Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

Effects of Napping During Shift Work on Sleepiness

and Performance in Emergency Medical Services
Personnel and Similar Shift Workers: A Systematic
Review and Meta-Analysis

Christian Martin-Gill, Laura K. Barger, Charity G. Moore, J. Stephen Higgins,

Ellen M. Teasley, Patricia M. Weiss, Joseph P. Condle, Katharyn L. Flickinger,
Patrick J. Coppler, Denisse J. Sequeira, Ayushi A. Divecha, Margaret E.
Matthews, Eddy S. Lang & P. Daniel Patterson

To cite this article: Christian Martin-Gill, Laura K. Barger, Charity G. Moore, J. Stephen Higgins,
Ellen M. Teasley, Patricia M. Weiss, Joseph P. Condle, Katharyn L. Flickinger, Patrick J. Coppler,
Denisse J. Sequeira, Ayushi A. Divecha, Margaret E. Matthews, Eddy S. Lang & P. Daniel
Patterson (2018): Effects of Napping During Shift Work on Sleepiness and Performance in
Emergency Medical Services Personnel and Similar Shift Workers: A Systematic Review and Meta-
Analysis, Prehospital Emergency Care, DOI: 10.1080/10903127.2017.1376136

To link to this article: https://doi.org/10.1080/10903127.2017.1376136

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Download by: [California Institute of Technology] Date: 13 January 2018, At: 03:12
 EFFECTS OF NAPPING DURING SHIFT WORK ON SLEEPINESS AND
PERFORMANCE IN EMERGENCY MEDICAL SERVICES PERSONNEL AND SIMILAR
SHIFT WORKERS: A SYSTEMATIC REVIEW AND META-ANALYSIS
Christian Martin-Gill, MD, MPH, Laura K. Barger, PhD, Charity G. Moore, PhD, J.
Stephen Higgins, PhD, Ellen M. Teasley, LAT, ATC, Patricia M. Weiss, MLIS, Joseph P. Condle,
MS, Katharyn L. Flickinger, MS, Patrick J. Coppler, MSPAS, PA-C , Denisse J. Sequeira, BS,
Ayushi A. Divecha, MPT, Margaret E. Matthews, BS, Eddy S. Lang, MDCM, CCFP (EM),
P. Daniel Patterson, PhD, NRP

ABSTRACT
Downloaded by [California Institute of Technology] at 03:12 13 January 2018

Background: Scheduled napping during work shifts may be

an effective way to mitigate fatigue-related risk. This study
aimed to critically review and synthesize existing literature
Received July 14, 2017 from the Department of Emergency Medicine, on the impact of scheduled naps on fatigue-related outcomes
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylva- for EMS personnel and similar shift worker groups. Methods:
nia (CMG, EMT, PJC, AAD, MEM, JPC, KLF, DJS, PDP); Division of A systematic literature review was performed of the impact of
Sleep and Circadian Disorders, Departments of Medicine and Neu- a scheduled nap during shift work on EMS personnel or sim-
rology, Brigham and Women’s Hospital, Harvard University Medical
ilar shift workers. The primary (critical) outcome of interest
School Boston, Massachusetts (LKB); School of Health and Rehabili-
was EMS personnel safety. Secondary (important) outcomes
tation Sciences, Department of Physical Therapy, University of Pitts-
burgh, Pittsburgh, Pennsylvania (CGM); National Highway Traf- were patient safety; personnel performance; acute states of
fic Safety Administration, Washington, District of Columbia (JSH); fatigue, alertness, and sleepiness; indicators of sleep duration
Health Sciences Library System, University of Pittsburgh, Pittsburgh, and/or quality; employee retention/turnover; indicators of
Pennsylvania (PMW); Department of Emergency Medicine, Cum- long-term health; and cost to the system. Meta-analyses
mins School of Medicine, University of Calgary, Calgary, Alberta, were performed to evaluate the impact of napping on a
Canada (ESL). Revision received August 30, 2017; accepted for pub- measure of personnel performance (the psychomotor vigi-
lication August 31, 2017. lance test [PVT]) and measures of acute fatigue. Results: Of
Work performed on this manuscript was supported with funding 4,660 unique records identified, 13 experimental studies were
from the U.S. Department of Transportation, National Highway Traf- determined relevant and summarized. The effect of napping
fic Safety Administration to the National Association of State EMS on reaction time measured at the end of shift was small and
Officials (NASEMSO): contract/grant number: DTNH2215R00029. non-significant (SMD 0.12, 95% CI −0.13 to 0.36; p = 0.34).
The views contained in this article are those of the authors Napping during work did not change reaction time from the
and not necessarily those of the National Highway Traffic Safety beginning to the end of the shift (SMD −0.01, 95% CI −25.0
Administration.
to 0.24; p = 0.96). Naps had a moderate, significant effect on
Authors CMG, LKB, CGM, JSH, PMW, ESL, and PDP contributed to sleepiness measured at the end of shift (SMD 0.40, 95% CI
the conception of the design of this work. Authors CMG, LKB, CGM, 0.09 to 0.72; p = 0.01). The difference in sleepiness from the
EMT, PMW, JPC, KLF, PJC, DJS, AAD, MEM, and PDP contributed start to the end of shift was moderate and statistically sig-
to acquisition of study data. All authors contributed to the analysis, nificant (SMD 0.41, 95% CI 0.09 to 0.72; p = 0.01). Conclu-
interpretation, drafting of the manuscript, and providing critically
sions: Reviewed literature indicated that scheduled naps at
important intellectual content. All authors reviewed and approved
work improved performance and decreased fatigue in shift
the final version and agree to be accountable for all aspects of the
work. workers. Further research is required to identify the optimal
timing and duration of scheduled naps to maximize the ben-
Supplemental data for this article can be accessed on the publisher’s eficial outcomes. Key words: napping; fatigue; shift work;
website.
emergency medical services
Address correspondence to P. Daniel Patterson, PhD, Univer-
sity of Pittsburgh, Emergency Medicine, 3600 Forbes Avenue,
PREHOSPITAL EMERGENCY CARE 2018; Early Online:1–11
Iroquois Bldg., Suite 400A, Pittsburgh, PA 15260, USA. E-mail:
[email protected]
Color versions of one or more of the figures in the article can be found BACKGROUND
online at www.tandfonline.com/ipec.
Greater than half of Emergency Medical Services
Published with license by Taylor & Francis © 2018 Christian Martin-
Gill, Laura K. Barger, Charity G. Moore, J. Stephen Higgins, Ellen M.
(EMS) personnel report fatigue and poor sleep quality
Teasley, Patricia M. Weiss, Joseph P. Condle, Katharyn L. Flickinger, (1–3). Naps improve alertness, vigilance, and cognitive
Patrick J. Coppler, Denisse J. Sequeira, Ayushi A. Divecha, Margaret performance in laboratory and field studies (4, 5).
E. Matthews, Eddy S. Lang, and P. Daniel Patterson In nightshift workers, naps can augment the sleep
doi: 10.1080/10903127.2017.1376136 obtained during daytime hours, often shortened due

