Asleep Behind the Wheel: Experiences of Night Shift Nurses on the Commute Home

Aim: The aim of this study was to obtain descriptions of nurses’ perceptions and experiences of falling asleep behind the wheel on the drive home after a worked night shift. Background: While the evidence suggests that the problem of drowsy driving and fall asleep driving is a strong contributor to vehicular accidents, little is known about nursing perceptions of the issue. Methods: The design of the study is qualitative and descriptive. Face-to-face interviews were conducted with 12 registered nurses who had experienced falling asleep behind the wheel on the drive home from work after a worked night shift. The interviews were transcribed verbatim and analyzed using content analysis. Results: The eight themes which emerged from the data evolved from factors identified by the participants during the interviews. They were: (1.) night shifts better for new grads, (2.) auto-pilot, (3.) struggling to stay awake, (4.) it’s scary, (5.) just need to get home, (6.) not a night person, (7.) feeling awful, and (8.) don’t know how to fix it. Conclusion: This study strongly suggests the need for additional research. Because we know that drowsy and fall asleep driving after a worked night shift is a ubiquitous phenomenon among night nurses, the need to develop interventions to mitigate the risks of the phenomenon was confirmed. The findings emphasize the importance of open dialogue and heightened awareness of the dangers faced by the nurses when they have finished their shift and are driving home. Understanding the context of nurses’ experiences with falling asleep behind the wheel may elicit stronger communications between nurses and their nursing leaders. Targeted education on sleep hygiene, drowsy driving, and fall asleep driving for nurses, nursing leaders, and hospital administrators may serve to open the dialogue. Negative physiologic and psychological influences of night shift centered around poor quality and quantity of sleep. These negative influences were consistently presented by all participants. The nurses’ beliefs that they are physically unable to adapt to shiftwork warrants further research into screening for physiological and psychological ability to engage in shiftwork. Further studies are needed to explore the efficacy of restorative napping, and other interventions to prevent drowsy and fall asleep driving. Many participants expressed the fact that they had little to no choice but to work the night shift as new graduates. We need to closely examine why the newest members of the nursing profession are placed on the shift with the least amount of resources. The phenomenon of fall asleep driving after a worked night shift environment in nursing is poorly understood. The goal of this qualitative descriptive study was to elicit a description of the experience of night shift nurses with the goal of obtaining information that would serve to find ways to eliminate the occurrence of drowsy/fall asleep driving in nurse shiftworkers. Nursing and hospital administrators may be able to utilize the information gleaned from this study to optimize the nurse scheduling, implement evidence based interventions, and subsequently, keep the nurses safe.


Justification for and Significance of the Study
Nurses who work the night shift must adjust to being awake at a time when their natural circadian rhythms are prompting them to sleep. Their work environment is focused on patient comfort in that the lights are dimmed, voices are hushed, patients are sleeping, and the cafeteria is closed. At the end of their shift, they step into daylight and must remain alert for the drive home.
Nursing will always be a 24 hour, 7 day a week profession. Eliminating the night shift is not an option. Those who drive when they are drowsy, place themselves and others in immediate danger. When sleepy drivers get behind the wheel, they risk their own lives and the lives of others.
Drowsiness is the last step before falling asleep. According to Dr. Dement, Division Chief of the Stanford University Division of Sleep, "The crucial event that occurs as we fall asleep is an abrupt shut down of the neural processes that allow us to perceive the world around us. At one moment we are awake, and can see and hear. A fraction of a second later we are asleep, and we are completely blind and completely deaf" (Dement, 1997, para.20). Although the vast majority of drivers recognize the serious threat of drowsy driving, a 'do as I say, not as I do' attitude exists when getting behind the wheel. Drowsy driving is no different in that it kills just as drunk, drugged and distracted driving does. "Drivers have a tendency to underestimate the impact being tired has on their driving ability, which puts themselves and others at risk." (AAA Foundation for Traffic Safety, 2004, para.2). These drivers are involved in one of every six deadly crashes and one in eight crashes resulting in serious injury, (AAA Foundation, 2010; AAA Foundation for Traffic Safety., 2004). The 2012 Safety culture index found that 96% of drivers find it unacceptable to drive when they are so sleepy that it is difficult to keep their eyes open (AAA Foundation, 2013).While few if any nurses would disagree with the statements above, many who work the night shift routinely get into their cars every morning after a worked night shift and drive drowsy placing their own lives as well as the lives of others at risk. sense of shame and embarrassment after falling asleep in front of others. I became depressed and isolative. I gained weight from a cycle of eating high glucose foods and caffeinated soft drinks in an effort to stay awake.
As part of a new graduate nurse cohort we met on a regular basis. During these meetings we discussed our experiences as new RNs. I was secretive and did not share my issue of falling asleep behind the wheel with the group. I saw it as a personal weakness and was concerned that it would reflect poorly on me as a professional.
After approximately six months of working the night shift I was driving home after work one morning. My commute was only twenty minutes in length. I felt drowsy, but no more so than usual. I awoke and found that my passenger window been broken by a police officer. I had fallen asleep behind the wheel and hit two parked cars. I sustained multiple lacerations as well as a severe concussion. The cars were parked near a busy sidewalk. Fortunately, there were no pedestrian injuries.
After the accident, for a period of approximately eight months, I suffered recurrent nightmares and anxiety about "what could have" happened? What if the parked cars had not shielded the busy sidewalk? What if I had harmed a pedestrian or another driver? I felt great shame, self loathing, and horror when I thought of the accident.
Despite all of this, I continued to work the night shift. As a new graduate nurse, working the day shift was not an option as this shift was reserved for the more "senior" nurses. I subsequently had multiple near misses and episodes of "nodding off" at the wheel.
Sadly, many nurses who work the night shift can easily relate to this personal story. I was able to go to the day shift by taking a position in nursing administration.
My transition to nursing administration was made possible in part by my length of experience as a staff nurse, which included the requisite years of shift work. Leaving the bedside care that I greatly enjoyed seemed a small price to pay for saving my life and/or someone else's.
I thrived on the day shift. I enjoyed my work in nursing administration as the Nurse Manager of a busy intensive care unit and put those difficult years of working the night shift behind me. I was on the unit one day when I received a call that we would be getting an admission from the Operating Room. The patient was a young woman, a nurse's aide who had worked the night shift the night immediately prior.
She had left work, picked up her young son and was driving him to his pre-school. She fell asleep and drove through a busy intersection. Her son died shortly after the accident. She had multiple injuries but would survive. What bed did I want to assign her to? , asked the operating room clerk. I caught my breath and assigned the room number. I ran into my office and had great difficulty catching my breath. I sobbed.
That could have been me. The feeling of terror and sadness that passed through me was overwhelming.
According to the New York State Partnership Against Drowsy Driving (NYPDD), a task force formed in 1994 to reduce drowsy driving, fatigue-related crashes tend to be single-vehicle crashes in which a car or truck leaves the roadway and then turns over or hits a fixed object. They estimated that between 40 and 60 percent of these "run-off-road" crashes are due to driver fatigue, drowsiness or inattention. Run-off-road crashes constitute a serious highway safety problem, accounting for one-third of all traffic fatalities nationally and two-thirds of fatalities in rural areas. While police officers may implicate fatigue in crashes, there is rarely sufficient evidence to prove sleep as a causal issue. The evidence is usually circumstantial using identifying markers such as the absence of skid marks, off the road single vehicle accidents and a lack of poor road conditions.
The significance of the issue of drowsy driving and fall-asleep driving cannot be understated. As I began to discuss this issue with my staff and colleagues, I learned that many of night nurses dealt with this issue on a regular basis. Countless nurses had stories of falling asleep on the commute home when they worked the night shift. I identified the need for heightened awareness of the issue of falling asleep at the wheel after a worked night shift.
Only by speaking candidly and openly about this issue, can we begin to work towards safe solutions that will keep nurses and the public safe. We cannot wait until the public sanctions us to police ourselves; we need to deal with this problem in a professional and ethically responsible manner.

