Valerie E. Rogers

Sleep, Sleepiness, Fatigue, and Performance of 12-Hour-Shift Nurses

Nurses working 12-h shifts complain of fatigue and insufficient/poor-quality sleep. Objectively measured sleep times have not been often reported. This study describes sleep, sleepiness, fatigue, and neurobehavioral performance over three consecutive 12-h (day and night) shifts for hospital registered nurses. Sleep (actigraphy), sleepiness (Karolinska Sleepiness Scale [KSS]), and vigilance (Performance Vigilance Task [PVT]), were measured serially in 80 registered nurses (RNs). Occupational fatigue (Occupational Fatigue Exhaustion Recovery Scale [OFER]) was assessed at baseline. Sleep was short (mean 5.5 h) between shifts, with little difference between day shift (5.7 h) and night shift (5.4 h). Sleepiness scores were low overall (3 on a 1–9 scale, with higher score indicating greater sleepiness), with 45% of nurses having high level of sleepiness (score  > 7) on at least one shift. Nurses were progressively sleepier each shift, and night nurses were sleepier toward the end of the shift compared to the beginning. There was extensive caffeine use, presumably to preserve or improve alertness. Fatigue was high in one-third of nurses, with intershift fatigue (not feeling recovered from previous shift at the start of the next shift) being most prominent. There were no statistically significant differences in mean reaction time between day/night shift, consecutive work shift, and time into shift. Lapsing was traitlike, with rare (39% of sample), moderate (53%), and frequent (8%) lapsers. Nurses accrue a considerable sleep debt while working successive 12-h shifts with accompanying fatigue and sleepiness. Certain nurses appear more vulnerable to sleep loss than others, as measured by attention lapses. (Author correspondence: jgeiger@son.umaryland.edu)

Cognitive behavioral therapy in persons with comorbid insomnia: A meta-analysis

Cognitive behavioral therapy for insomnia (CBT-I) is effective for treatment of primary insomnia. There has been no synthesis of studies quantifying this effect on insomnia comorbid with medical and psychiatric disorders using rigorous selection criteria. The objective of this study was to quantify the effect of CBT-I in studies including patients with medical or psychiatric disorders. Studies were identified from 1985 through February 2014 using multiple databases and bibliography searches. Inclusion was limited to randomized controlled trials of CBT-I in adult patients with insomnia diagnosed using standardized criteria, who additionally had a comorbid medical or psychiatric condition. Twenty-three studies including 1379 patients met inclusion criteria. Based on weighted mean differences, CBT-I improved subjective sleep quality post-treatment, with large treatment effects for the insomnia severity index and Pittsburgh sleep quality index. Sleep diaries showed a 20 min reduction in sleep onset latency and wake after sleep onset, 17 min improvement in total sleep time, and 9% improvement in sleep efficiency post-treatment, similar to findings of meta-analyses of CBT-I in older adults. Treatment effects were durable up to 18 mo. Results of actigraphy were similar to but of smaller magnitude than subjective measures. CBT-I is an effective, durable treatment for comorbid insomnia.

Measuring restorative care provided by nursing assistants: reliability and validity of the Restorative Care Behavior Checklist.

Background: Most prior research on the outcomes of restorative care programs has been focused on resident outcomes including such things as functional performance, behavior, and quality of life. Treatment fidelity issues and compliance with the programs were not addressed in these studies. Without such an evaluation, it is impossible to evaluate the effectiveness of restorative care activities. Purpose: To test the reliability and validity of the Restorative Care Behavior Checklist (RCBC), which is an observed measure of restorative care activities performed by nursing assistants (NAs). Methods: The study involved a single observation of care activities and completion of survey data among NAs working in nursing homes. A total of 386 participants from eight nursing homes were included in the study. In addition to completion of the RCBC during a 15-minute observation of care activities, demographic data were obtained, and participants completed a paper-and-pencil survey that included assessments of self-efficacy, outcome expectations, knowledge of restorative care, and job attitude. Reliability testing was based on person separation reliability and interrater reliability. Validity testing was based on evidence of the unidimensionality of the measure, the fit of the items using Rasch analysis, and evidence of convergent validity. Results: There was support for the reliability of the RCBC with a person separation reliability of.77 and interrater reliability, with 83% to 100% agreement on each of the care activities. Support for validity was provided based on evidence of unidimensionality and a good fit of the items. There was minimal support for convergent validity. Discussion: The development and psychometric testing of the RCBC are an important first step in the observational assessment of restorative care activities performed by NAs, or other caregivers of older adults, living in long-term care settings.