1
 2 PREHOSPITAL EMERGENCY CARE 2018 EARLY ONLINE

to circadian timing. Prior research shows that EMS Types of Participants

personnel use naps during shifts to achieve adequate
sleep (6, 7). Guyette et al. reported that air-medical Experimental research involving persons 18 years of
EMS clinicians earn a mean 6.8 hours of sleep during age and older classified as EMS personnel or similar
24-hour shifts and 1-hour of sleep during 12-hour shift worker groups were included (14). Studies were
shifts (6). A case study shows a paramedic sleeping excluded that did not include shift workers. Disagree-
nearly six hours on average on 24-hour shifts and ments were addressed through discussion between co-
0.3 hours on 8-hour shifts (7). investigators CMG, LKB, and PDP.
Naps are common among shift workers with 55%
reporting to have taken at least one nap in the last Types of Interventions
month (8). Moreover, napping during a work shift
is a countermeasure that may help mitigate fatigue The retained studies that tested the impact of a nap dur-
and fatigue-related risks for EMS personnel (9). Naps ing shift work as a component of one or more study
have been shown to improve performance, mood arms. Although the duration, timing and conditions of
and alertness better than caffeine (10, 11). A nap as the naps were different across studies, all allowed for
sleep during the work shift. Studies were excluded that
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short as 10-minutes reduced sleepiness and fatigue