REVIEW OF LITERATURE
"Sleep is the golden chain that ties health and our bodies together" -Thomas Dekker -The Guls Horne Book, 1609 The review of the literature for this dissertation was based on key terms taken from the question, "What is the experience of nurses falling asleep behind the wheel on the drive home after a worked night shift?" The goal of this review was to determine the state of the science regarding this topic and identify the existence of gaps in the literature.

Literature Search Method
Searches were performed in the databases of PubMed, CINAHL and Google Scholar and Dissertation Abstracts. Based on the research question, the key primary search terms were 1.) night nurses, 2.) night shift nurses, 3.) asleep behind the wheel, and 4.) drowsy driving. The terms were searched independently and in inclusive combinations.

Shiftwork
The term "shift work" holds different meaning to different people. Many researchers define shift work as working outside of the standard daylight hours of 8am-6pm. Most discussions involving nurses consider shift work to be hours worked between 7pm and 7am. The length of a standard nursing shift can vary between 8 and 12 hours. For the purpose of this dissertation, "shift work" refers to the hours of overnight work that begin either at 7pm or 11pm until 7am. "Rotational shift work" refers to a work schedule that alternates between the day shift and the night shift in the case of 12 hour shifts, and the day shift and the evening shift or night shift in the case of 8 hours shifts. A night shift is either a group of workers who work during the night, or the period in which they work. For the purpose of this dissertation, night shift is the time of work.
Until the invention of electricity, shift work was mainly limited to soldiers and sailors. With the advent of electric lighting, global travel, customer demands, the internet, and increasing economic and social demands, we have evolved into a 24 hour society. We are able to do the same work during the night hours as we can during the daytime. The history of shift work in America can be traced back to the industrial revolution in the 18th and 19th centuries. Factory owners realized that keeping their machinery running 24 hours a day could maximize production.
Care of patients in the hospital is a 24 hour, 7 days a week occupation. Natural human circadian cycles are no longer considered a time constraint. Technology in healthcare as well as the advanced illness of the hospitalized patient has led to a 24 hour health care system requiring nurses to work during the night hours. The level of performance and productivity expected of nurse shift workers is no different than that of their day counterparts. For most nurses, entry into the profession is their initial experience with shiftwork. "To further compound this issue, most healthcare professionals, including nurses, typically receive little or no formal education about normal sleep and circadian rhythms, or the essential role of sleep in maintaining adequate health and performance either during or after their training" (Owens, 2007, p.92).
The conveniences of maintaining a 24-7 society are not without cost. The loss of sleep incurred by working the night shift has its consequences in the areas of physical health, psychological health, social life, family life, work performance, and the economy. Individuals involved in shift work and rotating shifts rarely get enough sleep. In a study by Czeisler et al. (1980), it was determined that night shift workers obtain 1 to 4 hours less sleep than normal when they are working nights. While the amount of sleep required by adults varies, the effect of insufficient sleep is well documented. Intuitively, the leading cause of drowsy driving and fall asleep car accidents is sleep loss (National Highway Traffic Safety Administration & National Center on Sleep Disorders Research, 1999).
Interest in the effects of shift work on people developed because many experts have blamed shift work for the "human error" connected with medical errors, nuclear power plant incidents, airplane crashes, and other catastrophic accidents. The key accident that caused the 1979 meltdown at the Three Mile Island nuclear generator in Pennsylvania occurred at 4am, and was made by operators working the night shift.
The accident at the Chernobyl nuclear power plant in the Ukraine is the worst nuclear disaster in history. The accident started at 1:26 am on April, 26 1986. The cause of the disaster has been partially attributed to human error caused by confusion and fatigue.
According to Flight Duty Times (2013), in 2011 an airplane flying from Stockholm to Copenhagen was pilotless for a while after the co-pilot left the cockpit for a short time and the captain fell fast asleep. On October 22, 2009, the pilots of a Northwest Airlines airplane flew past their destination airport by about 150 miles and did not respond to any radio contact for over an hour. The cockpit was finally notified of the error by a flight attendant.
A pilot study of 23 Australian nurses found that they experienced sleepiness and related physical symptoms both at work and during their trip home. "Further, a measurable number of errors occur of various types and severity. "Less sleep may lead to the increased likelihood of making an error, and importantly, the decreased likelihood of catching someone else's error " (Dorrian et al., 2008, p. 92).
Approximately 30% of the nursing population is involved in shiftwork (Hughes & Stone, 2004). Many nurses find that shift work disrupts their family and personal life and leads to health problems including chronic fatigue, depression and gastrointestinal disorders. Nurses who do work the night shift must function optimally on a schedule that is not "natural." The imbalance in homeostasis caused by shift work can produce a wide range of effects on physiological systems. Epidemiological studies report decreased health in shiftworkers, including increased cardiovascular complaints and reproductive dysfunctions in night workers.

What is Sleep?
The effects of sleep on our physical and mental health are the topic of many research studies. An understanding of the mechanism of sleep is critical to this research. Neurotransmitters control whether we are asleep or awake by acting on different neurons in the brain. Neurons in the brainstem produce the neurotransmitters seratonin and norepinephrine. These neurotransmitters keep some parts of the brain awake while others sleep. Wakefulness includes Gamma, High Beta, Mid Beta, Beta Sensory Motor Rhythm, Alpha, and Theta brain waves. Our composite brain waves are made up of many of these brain waves all at the same time (Walcutt, 2009 (Walcutt, 2009).

stage two
The second stage of sleep lasts about 20 minutes. Our brain begins to produce very short periods of rapid, rhythmic brain wave activity known as Sleep Spindles (Walcutt, 2009 REM sleep is characterized by eye movement, increased respiration rate and increased brain activity. REM sleep is also referred to as paradoxical sleep because, while the brain and other body systems become more active, the muscles become more relaxed, or paralyzed. Dreaming occurs because of increased brain activity, but voluntary muscles become paralyzed. Voluntary muscles are those that you need to move by choice, for example, your arms and legs. Involuntary muscles are those that include your heart and gut. They move on their own (Walcutt, 2009). This period of paralysis is a built-in protective measure to keep you from harming yourself. When you are paralyzed, you can't leap out of bed and run. This state protects us from actually running or other movement as we often may wish to do in our dreams (Walcutt, 2009).

Sleep Cycles
Sleep does not progress through all of these stages in sequence. We pass through five stages of sleep. When we only get short periods of sleep, we can't really get through the stages we need to remain healthy and rejuvenated. This is why we need long periods of sleep each night. REM can last up to an hour as our sleep progresses.

