Over half of the 5.2 million registered nurses in the U.S. work in healthcare facilities where providers are needed around the clock (Smiley et al. 2023). Nurses often work long and/or irregular hours (e.g., night shifts, rotating shifts, early mornings), increasing their risk for shortened, poor-quality sleep and adverse health outcomes (Torquati et al. 2019; Li et al. 2020; International Agency for Research on Cancer 2020; Farag et al. 2021). Inadequate sleep among nurses can contribute to fatigue and decreased alertness, endangering worker and patient safety (Farag et al. 2024; Barker and Nussbaum 2011). While these negative outcomes can have serious consequences, solutions to improving sleep and managing associated risks are not simple. Employers cannot always control hazards stemming from personal factors (e.g., age, competing demands) (Farag et al. 2021; Groves et al. 2020). Work-related factors (e.g., scheduling, patient load, time pressure, inadequate staffing) (Farag et al. 2021; Groves et al. 2020) can fluctuate based on workforce availability and community demands for acute care (Dawson and Thomas 2019). As such, solutions to sleep- and fatigue-related issues in healthcare are rarely implemented (Steege, Pinekenstein, Rainbow, and Arsenault 2017).

Worker education and training is integral for occupational health and safety. In other around-the-clock, safety-critical work environments, such as aviation, sleep education and training is often a key part of a larger fatigue risk management system (FRMS) (Federal Aviation Administration 2012). This approach engages employees and employers in joint responsibility to collaboratively manage risk factors for inadequate sleep and fatigue. Employee-provided worker education and training for nurses, focused on obtaining adequate, restorative sleep, might address the complex contributors to fatigue stemming from nurses’ home and work, and in turn, bolster worker and patient safety in healthcare.

Sleep education and training for nurses has not been widely implemented (American Nurses Association 2014; Caruso et al. 2022; Caruso et al. 2019; Querstret et al. 2020). Only approximately 8% of U.S. nurse leaders among a sample of N = 158 reported that their organisations offer sleep and/or fatigue education for staff (Steege, Pinekenstein, Rainbow, and Arsenault 2017). Speculation on the limited uptake was attributed to a multitude of issues, including insufficient monitoring of fatigue-related errors, complexity in assessing fatigue, diffuse responsibility due to work vs. non-work causes of fatigue, and knowledge of the issue and desire for system change among healthcare leadership (Steege, Pinekenstein, Rainbow, and Arsenault 2017; Steege, Pinekenstein, Rainbow, and Arsenault Knudsen 2017). In a post-pandemic environment, where nurse fatigue, burnout, and retention issues persist (Lasater 2024), the call for change is resounding (Weaver and Wurmser 2024). However, nurse leaders and organisations may be hesitant to introduce sleep education or training, as there are few evidence-based programmes available designed to meet nurses’ needs (Hittle et al. 2023). Therefore, the purpose of this study was to identify components for a sleep education and training that nurses believe helpful in supporting their sleep and reducing fatigue. Identifying these components may lead to more effective programmes for use in the healthcare industry.

This study was guided by a Fatigue Risk Management Systems (FRMS) framework, based on Dawson and McCulloch’s (Dawson and McCulloch 2005) error trajectory model. The model proposes a chain of events or conditions leading up to a fatigue-related injury or error and identifies levels of control mechanisms for preventing progression along the trajectory. The initial basis of an incident is fatigue resulting from insufficient sleep, an extended period of wakefulness, and/or inadequate break time to obtain restful sleep and recovery, leading to experiencing behavioural fatigue symptoms (i.e., cognitive deficits). Those fatigue symptoms can result in a fatigue-related error which, when not stopped by later controls, culminates in a fatigue-related incident. For example, a sleepy nurse may select the wrong medication (fatigue-related error) and, if the patient’s wristband is not scanned (control mechanism), a medication error may result (fatigue-related incident).

For this study, we focused on a control early in this trajectory: using sleep and fatigue education to promote sleep during off-shift hours, reducing the likelihood of on-the-job sleepiness and eventual progression to fatigue-related incidents. Within the FRMS framework, controls providing a multi-layered, joint approach between employers and workers are outlined in detail by Wong, Popkin and Folkard (Wong et al. 2019) and the American College of Occupational and Environmental Medicine’s (ACOEM) Presidential Task Force Guidance Statement on Fatigue Risk Management in the Workplace (Lerman et al. 2012). Specifically, the ACOEM guidance (Lerman et al. 2012) includes a comprehensive 11-point plan for content to incorporate in such employer-based education and training. We based our list of content topics to present to participants on this 11-point plan (Table 1), tailoring the list for nurses, grounded in evidence found in nursing literature (Hittle et al. 2023; Lee et al. 2021; National Institute for Occupational Safety and Health 2015).

Virtual focus groups and interviews were conducted using a descriptive, qualitative approach, a method of inquiry aligning with our purpose for participants to explain their sleep education and training needs (Sandelowski 2000). Reporting follows the Standards for Reporting Qualitative Research (SRQR) guidelines (O’Brien et al. 2014).

Fifty-three nurses responded to the study invitation. After eligibility screening and consent, 23 participants completed a focus group or interview (see Figure 1). We conducted six focus groups and five interviews, resulting in 11 transcripts as units of study.

This study assessed night shift nurses’ acceptability of sleep education and training components (Hittle et al. 2023; Lerman et al. 2012; National Institute for Occupational Safety and Health 2015; McQuaid et al. n.d.; Baglioni et al. 2022; Edinger et al. 2021). Participants agreed the evidence-based topics presented were important to them, noting a few exceptions. They believed sleep physiology content should include the importance of quality, restful sleep instead of presenting it separately. They saw little distinction between daily sleep hygiene behaviours and strategies to use when experiencing insomnia symptoms. Still, the themes and subthemes presented underscore the significance of such training.