and improved vigor and cognitive performance (12). did not report on the effects of naps as a method to
Although allowing EMS personnel to sleep on-the-job mitigate fatigue, involved naps before or after a work
is not without controversy and operational challenges, period, and evaluated the impact of a break period not
scheduled naps during shifts may benefit safety, involving sleep.
performance, and other outcomes relevant to EMS
personnel, administrators, and the public they serve. Types of Outcome Measures
The benefits of napping during EMS shiftwork are
The primary (critical) outcome of interest was EMS
not widely known to EMS administrators and man-
personnel safety (e.g. incidence of needle sticks or
agers. Although a review of the evidence on napping
vehicle accidents) (14). The secondary (important)
was previously conducted, it was limited by small
outcomes of interest were: patient safety (e.g. medi-
heterogeneous studies (13). A more focused summary
cation errors or procedural complications), personnel
of the evidence exploring the effects of intra-shift nap-
performance; acute fatigue, alertness, and sleepiness;
ping on EMS or similar shift workers would benefit
indicators of sleep (e.g., sleep duration and quality);
EMS administration and their decisions germane to
employee retention/turnover; indicators of long-term
fatigue risk management. This research systematically
health (e.g., cardiovascular disease); and cost to the
reviewed the literature to assess the effects of a nap (i.e.,
system. All outcomes were assessed as defined by the
a brief scheduled interval of sleep) during shift work
individual study.
as a strategy for EMS personnel and similar worker
groups to impact patient and personnel safety, mitigate
fatigue, and improve sleep. This review was guided Search Methods for Studies
by the research question: “In EMS personnel, does the
A research librarian (PMW) searched 5 bibliographic
use of sleep or rest strategies and/or interventions
database products and one website. For the system-
mitigate fatigue, fatigue-related risks, and/or improve
atic review described here, the search incorporated
sleep?” (PROSPERO 2016:CRD42016040107) (14).
multiple terms covering each of three concepts: emer-
gency medical services and other critical shift-based
METHODS occupations; fatigue, sleep, and sleep disorders; and
napping and rest breaks. All searches included litera-
This study was a systematic review of literature rele-
ture from January 1980 to September 2016. An expla-
vant to napping during shift work indexed in multiple
nation provides the methods of the search strategies,
databases. This study has described the details of
all sources searched, the search terms incorporated,
the databases searched, the methodology and study
and the description of search vocabulary in a separate
protocol, and procedures for reviewing literature in a
paper in this supplement (15). See Online Supplement
separate publication (15). The components unique to
Appendix A for search strategy details specific to this
this systematic review are described in the following
systematic review.
sections.

Study Design Data Collection and Selection of Studies

Screening
The selection of literature was limited to experimen-
tal study designs (i.e., randomized controlled trials and Co-investigators (PJC and EMT) independently
quasi-experimental studies such as before and after screened titles and abstracts to identify potentially
designs) (16). relevant publications. Two additional co-investigators
 C. Martin-Gill et al. NAPPING DURING SHIFT WORK IN EMS PERSONNEL 3

(PDP and DJS) adjudicated disagreements based on germane to outcomes rated as critical and important
the following inclusion criteria: a) the study describes (20). Key information includes: number of studies per
the population of interest; b) the study describes outcome; judgments about underlying quality of evi-
use of a nap period as the primary intervention of dence (e.g., risk of bias, indirectness); statistical results;
interest; and c) the title and/or abstract describes and a quality rating (very low, low, moderate, or high).
one or more outcomes of interest. The Kappa statistic
was used to determine inter-rater agreement during
screening. Reporting
Findings were presented from this systematic review
Full-Text Review as prescribed by the Preferred Reporting Items for
Systematic reviews and Meta-Analyses (PRISMA)
Five investigators (EMT, JPC, KLF, AAD, and MEM) statement (21).
worked independently to abstract key information
from full-text articles. Co-investigators verified data
abstractions and disagreements were handled by RESULTS
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discussion with principal investigator PDP. Several The search strategy yielded n = 4,656 unique records
co-investigators (EMT, JPC, KLF, AAD, and MEM) (Figure 1). Two investigators (EMT and JPC) inde-
searched bibliographies to identify additional relevant pendently screened n = 4,656 titles and abstracts.
research. The interrater agreement for inclusion/exclusion was
substantial (Kappa = 0.78). Seventy-six records were
Risk of Bias Assessment judged potentially eligible based on title and abstract.
Seventeen studies were identified during bibliogra-
The team’s three senior co-investigators (CMG, LKB, phy searches as potentially relevant and reviewed in
and PDP) used the Cochrane Collaboration’s risk of full-text format. Thirteen experimental studies were
bias tool for experimental studies to document per- determined relevant and key findings abstracted in
ceived bias of individual studies (17). The Cochrane tables (See Online Supplement Appendix B). Eighty
tool appraised the risk of bias across six domains. studies were excluded with reasons given, organized
Disagreements between reviewers were handled by in the Population, Intervention, Comparison, Outcome
discussion. (PICO) format (See Online Supplement Appendix C)
(22–24).
Statistical Analysis Within the retained studies, naps were implemented
in various ways. In all cases, a nap opportunity was
Three investigators (CMG, LKB, and PDP) used a afforded to study participants. In all cases, the nap
system for categorizing findings in systematic reviews period included the opportunity to sleep. In some
to describe the impact of a nap intervention on critical cases, the nap opportunity was scheduled for a particu-
and important outcomes as favorable, unfavorable, lar time in the shift. The reviewed research and specific
mixed/inconclusive, or no impact (18). Additional nap interventions are described in Table 1.
details of the system for categorizing findings are
available in a separate publication (15).
When 2 or more studies used an experimental study Impact of Scheduled Naps on Personnel
design and reported results for a specific outcome, Safety Outcomes
these data were pooled for purposes of a meta-
analysis (15) This was possible for the impact of nap One experimental study assessed personnel safety by
on the psychomotor vigilance test (PVT) and acute determining the fraction of time during simulated driv-
fatigue (i.e., sleepiness). RevMan software (version 5.3, ing at or below a study-defined cut point of alertness
Copenhagen, Denmark) was used to calculate the stan- (25). The authors reported no aggregate differences in
dardized mean difference (SMD) and 95% confidence driving performance. Napping had no impact on the
intervals (CIs) of a pooled main effect. outcome.