Circadian Rhythm
The body is programmed to sleep when it's dark and to be awake during 'light' hours. The use of electric lighting, alarm clocks, pharmacologic sleep aids and engagement in shiftwork wreak havoc on the process of sleep. Stress hormones attempt to mediate anything that alters this schedule, which causes many types of internal inflammation, fat metabolism, and other issues leading to cancer and heart disease. Sleep/wake patterns, hormone levels, and physiological processes such as core body temperature and heart rate are controlled by a daily biological clock (Gamble, 2011 Circadian disruption occurs as a result of misalignment in the timing of circadian rhythms in relation to either the external light-dark cycle or to each other (Rogers & Dinges, 2002).
Our bodies naturally follow the circadian rhythms of wakefulness and sleepiness, with the desire to sleep strongest between midnight and 6 a.m., and between 2 p.m. and 4 p.m. When sleep/wake patterns are out of synchronization with the endogenous clock and/or the environment, such as during shift work, circadian misalignment can result. Circadian disruption, also known as chronodisruption, is a disturbance of the circadian organization of human physiology, endocrinology, metabolism, and behavior. The most basic principle underlying the circadian rhythm variation is readiness for action during daytime and rest at nighttime.
Circadian rhythms are largely driven by the internal body clock and synchronized to the external world by cues known as "zeitgebers." The word "zeitgeber" was coined in 1954 by a German biologist named Jurgen Aschoff who studied circadian rhythms. Literally translated, "zeitgeber" means "time giver". The zeitgeber cue influences the operations of the internal clock of an individual. Light is an example of a zeitgeber. Light, as an external cue leads many individuals to wake up with most people drawn to sleep between the hours of midnight and 6 AM (National Sleep Foundation, 2007). Interruptions in these cues can lead to functional difficulty and potential health problems. Since our bodies are programmed to relax after dark and be alert during the day, shiftwork forces the body to combat the natural time of rest. We are forcing the body to work counter to its natural cycle.  (Wever, 1985, p. 13 (Rogers, Hwang, Scott, Aiken, & Dinges, 2004).
The single most disrupting factor to the circadian rhythm is shift work. People engaged in shiftwork suffer from 'shift-lag' syndrome, which is characterized by feelings of fatigue, sleepiness, insomnia, disorientation, digestive troubles, irritability, poorer mental agility and reduced performance efficiency (Costa, 2003).
Epidemiologoical evidence reported by Knutssen identified certain health conditions that should be considered a relative or absolute contraindication to shiftwork with strong consideration for reassignment to a day shift.These conditions are: 1. Chronic sleep conditions, 2. Severe gastro-intestional diseases, 3: Hypertension and ischemic heart disease, 4. Insulin-dependent diabetes, 5. Thyroid and supra-renal diseases, 6. Epilepsy, 7. Chronic depression and anxiety, 8. Chronic renal disease, 9.
According to Charmane Eastman, PhD, a physiological psychologist at Rush University in Chicago, "all of the sleep in the world won't make up for circadian misalignment…The circadian clock is very stubborn and hard to push around (Price, 2011, para. 6).

Physical Effects of Shiftwork
Working the night shift and rotating shifts places not only the driver at risk for drowsy driving; the night shift and rotating shifts have been shown to potentially endanger workers' health (Dembe A.E., 2009 This brief period of disalignment resulted in multiple physical symptoms including increased blood pressure, increases in blood glucose, insulin, and cortisol levels.

cardiac/cardiovascular
In a study led by Kawachi, (Kawachi et al., 1995)  may be confined to women with a history of 15 or more years of rotating shift work.
Women appear to have a modestly increased risk of stroke after extended periods of rotating night shift work.
Shift work has been associated with increased risk of cardiovascular disease.
The study led by Su (2008), was designed to determine the hemodynamic effects of 12-hour shifts, and changes in blood pressure (BP) and heart rate variability (HRV) during a 36 h rest time following 12-hour shifts. Results showed that 12-hour night shift work gave a persistently elevated systolic and diastolic BP (SBP and DBP) and HR compared to 12-hour day shift work with the corresponding resting time. In addition, there was delayed SBP and DBP recovery on the first 12-hour rest time in night shift workers, which was further demonstrated on the second 12-hour rest time after adjustment for possible confounders through mixed models. They concluded that 12-hour night shift work may elevate BP and HR.

cancer
According to the International Agency for Research on Cancer (IARC), "shift work that involves circadian disruption" is considered a Group 2A carcinogen and "probably carcinogenic to humans (Straif, 2007(Straif, , p. 1065.Group 2A means that this conclusion was based on "limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals (Straif, 2007(Straif, , p. 1065." IARC based their conclusion on studies of long-term night workers who have shown a higher risk of breast cancer than women who do not work at night. These studies have involved mainly nurses and flight attendants (Straif, 2007) . This was the conclusion of 24 scientists who were convened by the IARC to examine the correlation between shiftwork and cancer.
The impact of shiftwork on physical symptoms has been extensively studied.
In a recently published nested case-control study of Norwegian nurses, an increased breast cancer risk was associated with working more than five consecutive nights for more than 5 years (Lie JA, 2011). Researchers from Harvard University found that women who worked shift work were at higher risk (50%) of developing breast cancer, and that the longer women worked shift work, the higher their risk became (Megdala, Kroenke, Laden, Pukkala, & Schernhammer, 2005 Women doing shift work for more than six years have been shown to be at greater risk for coronary heart disease (Kawachi, et al., 1995). "The physiological impact of shift work on several markers involved in the regulation of body weight, leptin, insulin and cortisol, seems to contribute to the increased risk for the development of diabetes, cardiovascular disease and obesity," said researcher Frank Scheer (2009, p.3) an instructor of medicine in the division of sleep medicine at Brigham and Women's Hospital and Harvard Medical School, in Boston.

psychological/cognitive effects
The effect of shiftwork can cause major problems for nurses whose job requires a constant level of high alert and vigilance and the ability to make splitsecond, life-or-death decisions during the night. Disruption of circadian rhythms affects the psychological aspects of an employee's personality, and several trials show increased anxiety and depression symptoms (Bajraktarov S et al., 2011).

Bara and Arber (2009) analyzed longitudinal data from a British Household
Panel Survey which found that undertaking night work for greater or equal to four years in men was associated with an increased risk of having a General Health Questionnaire (GHQ) score reflecting mental ill health and reporting anxiety/depression. Women were significantly more likely to report anxiety/depression and to have a GHQ score reflecting mental ill health, after working varied shift patterns for two to three years, and greater than or equal to four years, respectively. They concluded that different types of shiftwork had a differential impact on mental health, but this impact varied according to gender. Women's mental health was more adversely affected by varied shift patterns, while night work had a greater negative impact on men's mental health.
Owens (2007)  varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, and policy makers. The current version is the DSM-IV-TR (fourth edition, text revision). It is organized into a five-part 'axis' system, with the first axis incorporating 'clinical disorders' and the second covering personality disorders and intellectual disabilities.
Since some individuals are seriously affected by shiftwork, there is a diagnostic category called "Shift Work Sleep Disorder" (SWSD), also referred to as shift work disorder or shift work type in DSM IV. Misalignment between internal circadian physiology and the required work schedule is thought to be a primary cause of shift work schedule induced sleepiness and sleep disruption (Akerstadt & Wright, 2009).
Working against the circadian rhythm results in extreme fatigue which decreases cognitive functions, slows reflexes, and increases feelings of irritability.
This results in a diminished ability to make sound decisions as in the decision to drive while feeling drowsy or falling asleep. In addition, associated irritability, impatience and mood disorders such as anxiety and depression can negatively affect job and family relationships and have detrimental effects on social activities.
In a study conducted at Vanderbilt University, as many as 25 percent of hospital nurses go without sleep for up to 24 hours in order to adjust to working on the night shift, which is the least effective strategy for adapting their internal, circadian clocks to a night-time schedule. Changing from day to night shift often implies a period of 20-24 h without sleep. According to Dawson and Reid, the decrements in performance during the latter part of this sleep deprivation may be equivalent to an illegal level of alcohol in the blood (Dawson & Reid, 1997).
"Overall, night shift workers tend to get less sleep than their day shift counterparts, and their sleep is qualitatively poorer. Sleep during the day is shorter, lighter, more fragmented, and less restorative than at night, thus the night nurse arrives at work with a larger sleep deficit than does a day shift nurse (Stokowski, 2004, para. 9)."