Testing the reliability and validity of self-efficacy and outcome expectations of restorative care performed by nursing assistants.

The primary aims of this study were to determine the reliability and validity of 2 measures: the Nursing Assistant Self-efficacy for Restorative Care Scale and the Nursing Assistant Outcome Expectations for Restorative Care Scale. This study included 386 nursing assistants from 8 nursing homes. The findings provide some support for the reliability and validity of these measures on the basis of Rasch analysis, confirmatory factor analysis, and convergent validity.

Capturing PLMS and their variability in children with sickle cell disease: does ankle activity monitoring measure up to polysomnography?

OBJECTIVES To test agreement and define differences in periodic limb movements in sleep (PLMS) measured by polysomnography and an ankle activity monitor, and to describe PLMS variability across nights, feasibility of home monitoring, and correlates of PLMS in children with sickle cell disease (SCD). METHODS Twenty children with SCD and restless legs syndrome (RLS) symptoms or polysomnography-documented PLMS underwent concurrent attended polysomnography and ankle activity monitoring over one to two nights and home activity monitoring for three nights. Serum iron and ferritin were measured pre- and post-polysomnography. RESULTS Adequate sensitivity (1.00), specificity (0.69), and mean bias (5.0±7.4 PLMS/h) for identifying elevated PLMS by activity monitor were obtained when scoring the period from sleep onset to offset rather than time in bed per manufacturer recommendation, and using a cut-point of 10 PLMS/h. Compared to activity monitor, only polysomnographic PLMS demonstrated periodicity, at inter-movement intervals (IMI) 20-35 s; the activity monitor overscored PLMS at the beginning and end of sleep and at shorter IMI (5-15s; p≤0.003), suggesting misclassification of nonperiodic leg movements as PLMS by activity monitor. PLMS varied across four nights by 16.1±13.4 PLMS/h. Post-polysomnography ferritin was associated (positively) with PLMS (p=0.034); RLS symptoms were not. CONCLUSIONS Ankle activity monitoring is a valid screening measure for PLMS in children with SCD and can readily be performed at home. Interpretation should incorporate a threshold for elevated PLMS of 10/h and scoring from sleep onset to offset, which could be identified with concurrent wrist actigraphy, to better account for true PLMS.

Diagnostic Accuracy of Behavioral, Activity, Ferritin, and Clinical Indicators of Restless Legs Syndrome

STUDY OBJECTIVES Lack of a valid diagnostic measure of restless legs syndrome (RLS) for persons with dementia, who do not have the cognitive ability to report complex symptoms, impedes RLS treatment and research in this population. The aim of this study was to determine the sensitivity and specificity of a combination of indicators for identifying RLS that could eventually be used to diagnose RLS in persons with dementia. DESIGN 3-day, prospective instrument validation. SETTING Sleep laboratory. PARTICIPANTS Cognitively intact, 107 with RLS, 105 without RLS. INTERVENTIONS N/A. MEASUREMENTS Serial 20-min observations with a new measure, the Behavioral Indicators Test-Restless Legs (BIT-RL); leg movements with 3 nights of the Periodic Activity Monitor-Restless Legs (PAM-RL); ferritin; sleep history; clinical data; polysomnography; Hopkins Telephone Diagnostic Interview of RLS Symptoms. RESULTS The best-fitting diagnostic model for identifying RLS included previous history of iron deficiency (odds ratio [OR] 7.30), leg discomfort (OR 6.47), daytime fatigue (OR 6.15), difficulty falling asleep (OR 3.25), RLS family history (OR 2.60), BIT-RL (OR 1.49), and absence of diabetes (OR 0.27), with sensitivity 78%, specificity 79%, and 77% correctly classified. This model retained its predictive accuracy even with co-morbid sleep apnea. CONCLUSIONS When compared to those without RLS, persons with RLS have observable behaviors, such as rubbing the legs, that differentiate them, but the behaviors have no circadian and activity-related variability. The final model of clinical and sleep historical data and observation for RLS behaviors using the BIT-RL had good diagnostic accuracy.