Quality of Evidence Impact of Scheduled Naps on Personnel

Four investigators (CMG, LKB, PDP, and ESL) used
Performance Outcomes
the Grading of Recommendations Assessment, Devel- The impact of scheduled naps on personnel
opment and Evaluation (GRADE) framework to performance was judged favorable for eight
summarize and rate the quality of retained research of 11 studies that measured personnel per-
(evidence) (19). The GRADE evidence profile table formance (Table 2) (25–32). Two studies were
contains key information about the quality of evidence judged as no impact and one as mixed/
 4 PREHOSPITAL EMERGENCY CARE 2018 EARLY ONLINE

Idenficaon Records idenfied through

database searching
(n=4,660)

Duplicates removed manually (n=4)

Records screened independently by two Records with conflicts

screeners (n=4,656) (n=33)
Screening

Records retained by screeners

(n=60)
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Records retained aer conflict adjudicaon by two addional

screeners (n=76)

Full-text arcles assessed for eligibility

(n=76)
Eligibility

Potenally relevant arcles idenfied by

searching bibliographies
(n=17)
Full-text arcles assessed for eligibility
(n=93)

Full-text arcles excluded with reasons

(n=80)
Included

(n=6 duplicates)
Unique studies/arcles retained
(n=13)
Meta-analyses
(n=3)

FIGURE 1. PRISMA flow diagram for PICO#4 PROSPERO 2016: CRD42016040107.

inconclusive for personnel performance. Pooled anal- The effect of napping on the difference in reaction time
ysis was performed for three experimental studies that from the start to the end of shift was small (SMD −0.01,
measured reaction time at the start and end of shift (27, 95% CI −25.0 to 0.24; Figure 2b). The effect was non-
29, 31). Purnell et al. used the 10-minute Mackworth significant (p = 0.96). There was a moderate level of
Clock Vigilance Task (29). Signal et al. used the 10- heterogeneity (Chi(2) = 6.06; df = 2; p = 0.05; I2 = 67%).
minute psychomotor vigilance task (31). Sallinen et al.
used the two-choice visual reaction time test of the Impact of Scheduled Naps on Acute Fatigue
National Institute for Occupational Safety and Health
fatigue battery (27). The effect of naps on reaction
Outcomes
time measured at the end of shift was small, and the Eleven studies evaluated the impact of napping on
difference between the nap and no–nap condition was measures of acute fatigue (25, 27–29, 31–37). The impact
non-significant (SMD 0.12, 95% CI −0.13 to 0.36; p = of napping on acute fatigue (sleepiness) was judged
0.34; Figure 2a). This study detected a moderate level of favorable for five of 11 studies, mixed/inconclusive for
heterogeneity (Chi(2) = 3.94; df = 2; p = 0.14; I2 = 49%). three studies, and no impact for three studies (Table 2).
 C. Martin-Gill et al. NAPPING DURING SHIFT WORK IN EMS PERSONNEL 5

Table 1. Detailed information regarding napping intervention in retained studies

Author, Year Study Design Nap protocol Nap achieved [data collection method]