Effect of Lack of Sleep on Driving
Although the effect of lack of sleep has been compared to the effects of alcohol, limited public reaction to drowsy driving lies in juxtaposition to public awareness of drunk driving. In a New York State survey, nearly one-half the drowsy drivers who crashed (and more than one-third of those who drove drowsy without crashing) reported having worked the night shift or overtime prior to the incident Hammer, 1996). Novak and Auvil-Noval (1996) found that 95% of the intensive care nurses who participated in their examination of night shift workers (n=45) reported automobile-related injuries and near accidents on the commute to and from work.
According to the World Health Organization (WHO),"…the greatest danger facing drivers is falling asleep behind the wheel. Fatigue induces poor judgment, slower reaction times and decreased alertness" (WHO, 2010, p.60). Often, shift workers are not even aware that they have fallen asleep during their commute home.
By the time individuals are starting to feel fatigued and feel they may be impaired, their performance has deteriorated considerably (Jones, et al., 2006). In fact, many drivers who are involved in sleep related vehicular accidents deny having fallen asleep (Horne & Reyner, 1998). While there may be a degree of fear of prosecution, it is likely that the driver does not recall falling asleep. When people fall asleep for 1-2 minutes and are awakened in Stage 1 sleep, they generally do not realize that they fell asleep.
Microsleeps are brief and unintentional episodes of loss of attention associated with events such as blank stare, head snapping, and prolonged eye closure which may occur when a person is drowsy but trying to stay awake. Microsleeps often occur during the performance of monotonous tasks like driving a car, sitting in a lecture, or staring at a computer monitor. During a microsleep, part of the brain effectively falls asleep while the rest is awake. This could account for selective loss of awareness without the person feeling he or she has been asleep (Boyle, Tippin, Paul, & Rizzo, 2008).
In a driving simulator study, driving performance was significantly impaired in shift workers after the night shift (Akerstedt et al., 2005). Nurses who worked night or rotating shifts reported more than three times the odds of nodding-off while driving to or from work the preceding year as compared with nurses working only day or evening shifts (Gold et al., 1992). As compared to day shift workers, night shift workers are at increased risk for a sleep related motor vehicle accident due to the combined effects of driving while drowsy, driving after an extended period of wakefulness and driving at a vulnerable time in their circadian rhythm (Horne & Reyner, 1999;Philip & Mitler, 2000). Although working the night shift is contrary to the body's natural circadian rhythms, many nurses identify the night shift is their shift of choice. Nurses cite the following reasons for choosing to work the night shift: it allows flexibility for childcare, a strong sense of teamwork, increased hourly monetary compensation in the form of financial differentials, fewer nursing administrators on site, they are able to avoid commuting during rush hour, and, there is less activity than on the day shift resulting in a more manageable pace.
According to Dembe (2009), in healthcare, the use of overtime has increased in recent years as a response to nursing shortages in staffing. Rogers et al. (2004) noted that while most overtime is voluntary, many nurses feel compelled to work voluntary overtime. Night shifts are particularly difficult to fill and account for a high percentage of extra shifts that nurses voluntarily assume.
Shift work in hospital nurses is a particularly demanding example of shift-work disruption because: (i) the shifts change from on to off so frequently and (ii) most night-shift nurses strive to flip immediately back to day-activity/night-sleep on daysoff (Gamble, 2011). The ubiquitous 12 hour shift is the shift of choice by most nurses in that it allows for a three day work week. According to Rogers (2008), 75 percent of nurses work 12 hour shifts. Despite research that supports returning to 8 hour shifts, nursing administrations are reluctant to consider elimination of 12 hour shifts due to their popularity with staff nurses (Geiger- Brown & Trinkoff, 2010) and pushback from nursing unions.
With required break time configured into the 12 hour shift, the actual time of the shift is 12.5 hours. Nurses working 12.5 hours or more had twice the odds of driving drowsy and having a motor vehicle crash and near miss when compared to those working 8.5 hours (Geiger- Brown & Trinkoff, 2010). A significant finding of a focus group study conducted with 45 intensive care night shift nurses in a large metropolitan hospital was the discovery of an extremely high incidence (95%) of automobile-related injuries and near-accidents that occurred while driving to and from the workplace (Novak & Auvil-Novak, 1996).
In 2004, an AAA Foundation for Traffic Safety survey found that nine out of every 10 North American police officers had stopped a driver who they believed was drunk, but turned out to be drowsy instead. "When you are behind the wheel of a car, being sleepy is very dangerous. Sleepiness decreases awareness, slows reaction time, and impairs judgment, just like drugs or alcohol, contributing to the possibility of a crash," said AAA Foundation President and CEO Peter Kissinger (2012, para. 5) According to Falleti et al.( 2003), fatigue caused greater impairment than alcohol on the speed of continuous attention and memory and learning, and on the accuracy of complex matching. For example, the deterioration in cognitive function impairment observed after 17 hours of sustained wakefulness was equivalent to that observed with Blood Alcohol Concentration (BAC) levels of 0.05% or more (Dawson & Reid, 1997).
With 24 hours of sustained wakefulness, the magnitude of cognitive decline increased to levels equivalent to those observed with BACs of 0.10%.
Nurses who work the night shift often refer to "first night on" as being the most difficult. First night is the first night shift on duty after several days off. On first night on, nurses often do not sleep prior to coming in to work, resulting in a period of 24 hours of time awake at the end of their shift. Unfortunately, rest is not tantamount in the face of competing priorities and nurses will often skip sleep before first night on.
Most studies conducted on nurse drowsiness or fatigue, focus on patient safety, examining the nurses ability to remain awake during the night shift as well as their propensity for error due to drowsiness (Surani, Subramian, Babbar, Murphy & Aquillar, 2008;Scott, A, Hwang & Zhang, 2006). Gold, et al. (1992), conducted a study of 687 nurses assigned to rotating shift schedules. They concluded that those nurses were twice as likely to report accidents or errors (including medication errors, work-related injuries, or accidents on the commute home), and 2.5 times more likely to report "near-miss" accidents or errors. The excessive sleepiness experienced by the nurses resulted in "frequent lapses of attention and increased reaction time, leading to increased error rates (p. 4)." Akerstadt (2005) found that over 50% of shift workers reported severe decreased alertness while at work. The study authored by Folkard, Lombardi and Tucker (2005) revealed that the risk of medical errors compounds with each successive night shift worked with an error rate of 17 percent on the third successive night worked.
There is additional research on methods to counteract drowsiness during the night shift, for example, alternative scheduling methods and restorative napping. A study of restorative napping by nurses completed by Fallis, McMillan and Edwards (2011) identified personal health, safety, and patient care issues supporting the need for a restorative nap during night shift. Barriers to napping exist within the organization/work environment. These barriers can be due to lack of sufficient coverage for break times, cultural norms that disparage sleeping while at work-even while on break, and a lack of a secure and quiet space to nap.
The benefits of increased alertness after restorative napping on the night shift are varied. While some nurses have found napping improves alertness and performance (Rogers, 2005), others report the effect of "sleep inertia" after napping during the night shift. Sleep inertia is the period of decreased alertness and performance reaction that occurs when waking from sleep.
Alternative scheduling has been evaluated to increase compatibility with circadian rhythms. Rogers (2004) suggests that nursing administrators consider altering the starting times of shifts whenever possible to make schedules more compatible with circadian rhythms; to avoid scheduling employees to work more than two or three consecutive night shifts; and to provide adequate recovery time between shifts, especially when an employee is rotating off night shift. The National Research Report, Keeping Patients Safe: Transforming the Work Environment of Nurses (Institute of Medicine, 2003) concluded that "…the typical work environment of nurses is characterized by many serious threats to patient safety. These threats are found in all four basic components of all organizations-organizational management practices, workforce deployment practices, work design, and organizational culture (p. 3)." Nurses and nursing administrators need to be aware of the alertness decrements associated with working the night shift. Staffing patterns need should be based on the optimization of circadian rhythms.
A study conducted by Dr. Linda  analyzed the consequences of sleep deprivation among nurses who work the night shift. The study results demonstrated that nearly during the four week period of the study, 67% of nurses reported driving while feeling drowsy. Dr. Scott argues this study shows that nurses need to become more aware of the risks their chronic sleep deprivation and the risks of driving while drowsy. Nurses and hospital staff need to begin developing strategies to prevent drowsy nurses from driving. As Dr. Scott phrases it, "Without mitigation, fatigued nurses will continue to put the public and themselves at risk (p. 1801)." Who is responsible when a nurse is involved in a motor vehicle accident on his/her commute home after a worked night? The common-law doctrine known as respondeat superior [Latin, Let the master answer] makes an employer liable for the actions of an employee when the actions take place within the scope of employment.
The state of New Jersey currently has legislation that would bring charges of vehicular homicide against any driver who causes a death while knowingly driving while fatigued. According to Swinhart (2007), the profession with the most case law on driving while fatigued is the long-haul trucking industry. In most cases where a fatigued long-haul truck driver has caused an accident, the employer has been held 100 percent responsible both legally and financially. Hospitals and nurses cannot depend on the sympathy of a jury in the event of a fall-asleep accident.
The first federal bill to focus on drowsy driving was introduced in the House of According to Falleti et al. (2003), fatigue caused greater impairment than alcohol on the speed of continuous attention and memory and learning, and on the accuracy of complex matching. Alcohol was more detrimental than fatigue only on the accuracy of memory and learning. For example, the deterioration in cognitive function impairment observed after 17 hours of sustained wakefulness was equivalent to that observed with BAC levels of 0.05% or more Reid, 1997, Lamond andDawson, 1999). With 24 hours of sustained wakefulness, the magnitude of cognitive decline increased to levels equivalent to those observed with BACs of 0.10%.
According to the Sentinel Event Alert issued by The Joint Commission, "Shift length and work schedules have a significant effect on healthcare providers' quality and quantity of sleep, and consequently on their job performance, as well as on the safety of their patients and their individual safety" (2011, p.1). Patients rely on care provided by nurses who may have significant impairment of their mental and physical functions due to fatigue.