Impairment in Circadian Activity Rhythms Occurs During Dexamethasone Therapy in Children With Leukemia

Circadian rhythm disturbances in adults with cancer are associated with fatigue, time to relapse, and death. This study of circadian activity rhythms (CAR) of children with acute lymphoblastic leukemia (ALL) on continuation chemotherapy aimed to describe CAR before and after starting dexamethasone, and to determine whether fatigue was associated with less robust CAR.

Experience of insomnia, symptom attribution and treatment preferences in individuals with moderate to severe COPD: a qualitative study

Persons with chronic obstructive pulmonary disease (COPD) are known to have poor sleep quality. Acceptance of and adherence to therapies for sleep problems may depend on how the person with COPD regards the source of his sleep problem, yet little is known about their attribution as to the cause of these sleep symptoms. The objective of this study was to describe the subjective sleep complaints of individuals with COPD along with their attributions as to the cause of these symptoms, and their treatment preferences for insomnia. Three focus groups were conducted (N=18) with participants who have moderate to severe COPD. Focus group data were transcribed, compared and contrasted to identify themes of attribution. Participants reported difficulty falling asleep, staying asleep, and daytime sleepiness. They attributed their sleep problems primarily to their pulmonary symptoms, but also poor air quality (thick humid air) and death anxiety when awake during the night. There was no clear preference for type of treatment to remedy this problem (medication, cognitive therapy), although they indicated that traveling to the clinic was difficult and should be avoided as much as possible. These data suggest that environmental manipulation to improve air quality (eg, air conditioning) and modifications to reduce death anxiety could be beneficial to persons with COPD. In-person multi-session therapy may not be acceptable to persons with moderate to severe COPD, however internet-based therapy might make treatment more accessible.

Similar gastrostomy peristomal skin irritations in three pediatric patients.

Gastrostomies are frequently created for the management of pediatric patients with conditions such as necrotizing enterocolitis, failure to thrive, cystic fibrosis, cardiac conditions, gastroesophageal reflux disease (GERD), tracheal esophageal anomalies, trauma, and children with neurologic impairment and developmental delays. These children may require a gastrostomy for nutritional support and to meet caloric needs for growth and development. The primary nurse, physician, and parents and family are responsible for the care and management of the gastrostomy tube (GT) or a low-profile gastrostomy device. The WOC nurse often is consulted for management of the peristomal skin. This article presents 3 patients with the same type of gastrostomy peristomal skin breakdown and 3 alternative modes of management to meet their individual needs. The goal of the primary nurse is to maintain optimal function of the GT or low-profile replacement device to prevent complications and to provide patient/family teaching. Frequent problems associated with a Foley GT may include dislodgment, migration, clogging, stomal enlargement, leaking, and skin breakdown. The aim of the WOC nurse is to provide an environment that maintains skin integrity and wound healing to prevent infection. The WOC nurse will also instruct the staff and family wound care techniques to provide ease, effectiveness, cost efficiency, and patient satisfaction.

Bowel and bladder continence among children with spina bifida: a retrospective study

Address: 1Neurology & Developmental Medicine, Keelty Center for Spina Bifida, Kennedy Krieger Institute, North Broadway, Baltimore, Maryland, USA, 2Behavioral Psychology, Keelty Center for Spina Bifida, Kennedy Krieger Institute, North Broadway, Baltimore, Maryland, USA, 3Neuropsychology, Kennedy Krieger Institute, Keelty Center for Spina Bifida, Kennedy Krieger Institute, North Broadway, Baltimore, Maryland, USA, 4Urology, Johns Hopkins Hospital, Baltimore, Maryland, USA and 5School of Nursing, University of Maryland, Baltimore, Maryland, USA