Amin et al. (26) Non-randomized A 20-minute nap opportunity versus Mean nap duration was 8.4 ±
RefID-152 controlled trial 20-minute break (investigators chatted 3.0 minutes
PMID-22914520 with control group residents during [electroencephalogram (EEG)].
20-minute break to prevent them from
napping).
Sallinen et al. (27) Non-randomized cross-over A 50 or 30-minute nap opportunity at 01.00 Timing / total sleep period / mean
RefID-3575 (early) or 04.00 hours (late). nap duration [polysomnography
PMID-9844850 (PSG)].
Early / 50 minutes / 38.1 ±
12.1 minutes
Early / 30 minutes / 24.5 ±
6.7 minutes
Late / 50 minutes / 46.6 ±
2.1 minutes
Late / 30 minutes / 27.5 ±
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1.9 minutes
Smith et al. (28) Randomized cross-over A 30-minute nap opportunity between 02:00 Mean nap duration was 13.44 ±
RefID-3851 and 03:00. 8.96 minutes [EEG].
PMID-n/a
Smith-Coggins Randomized controlled trial A 40-minute nap opportunity at 03:00. Mean nap duration was 24.8 ±
et al. (25) 11.1 minutes (90% of subjects
RefID-3852 napped) [PSG].
PMID-17052562
Matsumoto et al. Quasi-experimental A 2-hour nap opportunity during the night Mean nap duration not defined. No
(33) shift. Nap allowed in the control group difference in total sleep time
RefID-2621 without a defined nap period. between nap and no nap period
PMID-8206058 groups [subjective measurement].
Purnell et al. (29) Cross-over A 20-minute nap opportunity between 01:00 Half of the engineers (50%) taking a
RefID-3297 and 03:00 on two night shifts. nap during the first night shift
PMID-12220318 reported that they had not fallen
asleep during the nap and 42%
reported not having fallen asleep
during the nap taken on the
second night shift. Mean nap
duration for subjects that
reported sleeping during the nap
was 19 ± 11.62 minutes on the
first night shift and 21 ±
14.49 minutes on the second night
shift [subjective measurement].
Bonnefond et al. Quasi-experimental A 1-hour nap opportunity between 23:30 Mean nap duration was
(34) and 03:30. approximately 31.5 minutes
RefID-455 (based on monthly
PMID-11681794 questionnaires; approximately
79% of rest periods had sleep)
[subjective measurement].
Gillberg et al. (37) Counter-balanced experiment A 30-minute nap opportunity during night Mean nap duration was 18.7 ±
RefID-1457 shift. 2.8 minutes [PSG].
PMID-8795796
Chang et al. (30) Randomized controlled trial A 30-minute nap opportunity between 02:00 No information on mean nap
RefID-660 and 03:00. duration [subjective
PMID-25683536 measurement].
Signal et al. (31) Cross-over design A 40-minute nap opportunity approximately Mean nap duration was 19 minutes
RefID-3772 2 hours into an early (22:30–06:00) or late (early shift) or 20 minutes (late
PMID-19250171 (23:30–06:30) night shift. shift) [EEG].
Takahashi et al. Quasi-experimental A 15-minute nap opportunity during a No information on mean nap
(35) post-lunch rest period. duration [actigraphy].
RefID-4037
PMID-15204275
Tempesta et al. (36) Quasi-experimental No Information on duration of nap No information on mean nap
RefID-4093 opportunity. duration [actigraphy].
PIMD-24016171
Howard et al. (32) Randomized cross-over A 30-minute nap opportunity at start of Mean nap duration during evening
RefID-1821 night shift (19:45) or during overnight nap was 4.88 ± 8.28 minutes (38%
PMID-n/a shift (04:00). of subjects napped). Mean nap
duration during early morning
nap was 23.5 ± 5.48 minutes
(100% of subjects napped) [PSG].
 6 PREHOSPITAL EMERGENCY CARE 2018 EARLY ONLINE

Table 2. Synthesis of findings of individual studies comparing Napping/Sleeping during shift work to No
Napping/Sleeping during shift work in relation to outcomes rated critical or important

Experimental Study Designs

Critical
Outcomes Important Outcomes

Sleep and Retention Long-

Personnel Patient Personnel Acute Sleep / Term Cost to
† ‡ § ║ #
Author, Year RefID PMID Study Design Safety Safety∗ Performance Fatigue Quality Turnover Health System

Amin et al. RefID-152 Non-randomized — — Favorable — — — — —

(26) PMID- controlled trial
22914520
Sallinen RefID-3575 Non-randomized — — Favorable Favorable Unfavorable — — —
et al. (27) PMID- cross-over
9844850
Smith et al. RefID-3851 Randomized — — Favorable Favorable No Impact — — —
(28) PMID-N/A cross-over
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Smith- RefID-3852 Randomized No Impact — Favorable Favorable No Impact — — —

Coggins PMID- controlled trial
et al. (25) 17052562
Matsumoto RefID-2621 Quasi- — — — Mixed/ Mixed/ — — —
et al. (33) PMID- experimental Incon- Inconclu-
8206058 clusive sive
Purnell et al. RefID-3297 Cross-over — — Favorable No Impact No Impact — — —
(29) PMID-
12220318
Bonnefond RefID-455 Quasi- — — — Mixed/ No Impact — — —
et al. (34) PMID- experimental Incon-
11681794 clusive
Gillberg RefID-1457 Counter- — — No Impact No Impact — — — —
et al. (37) PMID- balanced
8795796 experiment
Chang et al. RefID-660 Randomized — — Favorable — — — — —
(30) PMID- controlled trial
25683536
Signal et al. RefID-3772 Cross-over — — Favorable Favorable No Impact — — —
(31) PMID- design
19250171
Takahashi RefID 4037 Quasi- — — No Impact Favorable No Impact — — —
et al. (35) PMID- experimental
15204275
Tempesta RefID-4093 Quasi- — — Mixed/ Mixed/ No Impact — — —
et al. (36) PIMD- experimental Inconclu- Incon-
24016171 sive clusive
Howard RefID-1821 Randomized — — Favorable No Impact — — — —
et al. (32) PMID-n/a cross-over

Note: Findings are classified as favorable for use of napping during shift work, unfavorable, mixed/inconclusive, or no impact. ∗ Includes quality of care. † Includes
external subjective ratings of the study subject’s performance including perceived satisfaction with the subject’s performance. ‡ Includes acute states of fatigue,
sleepiness, alertness. § includes sleep latency, total sleep time, recovery, and related measures. ║ Includes job satisfaction and measures of preference for a particular
shift pattern. # General wellness or well-being measures included.