Potential Actions to Counteract Drowsy Driving
Keeping Patients Safe:Transforming the Work Environment of Nurses (Page, 2004) concluded that "…the typical work environment of nurses is characterized by many serious threats to patient safety. These threats are found in all four of the basic components of all organizations-organizational management practices, workforce deployment practices, work design, and organizational culture" (Institute of Medicine, 2003). Nurses and nursing administrators need be aware of the alertness decrements associated with working the night shift and staffing patterns need to consider the optimization of circadian rhythms.

Summary
Our society does not believe that it is acceptable for any driver to drive in a drunken state, in fact, it is against the law. Drowsy driving, which can lead to fall asleep driving is not viewed with the same amount of societal opprobrium as driving while intoxicated. Fall asleep vehicular accidents must be prevented through greater awareness by nurses and their employers.
While the evidence suggests that the problem of drowsy driving is a strong contributor to vehicular accidents in that drowsiness portends sleep, little is known about nursing perceptions of the issue. When the literature review focused on the experiences of nurses with falling asleep on the commute home from the night shift, only a single study, (Novak & Auvil-Novak, 1996) in part, addressed the research question of this document. Existing studies in the area of nurse fatigue focus primarily on the areas of patient safety, countermeasures to combat nursing fatigue and the physical and mental effects of fatigue and shift work on the nurse. As members of a high risk work group, nurses working the night shift merit tailored research. "Given the large number of nurses who reported struggling to stay awake when driving home from work and the frequency with which nurses reported drowsy driving, greater attention should be paid to increasing nurse awareness of the risks and to implementing strategies to prevent drowsy driving episodes to ensure public safety.
"Without mitigation, fatigued nurses will continue to put the public and themselves at risk" (Scott et al., , p. 1801.
Societal changes rarely occur in response to evidence of research studies; they come from "real life" situations, experiences and stories. There is a paucity of literature focused on nurses' experience of falling asleep at the wheel after a worked night shift. This gap in the literature is significant in a time of heightened public safety awareness and increasing litigation for those held responsible in fall asleep vehicular accidents. With the lack of research related to the experiences of nurses falling asleep behind the wheel after a worked night shift, there is a need to explore this topic.
In order to continue to develop strategies to address this safety issue, it is important to explore the phenomena of drowsy driving from the nurses' perspective.
This author hopes that this data will contribute to our understanding of the phenomena, which in turn, will inform the development of organizational policies.

Personal Perspective/Assumptions
In Chapters 1 and 2, this author discussed the current knowledge of the phenomenon of shiftwork and its effect on physical and psychological processes as well as its effect on driving. The existing gap in the literature, a lack of nurses' voices who have experienced this phenomenon, is justification for further study. It is also important to present what I bring to the study as a researcher so that I can put any assumptions aside and allow the situation to speak for itself.
I have been a registered nurse for 32 years. For approximately twenty of these years I have worked the night shift off and on. As discussed in Chapter 1, I was in a vehicular accident after falling asleep at the wheel. I also had numerous close calls during those periods. As a nursing administrator, I spent a great deal of time working with nurse scheduling which included allocating staff to the night shift. My experience as a nurse specializing in trauma, a shiftworker, a vehicular accident victim, and staffing scheduler, have led to the following assumptions:  I believe some nurses cannot physically adapt to the night shift and in fact, are faced with significant assault to their physical and psychological wellbeing when working the night shift.
 I believe that while many nurses are frightened about the prospect of a fall asleep motor vehicle accident, they see it as part of working nights, an occupational hazard so to speak. They place other considerations, such as getting home to take over child care or the desire simply to get home to their own bed as more compelling.
 I believe that nursing administrators are largely focused on what occurs during the hours of work and on the worksite. Once the nurse in his/her car after the shift it is no longer their concern or responsibility.

Research Design
A qualitative descriptive approach was selected to address the research questions. While quantitative research can inform us on many aspects of nurses involved in falling asleep while driving on the commute home, it is limited in informing us about the experience of those nurses from their own perspective.
Qualitative research seeks to understand and explore beliefs and behaviors.
The social world is seen as fundamentally different from the physical world. Human behavior is seen as being infused with meanings, intentions, motives, beliefs, values, etc., all of which must be taken into account in order to understand and explain it. The world is constructed, interpreted and experienced by people in their interactions with each other and with social systems (Maxwell, 2006).
According to Kvale (1996), qualitative research attempts to understand the world from the subjects' point of view, to unfold the meaning of peoples' experiences, and to uncover their lived world prior to scientific explanations. Qualitative descriptive research results in descriptions of the phenomenon. It provides the researcher with the who, what , and where of events ..."without the mandate to produce anything other than a descriptive summary of an event that best contains the data collected and that will be most relevant to the audience for whom it was written" (Sandelowski, 2000, p. 339).
This method uses interpretation that is low-inference by analytically "staying closer to their data and the surface of the words and events" (Sandelowski, 2000, p. 336). Descriptions are elicited about the experience by those individuals who had the experience (Sullivan-Bolyai, Bova & Harper, 2005). Knowledge representing the phenomenon is presented using everyday language. The picture is provided using data in the form of words rather than numbers.
The use of a qualitative descriptive approach allowed this researcher to learn more about the experience of falling asleep behind the wheel on the drive home after a worked night shift from nurses who had experienced the phenomenon themselves.

The Qualitative Descriptive Method
While other qualitative methods such as ethnography, grounded theory and phenomenology are better known, qualitative descriptive studies are also powerful.

