Journal of Hypertension, 26,
student nurses’ initial sleep patterns in response to clinical 903-911.
rotations can yield insights into opportunities for Gu, F., Han, J., Laden, F., Pan, A., Caporaso, N. E., Stampfer, M. J., . . .
occupational interventions at the university and hospital Schernhammer, E. S. (2015). Total and cause-specific mortality of U.S.
nurses working rotating night shifts. American Journal of Preventive
level. With approximately 2.9 million licensed and registered Medicine, 48, 241-252.
nurses, they make up the largest professional group in the Hankinson, S. E. (2015). The Nurses’ Health Study. Harvard University.
U.S. health care workforce.2 We owe it to them to ensure that Retrieved from http://www.channing.harvard.edu/nhs/
new nurses joining this workforce feel fully confident in their Health Services and Resources Administration. (2015). The registered
ability to practice safely and take care of themselves and nurse population: Findings from the 2008 National Sample Survey of
their patients. Registered Nurses. Washington, DC: Author.

6
vol. XX  ■  no. X Workplace Health & Safety

Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, Ryan, C., Ross, S., Davey, P., Duncan, E. M., Fielding, S., Francis, J. J., . . .
L., . . . Adams Hillard, P. J. (2015). National Sleep Foundation’s sleep Bond, C. (2013). Junior doctors’ perceptions of their self-efficacy in
time duration recommendations: Methodology and results summary. prescribing, their prescribing errors and the possible causes of errors.
Sleep Health, 1, 140-143. British Journal of Clinical Pharmacology, 76, 980-987.
James, S. M., Honn, K. A., Gaddameedhi, S., & Ven Dongen, H. P. Satterfield, B. C., & Van Dongen, H. P. (2013). Occupational fatigue,
A. (2017). Shift work: Disrupted circadian rhythms and sleep— underlying sleep and circadian mechanisms, and approaches to fatigue
Implications for health and wellbeing. Current Sleep Medicine Reports, risk management. Fatigue: Biomedicine, Health & Behavior, 1, 118-136.
3(2), 104-112. doi:10.1080/21641846.2013.798923
The Joint Commission Sentinel Event Alert. (2011). Health care worker
Shao, M. F., Chou, Y. C., Yeh, M. Y., & Tzeng, W. C. (2010). Sleep quality
fatigue and patient safety. Retrieved from http://www.jointcommission.
and quality of life in female shift-working nurses. Journal of Advanced
org/assets/1/18/sea_48.pdf
Nursing, 66, 1565-1572.
Niu, S. F., Chu, H., Chen, C. H., Chung, M. H., Chang, Y. S., Liao, Y. M., &
Chou, K. R. (2013). A comparison of the effects of fixed- and rotating- Waage, S., Pallesen, S., Moen, B. E., Magerøy, N., Flo, E., Di Milia, L., &
shift schedules on nursing staff attention levels: A randomized trial. Bjorvatn, B. (2014). Predictors of shift work disorder among nurses: A
Biological Research for Nursing, 15, 443-450. longitudinal study. Sleep Medicine, 15, 1449-1455.
Noland, C. M., & Carmack, H. J. (2014). “You never forget your first mistake”: Williamson, A., & Lombardi, D. A. (2011). The link between fatigue and
Nursing socialization, memorable messages, and communication about safety. Accident Analysis & Prevention, 43, 498-515. doi:10.1016/j.
medical errors. Health Communication, 30, 1234-1244. aap.2009.11.011
Postma, J., Tuell, E., James, L., Graves, J. M., & Butterfield, P. (2017).
Nursing students’ perceptions of the transition to shift work: A
total worker health perspective. Workplace Health & Safety, 65, Author Biographies
533-538. Lois James is an assistant professor at the College of Nursing,
Ramin, C., Devore, E. E., Wang, W., Pierre-Paul, J., Wegrzyn, L. R., & Washington State University.
Schernhammer, E. S. (2015). Night shift work at specific age ranges and
chronic disease risk factors. Occupational & Environmental Medicine,
72, 100-107. Patricia Butterfield is the Associate Dean for Research at the
Elson S. Floyd College of Medicine, Washington State University.
Rogers, A. E. (2008). The effects of fatigue and sleepiness on nurse
performance and patient safety. In R. G. Hughes (Ed.), Patient safety
and quality: An evidence-based handbook for nurses (pp. 1-37). Erica Tuell is a research coordinator at the College of Nursing,
Rockville, MD: Agency for Healthcare Research and Quality. Washington State University.