Purnell et al. measured sleepiness with a visual analog Impact of Scheduled Naps on Indicators of
scale (29). Sallinen et al. measured sleepiness with the Sleep and Sleep Quality
Karolinska Sleepiness Scale (KSS) (27). Naps had a
moderate, significant effect on sleepiness measured at Nine experimental studies assessed indicators of sleep
the end of shift (SMD 0.40, 95% CI 0.09 to 0.72; p = 0.01; and/or sleep quality and judged unfavorable (n =
Figure 2c). The researchers detected no evidence of 1), mixed/inconclusive (n = 1), or no impact (n = 7;
heterogeneity (Chi (2) = 0.20; df = 1; p = 0.66; I2 = 0%). Table 2) (25, 27–29, 31, 33–36). Sallinen et al. deter-
The difference in sleepiness from the start to the end mined that subjects felt they slept better in the control
of shift between the nap and no–nap condition was (no–nap) condition (27). Matsumoto et al. compared
moderate (SMD 0.41, 95% CI 0.09 to 0.72; Figure 2d), self-reported sleep times prior to, during, and fol-
the effect was statistically significant (p = 0.01) and lowing scheduled shifts stratified by day/night shift
there was a low level of heterogeneity (Chi (2) = 1.35; work (33). Matsumoto and colleagues reported that
df = 1; p = 0.25; I2 = 26%). day sleep was affected when a nap was taken on night
 C. Martin-Gill et al. NAPPING DURING SHIFT WORK IN EMS PERSONNEL 7

a: Forest Plot (outcome:: reaction time

t at end
d of shift b
by nap vs. no-nap)

Forest Plot (outcome: delta/cha

b: F ange in rea
action time from startt-to-end off shift within
condition [nap
p vs. no-na
ap])
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c: Forest Plot (outcome:: difference

e in sleepiness at en
nd of shift b
by nap vs. no-nap)

Forest Plot (outcome: delta/ cha

d: F ange in sle
eepiness frrom start-tto-end of s
shift within condition
p vs. no-na
[nap ap])

FIGURE 2. Figure 2a-2d: Forest Plots (2a: outcome: reaction time at end of shift by nap vs. no-nap), (2b: outcome: delta/change in reaction
time from start-to-end of shift within condition [nap vs. no-nap]), (2c: outcome: difference in sleepiness at end of shift by nap vs. no-nap), (2d:
outcome: delta/change in sleepiness from start-to-end of shift within condition [nap vs. no-nap]). Notes: The aforementioned figures report the
standardized mean difference (SMD) for reaction time and acute fatigue (using sleepiness measures) for the control compared to the intervention
(mean outcome under the control condition minus the mean outcome under the nap condition). The SMD is the estimated intervention effect
of each study relative to the variability in the study and also known as Cohen’s d measurement of effect size. The effect size is not tied to a
specific scale or scales used in the pooled analysis. An SMD of zero implies the intervention and control condition (placebo) are equal. An SMD
greater than zero indicates that the napping group had a lower mean value than the control group (treatment condition leads to better/faster
reaction time and lower sleepiness). Common delineations or cut-points for interpretation include: 0.2 = small; 0.5 = medium/moderate; 0.8 or
greater as large. The SMD is non-significant if the corresponding 95% confidence interval is wide and overlaps 0. RevMan software (V.5.3) was
used to generate SMDs for reaction time and sleepiness and for producing forest plots. For the Purnell et al. study, reaction time data (means
and standard errors) were abstracted from Table 1 of the manuscript for the start and end of the 1st shift for both the control condition and the
nap condition (29). The use of data from the 1st shift was appropriate as the participants would be more naïve to the intervention compared
to the participants in the 2nd shift. Signal and colleagues generated reaction time with use of the 10-minute psychomotor vigilance test (PVT)
(31). Raw means and SDs were not reported in the manuscript. These data were obtained from Signal upon request specific to the “early night
shift” start of shift and end of shift PVT measures (31). Data for reaction time (means and SDs) for the Sallinen et al. study were abstracted
from Table 2 of the manuscript specific to the early 30 arm (27). Data from these three studies was combined and the specific study arms from
each study given the similarities in timing of the napping intervention and nap duration across studies. The studies all used crossover designs
with each participant having measurements during intervention and control periods. For purposes of Figure 2a, the difference in mean reaction
time taken at the end of the shift between the control condition and nap condition was calculated. When standard deviations (SDs) were not
provided, the study used the following formula to generate SDs [SD = SE ∗ SQRT(N)]. The standard deviation with person difference between
the intervention and control periods was calculated assuming the correlation within person was 0.5 (SD for the difference = (SD2 intervention
+ SD2 control −2∗ 0.5∗ SDintervention ∗ SDcontrol ). Figure 2b shows the calculation of the change (delta) in reaction time from the start-to-end of shift
within each condition (the nap and no-nap groups). The difference in the change was then calculated by subtracting the intervention change
from the control condition change. The SD for the within shift change were approximated assuming the correlation within shift for the same
individual was 0.5 (SD for the within shift change = (SD2 before shift + SD2 after shift −2∗ 0.5∗ SDbefore shift ∗ SDafter shift ). This study applied the same
approach when calculating the SD for the control versus intervention changes due the crossover nature of the study designs (SD for the difference
in deltas = (SD2 intervention within shift delta + SD2 control within shift delta −2∗ 0.5∗ SDintervention within shift delta ∗ SDcontrol within shift delta ). Figure 2c shows
the abstracted data from Sallinen et al. and Purnell et al. (27, 29). For the Purnell et al. study, the current research abstracted data from Table 1, for
the measurement of subjective ratings of sleepiness measured with a visual analog scale (scored 0–100), where higher scores indicate worsening
sleepiness (29). For the Sallinen et al. study, the current research abstracted data from Table 2, where authors reported results of the Karolinska
Sleepiness Scale (KSS), with scores ranging from 1–9 where higher scores imply worsening sleepiness (27). For purposes of Figure 2d, this study
used the aforementioned calculation for the delta/change within sleepiness from start to end of shift by nap vs. no-nap condition.
 8 PREHOSPITAL EMERGENCY CARE 2018 EARLY ONLINE