Participants/Sample
This study was carried out in Southern California. The sample consisted of 12 night shift nurses who had the experience of falling asleep behind the wheel during their commute home after a worked night shift. A non-probability purposive sampling technique combined with snowball sampling was used. Purposive sampling is a sampling method in which participants are selected based on purpose of the study.
"Purposive sampling or judgmental sampling is based on the belief that researchers' knowledge about the population can be used to hand pick sample members" (Polit & Tatano-Beck, 2004, p. 294).
As a non-probability sampling method, purposive sampling resulted in a group of nurses who had fallen asleep on the drive home from a worked night shift, a clearly defined group. Sample size selection was based on the research of Guest, et al. (2006) and his team who systematically examined data from a study involving sixty in depth interviews. They documented the degree of saturation and variability over the course of thematic analysis. Based on the data set, they determined that "…saturation occurred within the first twelve interviews, although basic elements for meta-themes were present as early as six interviews" (Guest, Bunce, & Johnson, 2006 sampling. Snowball sampling is the selection of participants through referrals from earlier participants in which one person refers another (Polit & Tatano-Beck, 2004) .
Inclusion criteria for this study were: 1. Registered nurses who work exclusively on the night shift.
2. Registered nurses who believe they fell asleep while driving after a worked night shift.
Interviews were arranged with the participants via telephone or email. The participants selected a location that was conducive to the interview process in that it was quiet and afforded a measure of privacy. Each participant was provided with a $25.00 gift card to Starbucks at the end of the interview as a token of appreciation for their time and willingness to participate.
Prior to the beginning of each interview, a clear description of the study was provided and informed consent obtained. At the close of each interview, permission to contact each participant was requested

Data Collection Procedures
Data was collected using a semi-structured interview guide (Appendix 4). A semi-structured open-ended interview guide was used in order to avoid limitation of responses and to encourage free expression. The guide provided a list of questions and topics that needed to be addressed during the conversation. The interviewer followed the guide, but was able to be flexible and pursue the conversation that strayed from the guide when appropriate (Polit & Beck, 2004;Seidman, 1991). what was asked in individual interviews to the overall design (Rubin & Rubin, 1995).
When answers to the main questions lacked sufficient detail, depth, or clarity, the interviewer asked a probing question to complete or clarify the answer; to request further examples and evidence (Rubin & Rubin 1995). The probing questions facilitate obtaining the level of depth the researcher wants; it can indicate that further information is needed and that the interviewer is paying attention. Follow up questions were asked in order to attain the depth of information requested by the researcher. All questions should be worded such that the participant understands the question focus.
The use of a responsive interviewing technique was guided by Rubin & Rubin (2005). Responsive interviewing aligns with the philosophical beliefs of the researcher in that it relies heavily on the interpretivist constructionist philosophy. According to Rubin & Rubin (2005) "The responsive interviewing model emphasizes that the interviewer and the interviewee are both human beings and not recording machines, and that they form a relationship during the interview that generates ethical obligations for the interviewer (p.30)." The goal of responsive interviewing is to generate a depth of understanding. A solid and deep understanding is preferable to a large breadth.
Additionally, in responsive interviewing, the design of the research remains flexible throughout the project" (Rubin & Rubin, 2005, p. 30). This flexibility is essential in attainment of a depth of understanding. The main characteristics of Rubin & Rubin's Responsive Interviewing Model is detailed in Table 4.
The decision to interview implies a value on personal language as data (Newton, 2010). Face-to-face interviewing was selected in order to obtain depth of meaning and context. The interviews varied in length from 40 minutes to one hour.
The interviews were carried out in a conversational style based on Rubin & Rubin's conversational partners approach. Settings varied from coffee shops to conference rooms. These settings were mutually negotiated by the researcher and participant. The times and dates of the interviews were also negotiated between the researcher and participant.
Each of the interviews was tape recorded. "Electronic recording can distract both the interviewer and interviewee and influence what people say so you want to make the recording as smooth and unobtrusive as possible" (Rubin & Rubin, 2005, p. 111). During each interview, the interviewee was informed when taping began and ended. The small digital tape recorder was placed in a location that was not conspicuous.
Digital tape recordings of each interview were transcribed into a typed document by a professional transcriber. Names of the participants were removed and replaced with participant numbers. Each individual recording was assigned a code number by the investigator. Only that number appears on the typed transcripts. Names and contact information was kept on a secured and encrypted flash drive that could only be accessed by the investigator. No other individual has/had access to the names with the associated participant numbers.
Once the interviews were transcribed, a copy of each participant's transcript was sent in order for them to verify accuracy. All participants reviewed their transcripts and provided feedback via email as to whether or not the transcript had accurately captured the content of the interview. This process was conducted to address trustworthiness. Of the twelve participants, 11 responded either with complete agreement or minor clarifications. One respondent had discussed an identifying characteristic of her place of employment and asked that this be removed.
The orientation of the researcher to the subject is critical to the success of the study. According to Rubin & Rubin (2005), "Rather than pretend that interviewers come into the situation with no biases and can listen to answers without sifting them through their own experiences and cultural lenses, the responsive interviewing model argues that researchers need to continually examine their own experiences and cultural lenses; the responsive interviewing model argues that researchers need to continually examine their own understandings and reactions" (p. 31). This researcher used a detailed reflexive journal throughout the study. The journal entries were completed immediately after each interview. The journal was used to record personal experiences and observations regarding the data and interviews. The journal helped to sort out ideas that evolved from participant to participant and assisted this researcher in identifying emerging themes and when data reached saturation. The journaling process also provided a way for the researcher to de-brief after each interview.