Findings reinforced the need and interest of nurse sleep education and training, content lacking in schools and workplaces (Meaklim et al. 2020). Participants believed health professionals are inherently eager to learn about sleep physiology and such knowledge will empower them to prioritise sleep. This finding is similar to studies among nursing students who reported receiving little sleep education in school, despite valuing and needing this information (Sawyer et al. 2022; Gellerstedt et al. 2019). By offering evidence-based nurse sleep education and training, employers can ensure their workers have tools for adequate and restful sleep. Training may allow workers to recognise when sleep difficulties are indicative of sleep disorders, another aspect of training participants desired. Increasing sleep disorder awareness could impact nurse health and patient safety, as estimates suggest approximately 25% of shift workers suffer from shift work disorder, a clinically diagnosed disorder characterised by both insomnia symptoms and sleepiness, resulting in extreme dysfunction at work and home (Wickwire et al. 2017; Pallesen et al. 2021).

Participants stressed wanting to learn how to obtain adequate sleep while working night shifts, maintaining relationships, and balancing competing demands. These findings reinforce what has been well documented among nurses (Groves et al. 2020) and shift workers more broadly (Arlinghaus et al. 2019). Some workplace strategies can help decrease work-life conflicts, such as giving workers control over their schedules and providing training (Arlinghaus et al. 2019). Sleep education and training can be designed to help nurses develop routines for workdays and off days, learn strategies to communicate need for restorative sleep, and help to foster relationships. Thus, training could offer a toolbox of solutions, so nurses can benefit from multiple strategies.

Similar to previous research, (Steege and Rainbow 2017; Hittle, Keller, et al. 2024) participants in our study initially identified sleep and fatigue risk mitigation as nurses’ responsibility, as opposed to a joint approach between employers and employees (Wong et al. 2019). After consideration, they soon identified ways employers can support sleep and reduce fatigue risks, such as ensuring nurses have breaks during shifts. Participants acknowledged a need for skills to communicate more easily about fatigue with coworkers and employers. Workers in other industries where public care and safety is prioritised before their own, such as firefighting, similarly find communicating about fatigue challenging and vulnerable (Dawson et al. 2015). Vulnerability can indicate professional and organisational cultural barriers around sleep (Hittle, Gillespie, et al. 2021; Arora et al. 2007). Instituting FRMS with sleep education and training can be successful with a strong safety culture; however, more research is needed on how best to overcome cultural safety barriers (Sprajcer et al. 2022).

Our study was strengthened by a purposeful sampling of night shift working nurses, as qualitative data benefits from homogenous groups (Cresswell 2013). Specifically, we restricted recruitment to night shift nurses, as night shift is directly in opposition to natural circadian rhythms, and thus challenging for obtaining restorative sleep. However, evidence supports nurses from all shifts experience fatigue and barriers to quality, restful sleep as a result of work and/or home circumstances (Farag et al. 2021; Groves et al. 2020). Therefore, as recommended by experts in the field (Caruso et al. 2019), sleep education and training for night shift nurses may be of value to any nurse managing sleep loss or fatigue, and applicability to those working other shifts should be explored. Because of the small, homogenous sample, the findings may not reflect the broader population of U.S. nurses. However, the purpose of qualitative research is to explore a deeper understanding of perceptions on a specific phenomenon with a homogenous group (Lincoln and Guba 1985). This demonstrates a strength of the study findings, reflecting individual experiences from our group of night shift nurses, with multiple participants confirming the responses. Still, future research is needed to evaluate these sleep education and training components among nurses from other regions (e.g., rural, international), as well as a larger group of nurses representative of the broader nursing community.

Findings from this study highlight the need and desire for sleep education and training for night shift nurses, along with identifying content areas nurses deemed to be most relevant (noted in Table 3). Specifically, nurses discussed their experiences working irregular hours impacting their sleep and the downstream physiological and social implications, as well as their desire for evidence-based strategies for improving sleep under challenging environments and approaches to managing occupational fatigue symptoms. Identifying nurse-specific content allows healthcare employers to offer training that addresses unique barriers and promotes sleep health within shift-working nurses. Future research should test the impact of such a programme on nurses’ sleep health, organisational outcomes (e.g., burnout, job satisfaction, patient safety), the effectiveness of various delivery methods (e.g., in-person, online synchronous, online self-paced), and training integration within different healthcare systems. In addition, acceptability of the content areas should be assessed, noting where adjustments would be needed. Finally, relevance of the content areas among other shift-working healthcare workers, such as support staff (e.g., nursing assistants), allied health personnel, and medical professionals, should be evaluated prior to introducing the training to a wider audience.

Information on sleep loss when working shifts is rarely shared with nurses at school or work, despite the hazards poor sleep and fatigue can pose to personal and public health and patient safety. Sleep education and training could fill this gap with evidence-based strategies nurses have been seeking, while trying to improve their sleep and reduce fatigue. By implementing such programmes, employers can work with nurses to address these concerns and limit fatigue and the associated risks to workers and patients. The present study helps guide what topics and strategies night shift nurses might value most. More research is needed to explore acceptability of content to nurses working other shifts. In addition, exploration on how best to overcome professional and organisational cultural barriers is needed. Understanding how to surmount these issues may lead to greater success in training implementation.

Supporting Information

Additional supporting information can be found online in the Supporting Information section.