shift, however, there was no difference in the night DISCUSSION

sleep totals between the nap versus no nap group and
findings were overall judged to be mixed/inconclusive Summary of Main Results
(33). Smith et al. showed no difference in sleep hours There is favorable evidence from experimental stud-
prior to work between the nap and no-nap conditions ies to suggest that brief scheduled naps during shift
(28). Smith-Coggins et al. detected no differences in work mitigate fatigue in shift workers, with the great-
total sleep time between conditions (25). Purnell et al. est impact apparent for acute fatigue (sleepiness) and
detected no difference in sleep duration following personnel performance. The findings show a small,
night shift work with use of actigraphy and sleep non-significant effect of short duration scheduled naps
diaries (29). Bonnefond et al. detected no differences on personnel performance (reaction time) during the
in the main sleep duration over a 12-month period night shift (Figures 2a and 2b). The effect of naps
after instituting a nap period during shift work (34). on acute fatigue was modest and statistically signifi-
Signal et al. showed that a nap during the night shift cant (Figures 2c and 2d). These findings suggest that
did not affect timing, duration, or efficiency of sleep short duration naps are a promising strategy for fatigue
at home after the night shift (31). Takahashi et al. used risk management. The lack of research assessing the
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a sleep diary and actigraphs to measure sleep latency, impact of scheduled naps on patient safety, reten-
sleep onset, sleep offset, total sleep time, time awake tion/turnover, indicators of long-term health, or cost
after sleep onset, and mean activity during sleep (35). to the system highlights the need for more research.
The authors detected no differences in sleep measures The optimal duration of on-duty naps cannot be
between the nap and no nap conditions (35). Tempesta answered by the systematic review. Naps were not
et al. detected no differences in actigraph-measured implemented in the same manner in the reviewed
total sleep time between the wake group and nap research (Table 1). The duration of time allowed for
group (36). Findings of Sallinen et al. were unfavorable naps on shift varied from 15 minutes (35) to 120 min-
(27). Findings of Smith et al., Smith-Coggins et al., utes (33). The acceptability of naps also varied greatly
Purnell et al., Bonnefond et al., Signal et al., Taka- with 38% to 100% actually sleeping during the nap
hashi et al., and Tempesta et al. (25, 28, 29, 31, 34–36) opportunity, sometimes depending on the timing of
were categorized as no impact. Findings by Mat- the nap (32). Mean sleep duration during nap oppor-
sumoto et al. were categorized as mixed/inconclusive tunities varied between studies as well from a low
(33). of 8.4 minutes (26) to a high of 46.6 minutes (27). It
is possible that the duration of naps influenced the
outcomes examined; however, with the vast diver-
sity in nap duration, circadian placement of nap and
Impact of Scheduled Naps on Indicators of implementation methodology present in the limited
Patient Safety, Retention/Turnover, literature available, the researchers were not able to
Long-Term Health, and Cost to the System explore this aspect of napping. Future research on
heterogeneous nap durations is warranted.
None of the retained studies evaluated the impact of
Because EMS personnel often work extended dura-
napping on these measures.
tion shifts (e.g.,  24 hours), there are many other
aspects of napping that need further research. In the
reviewed studies, the scheduled napping opportuni-
Quality of Evidence ties were protected for the participants. In the EMS
environment, such nap opportunities might be unpro-
Most studies were judged to have serious risk of bias. tected by necessity, such that the EMS clinician’s nap
The biases for individual studies are presented in the might be interrupted by an emergency call. Those
Cochrane Collaboration’s risk of bias tool for exper- workers without scheduled nap opportunities may
imental studies and appear in Online Supplement nap anyway, intentionally or unintentionally, compli-
Appendix D. Common biases across studies, strati- cating experimental studies and operational policies.
fied by outcome, are presented in the GRADE Evi- This study judged the quality of evidence for all out-
dence Profile Table (See Online Supplement Table 3). comes as very low (Online Supplement Table 3). Most
The most common biases detected are those inherent studies were judged to have a serious risk of bias due
in operational field studies, including lack of random- to crossover study designs. Many did not incorporate
ization, allocation concealment and blinding. Given randomization and blinding was not possible or fea-
these biases, the researchers downgraded the certainty sible. The researchers downgraded for small sample
in the evidence, which contributed to the very low sizes, inconsistency (wide confidence intervals in meta-
quality rating shown in the GRADE Evidence Profile analyses for select outcomes), indirectness of evidence
Table. involving shift workers other than EMS personnel, and
 C. Martin-Gill et al. NAPPING DURING SHIFT WORK IN EMS PERSONNEL 9