Data Analysis
"Data analysis is the process of moving from raw interviews to evidence-based interpretations that are the foundation for published reports" (Rubin & Rubin, 2005, p. 201). The process of analysis included classifying, comparing, and weighing of meanings to reveal patterns and descriptions. While the analysis was based on the descriptions presented by the interviewees, the interpretations were those of the researcher (Rubin & Rubin, 2005).
The theoretical framework of social constructivism guided the analysis of data.
In alignment with the qualitative descriptive method, the aim of the analytical process and presentation of the data was to remain close to the data (Sandelowski, 2000).
Whereas other qualitative approaches often aim to develop concepts and analyze data using reflective or interpretive interplay with existing theories, the final product of qualitative description is a description of informants' experiences in a language similar to the informants' own language (Neergaard, Olesen, Andersen, & Sondergaard, 2009).
Inductive manifest and latent content analysis was used to analyze the data.
Content analysis is a method of gathering and analyzing the content of written, verbal or visual communication. This method can be used with either qualitative or quantitative data and in an inductive or deductive way (Elo & Kyngas, 2008). In inductive content analysis concepts are derived from the data. In deductive content analysis the structure of analysis is operationalized on the basis of previous knowledge (See Figure 1). Inductive content analysis is used in cases where there are no previous studies dealing with the phenomenon or when it is fragmented. A deductive approach is useful if the general aim is to test a previous theory in a different situation or to compare categories at different time periods (Elo & Kyngas, 2008).
According to Graneheim & Lundman (2004), a characteristic of qualitative content analysis is the method focuses on the subject and context and emphasizes differences between and similarities within codes and categories. The content analysis approach adheres with the naturalistic paradigm in that meaning is derived from the context of the data. "A basic issue when performing qualitative content analysis is to decide whether the analysis should focus on manifest or latent content." Manifest content analysis deals with content and describes the visible and obvious components.
Latent content analysis deals with a relationship aspect and involves interpretation of underlying meaning of the text. "Manifest and latent content both facilitate interpretation but vary in depth and level of abstraction" (Graneheim & Lundman, 2004, p.106).
Given that inductive content analysis was the selected method, the next step was to organize the data. Each transcript was read and re-read multiple times to obtain a sense of the content and the meaning. The goal in reading and re-reading the data was to obtain a sense of the whole (Graneheim & Lundman, 2004 After open coding was completed and intercoder reliability established, the lists of categories was grouped under higher order headings. The primary aim of grouping data is to reduce the number of categories by collapsing those that are similar into higher categories. For this study, initially all of the codes were taken from the twelve transcripts, written onto post-it notes and grouped them into tentative categories. They were left for a two week period in order for this researcher to immerse or "dwell" in the data. During the two weeks, the post-its were arranged and re-arranged into categories. According to Polit & Beck (2004), researchers whose aims are primarily descriptive tend to use categories that are fairly concrete, e.g., the category scheme may focus on differentiating various types of actions or events, or different phases in the unfolding of an experience. In order to develop the category scheme, related concepts were grouped together to facilitate the coding process. When categories are formulated through inductive content analysis, the researcher decides, through interpretation as to which things belong in the same category (Dey, 1993). It is important to note, that creating categories is not simply bringing together observations that are similar or related. The data is classified as 'belonging' to a group (Dey, 1993). The purpose of creating categories was to provide a means to describe the phenomenon.
The process of abstraction entails the formulation of a general description of the research topic through the generation of categories (Elo & Kyngas, 2008). "Each category is named using content-characteristic words (Elo & Kyngas, 2008, p. 111)." Through the extraction of common themes from the data, some differences stood out.
While many of the participants felt frightened when awakening to the honking of horns by other motorists, one participant felt extreme anger. These differing viewpoints about an emerging theme regarding being awakened led me to investigate other differences that I may have overlooked in the data.
In sorting the content into themes a coding scheme was developed. This coding scheme was used to reorganize the themed content into manifest content. The next step was to engage in latent coding. Of note, the researcher cannot make inferences regarding intent or motivation on the part of the participant. Content analysis is only that which is in the transcripts. One cannot infer intentional bias or intended effect from the data.
After sorting through multiple codes and categories among the data, 3 to 5 quotes or meaning units, for each category and theme were selected. At this point, these meaning units evolved into condensed meaning units and eventually into codes (See Tables 3, 5-11). For example, participants recounted their experiences with having no recollection as to how they arrived at their home. They recounted a feeling of lost time. The analysis indicated that these could be explained with one code. In essence, the meaningful units were condensed into meaning units and then into a code. A total of eight codes emerged from the iterative process of coding the data.
The qualitative content analysis process offered this researcher several benefits. It provided the researcher with an in-depth description of the phenomenon of falling asleep behind the wheel on the drive home after a worked night shift.
Qualitative content analysis is not a linear process. T "Qualitative analysis is more complex and arduous than quantitative analysis, in part because it is less formulaic (Polit & Tatano-Beck, 2004, p. 570)." The researcher initially utilized the Vivo software program to organize the data, however, manual indexing was selected to organize and code the data in that it physically brought this researcher closer to the data. As mentioned earlier, the use of post-it notes physically posted on this researcher's walls allowed for easy grouping and regrouping allowing engagement in an iterative process that was visual and easily manipulated into different categories.
Dwelling in the physically represented data, prevented the risk of premature closure of analysis.

Achieving Trustworthiness
The findings of qualitative research studies must be as trustworthy as possible. Lincoln and Guba (1985) note that credibility is the 'overriding goal' of qualitative research. Credibility refers to confidence in truth of the data (Polit & Tatano-Beck, 2004). It addresses how well data and the process of analysis address the intended focus. According to Lincoln and Guba (1985), credibility involves two aspects, performing the study in a manner that enhances the believability of the findings and secondly, proceeding in a way that demonstrates credibility to consumers.
In order to produce credible data and subsequent interpretations, prolonged engagement in the collection of data was afforded this study. The twelve interviews were collected over a period of six months. Sufficient time was allotted for collection of the interviews, as well as the actual interviews themselves. It was important for this author to take the time to build a rapport with each participant prior to the beginning of the interview.
The aim of trustworthiness in a qualitative inquiry is to support the argument that the inquiry's findings are "worth paying attention to" (Lincoln & Guba, 1985). This author and a member of her dissertation committee independently coded the data.
Discussion of the codes with a re-examination of the data occurred until there was An audit trail was conducted by a member of the dissertation committee. "An audit trail involves scrutiny of the data and relevant supporting documents" (Polit & Beck, 2008, p. 545). Although this is a tedious and complex process, it is an important tool in addressing confidence in study findings (Lincoln & Guba, 1984;Polit & Beck, 2008).

Nature and Limitations
All methods of research have their limitations. In this study, the sample consisted of 12 nurses who lived in Southern California. Although this sample is limited, the quality and depth of the comments did answer the research questions. The low inference approach of qualitative description does limit the ability to generalize.
All of the participants work in the state of California. California is the only state in the United States that has enacted legislation calling for the same unit specific nurse to patient ratios to be utilized in all nursing units. It could be construed that with favorable staffing ratios, the nurses experience of drowsy and fall asleep driving does not reflect that of those nurses working in conditions with higher nurse to patient ratios. The exclusion of participants from other states could be considered a weakness of the study.
An additional limitation of the qualitative approach is that the findings cannot be generalized to wider populations with a high degree of certainty. The findings of qualitative research are not evaluated for statistical significance.
In the analysis of qualitative data, no theoretical attachments are made. This allows the analysis to stay close to the data (Sandelowski, 2000). A limitation is that the analytical process seems subjective in that it depends on the researcher's perceptions. However, it is the best way to gain insight into the participants' views of the phenomenon.

Ethical Considerations
Participant confidentiality was a priority in this study. Interviews took place in a location that provided privacy and was agreeable to each participant. Audio tapes were kept in a locked file until transcribed. Audio-taped interviews were destroyed after they had been transcribed and the transcriptions were entered into a password protected computer. Interviews were coded for identification. These codes and demographic data were currently kept in a locked file, separate from transcriptions.
All transcriptions, consents, demographic data, and key codes will be destroyed after three years. This information, regarding data management, was presented to all interview participants prior to the interview.

Human Subjects
Approval from the University of Rhode Island Institutional Review Board was obtained on May 18, 2012.

Summary
In summary, the qualitative descriptive approach provided strong conceptual descriptions and an understanding of falling asleep behind the wheel on the drive home from a worked night shift.

FINDINGS
The results of this study are based on twelve interviews with nurses who had experienced falling asleep behind the wheel on the drive home from work after a worked night shift. Data collection involved face-to-face interviews in which the participants were asked to reflect on a time when they fell asleep behind the wheel driving home from work. Cognitive probes were utilized throughout the interviews to elicit details regarding each participant's experience. Qualitative content analysis was used to analyze the data and eight themes emerged.
In the following sections, a synthesis of the qualitative content analysis of the data will be presented. This was achieved in collaboration and with Drs. Marlene Dufault and Ginette Ferszt. Discussion of the data is presented from the perspective of the themes emerging within the research questions posed in Chapter 1.

Demographic Data
Demographic data from a purposive sample of 12 Registered Nurses working the night shift in the Southern California area of the United States is described below.
One participant did not submit her data which had been requested electronically. The experience of falling asleep behind the wheel was described by each of the participants in their own voices. The nurses demonstrated an openness and eagerness to share their stories. The following eight themes emerged: (1.) night shifts better for new grads, (2.) auto-pilot, (3.) struggling to stay awake, (4.) it's scary, (5.) just need to get home, (6.) not a night person, (7.) feeling awful, and (8.) don't know how to fix it.