imprecision of select outcomes (e.g., use of diverse out- All the studies reviewed were collected data in opera-
comes across studies with uncertain reliability). tional settings. In these field studies, confounding from
other fatigue countermeasures (e.g., caffeine), prior
Agreement and Disagreement with other wakefulness or work conditions were not controlled.
This lack of standardization may contribute to the vari-
Systematic Reviews ability seen in the results. Data on long-term outcomes,
Ruggiero and Redeker performed a narrative review of including employee retention (at an EMS agency) or
the evidence on napping while incorporating elements social/biological outcomes (e.g., long-term health mea-
of a systematic review (e.g., exploring literature from sures, social interaction measures) are lacking. Future
multiple repositories) (13). While the current study’s research should evaluate the impact of naps on long-
systematic review and meta-analysis was isolated to term as well as short-term outcomes.
shift workers (14), Ruggiero and Redeker included Although the judgments of evidence quality were
studies involving healthy volunteers or non-shift guided by the GRADE framework and formulated
worker study participants (13) (e.g., Sagaspe et al., based on consensus between co-investigators (19, 20),
2007; 38). The current study’s analysis was aimed to others reviewing the same evidence may evaluate the
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more directly evaluate outcomes on participants that evidence differently.

are most like EMS personnel. Still, the findings of
Rugiero and Redeker agree with this study, as they
identified that most investigations found night shift CONCLUSIONS
napping led to decreased sleepiness and improved In this systematic review, evidence supported napping
sleep-related performance (13). Similarly, they did during shiftwork. However, the effect of scheduled
not find any studies, even in non-shift worker par- naps on select outcomes was not consistent across
ticipants that evaluated the effects of naps on safety studies and some studies showed no impact or mixed/
outcomes. This review and meta-analyses advance inconclusive findings. The quality of evidence was
prior findings that specifically examine the impact of judged very low, mostly due to a lack of randomized
intra-shift napping on shift worker performance and clinical trials conducted in operational shift workers.
sleepiness. This systematic review identifies gaps in research
involving EMS personnel and similar worker groups
LIMITATIONS on the efficacy of intra-shift naps as a fatigue risk man-
agement strategy. In order to improve the health and
The collection of relevant literature to select databases safety of EMS personnel and the patients under their
was limited. Other databases may index literature and care, further research evaluating the timing, duration,
research relevant to the PICO question. The decision to feasibility and acceptability of napping interventions
include or exclude a study was based on pre-specified with multiple health and safety outcomes is war-
criteria, yet the decisions are ultimately subjective. The ranted. Cost benefit analyses of napping interventions
researchers examined the judgment of screeners to and dissemination strategies are also necessary to
include or exclude a title/abstract by having the princi- maximize the implementation of successful napping
pal investigator (PDP) review and adjudicate a random countermeasure strategies.
sample of n = 50 titles and abstracts of the n = 4,656
reviewed by screeners PJC and EMT. Principal investi-
gator (PDP) completed the review with no knowledge ORCID
of prior judgments by screeners. Findings from this Patrick J. Coppler http://orcid.org/0000-0002-0731-
comparison revealed 100% agreement between inves- 7989
tigators PDP, PJC, and EMT.
There are limitations with the meta-analysis of reac-
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