Frequency and Percentage Distribution of Registered Nurses
The development of the themes as described in the voices of the participants provided rich descriptions of their experiences with regard to the research questions. Direct quotes from the participants are provided to allow the reader to reflect on the participants responses to the interview questions. Each of the eight primary themes is discussed in the next paragraphs.

night shifts better for new grads
This theme was generated by responses to the research question "Are there any specific reasons that you are working the night shift?" Three patterns of the data were categorized from this question which illustrate the participants' experiences; having only night shift positions available to them as a new graduate; feeling that the pace of the night shift was more conducive to their learning and acclimation to practice; and feeling that there is more support and teamwork on the night shift as opposed to the day shift. Most of the nurses identified the reason they worked or had worked the night shift as a lack of shift choice available to them as a new graduate nurse. Despite this, it was clear that the tempo and atmosphere of the night shift was better for a new graduate. One participant described an experience that she had while orienting on the day shift. She felt that the pace on the night shift was conducive to providing the type of patient care that she felt was needed.
"…but as a new graduate, the workload is crazy on days, so I thought Relationships with colleagues on the night shift were an important factor in the support of new graduates on the night shift. Confidence that their colleagues would be supportive and mentor them was a positive factor despite the many stated negative effects of the night shift. There was praise for the support that new graduates received on the night shift as well as less stress with the pace of the night shift. There is a relationship that is both interpersonal and professional. "I've had the option to move to days, but the nightshift, the people that I work with is one of the major reasons, to (stay on nights). Because we work as a team at night. It's a little different during the day. I just … I think also being like a newer nurse I will … I have all this work, and my nurses, I could go to and they would help me. So, that's a major reason." One participant discussed her hesitation to go to days although she had completed her requisite time on the night shift. The relationship with her night colleagues resulted in a commitment to the night shift despite the physical stressors she experienced working the night shift.
"I worked about four and a half years of nights. Maybe after the third and a half year or so... I actually wanted to go to days longer than I had been looking for a day job. But the day shift nurses were so different and I didn't like being around when administration was there. It's just different working days. So I liked the vibe on nights." The statements made by the participants with regard to the teamwork and support received on the night shift revealed consistency with literature findings validated by the Joint Commission statement on the importance of teamwork for safe patient care. "Teams whose members have experience working together know each other's strengths and weaknesses, and can better support each other and compensate for each other-even under extreme stress and fatigue conditions. They know how to balance each other out and they know that others are available to complement their strengths and weaknesses, which may also lead to lower stress levels for all participants" (The Joint Commission, 2003, p. 12). According to a night nurse quoted in an article by Domrose (2006, para. 4), "Because there are fewer people on the night shift, the nurses tend to rely on each other more…people will jump in and help without being asked." The participants feared they would not receive that if they were changed to a different shift. All but three of the participants stated that they had been required to start on the night shift when they were new graduates. The most consistent thread throughout the data was that the pace and collegial support present on the night shift helped the new graduate make the transition from graduate novice nurse to experienced and proficient nurse smoother.

auto-pilot
This theme was both puzzling and frightening to many of the participants.
They shared their experiences of having no recollection of passing exits or of parts of the drive home. They weren't sure what had transpired. Had they fallen asleep or just become unaware of their surroundings? One explanation for this may be the occurrence of microsleeps. As discussed in Chapter 2, microsleeps are episodes that occur when a person is fatigued and trying to stay wake. During these episodes which may last only seconds, the individual is not aware of external information and may have no recollection. In essence, there is a feeling of missed time and the individual may come to realize they have "missed" a part of their drive. These episodes are frightening when you realize that at 70 miles an hour a car travels 102.5 feet per second. If the driver falls asleep or experience a microsleep that lasts 3 seconds, they have traveled a little more than the length of a football field. "There were times where, obviously I don't recall at what point that happened, but then I would just be rolling up to the stop sign right before my house, and sort of awaken if you will, and be like, "How did I get here? And that was … that was very scary." Most participants shared some stories of their inability to remember how they got home or being on "auto-pilot." "…there were days that I was on auto pilot, so it was almost like I went through my daily routine…without recalling. Like, this has been done, but I don't remember doing it." When describing the experience of not remembering, or feeling like they were on auto-pilot, the participants relayed to the researcher their feelings of being frightened when they realized they had lost time, missed exits, or lost awareness of the atmosphere around them. Immediately after this realization, some participants described feeling their hearts pounding and becoming shaky as with a sudden adrenaline rush. Yet, they noted that they were soon, once again feeling the effect of overwhelming sleepiness shortly after the episode.
The oddness of the experience is largely due to the knowledge that there is a missing piece of time in their temporal awareness. Other terms used to describe this phenomenon are: driving without awareness, highway hypnosis, white line fever, and time gap experience. When describing this phenomenon some of the participants described their distress and became visibly distressed. "After a long drive the motorist will commonly report that at some point in the journey he "woke up" to realize that he had no awareness of some preceding period of time" (Goleman, 1979). This experience was echoed by the participants. These periods of no recollection pose a serious threat to driver safety and left the participants feeling unsettled and anxious.

struggling to stay awake
All participants were at risk for fall-asleep accidents because they suffered from sleep deprivation. The participants universally discussed feeling tired while driving home. They relayed difficulties sleeping during the day, at times getting as little as three to four hours per day or conversely sleeping all day and not feeling rested.
"You know, so I think after that shift when I was coming back I think I must have slept at least ten times during my entire journey back home.
I think; at least if not more. I can't count for sure." The feelings of overwhelming fatigue were undeniable. The participants discussed their struggle to stay awake during the drive home. Staying awake and alert on the drive home was physically impossible. The nurses described ways that they tried to fend off the strong urge to sleep.
They described various methods such as: "so you turn on the radio really loud, you roll down the windows, you'd be singing, you'd be dancing, you'd just, I mean, I-I did slap myself, my face, uh, my legs. Just constant movement"; drinking coffee before the drive home; "I had a strong shot of coffee with me. Um, I had music loud initially but then it's not working; I thought maybe I can start singing to myself or talking to myself or something. You know and so I was trying-but I fell asleep behind the wheel in between two trucks." "Yeah, the fatigue that you experience is-is just like no other." Two of the participants routinely had family members bring them to work and pick them up after work. While the researcher was interviewing one of the participants on the morning after a worked night shift, the participant paused the interview twice to answer a call from her mother who was calling to check on when she needed to come to pick her up. Her mother was concerned that perhaps she might catch a ride with another fatigued colleague.
According to Stanford Sleep Expert Dr. William Dement (1997), "The powerful brain mechanism that regulates the daily amount of sleep is called the sleep homeostat. By increasing the tendency to fall asleep progressively in direct proportion to the increasing size of sleep debt, this homeostatic process ensures that most people will get the amount of sleep they need, or close to it. The elevated sleep tendency together with associated drowsiness and an intense desire to sleep would ordinarily prevent most people from becoming dangerously sleep deprived because they would go to bed early or sleep late, when such excessive daytime sleepiness occurred" (Dement, 1997, para. 7).
When the nurse has not had a sufficient amount of sleep and resists the signals from the sleep homeostat, the urge to fall asleep becomes insurmountable. The signals from the sleep homeostat coupled with driving can result in tragedy.

it's scary
During their drive home after work, the participants were exposed to fall asleep driving and realized that they were at risk for involvement in a fall-asleep crash. Many of the participants believed that they were fortunate to be alive.
"And there are a lot of times that like, thank God nothing happened to me. I haven't gotten in an accident, but I don't want it to happen." 'I still dozed off or got home and fell asleep in my garage… which is even I think a little more scarier than falling asleep on the road.' Participants discussed the feelings after a near miss. In a study conducted by sleep expert Dr. Charles Czeisler, hospital interns who had been scheduled to work for at least 24 consecutive hours increased their risk of a near miss 460%.
"It was so horrible. It was such a nauseating experience. It was so frightening." "I tend to be a really spiritual person so I was like praising God for sparing my life because I could've killed myself and a bunch of other people too um, and... I mean I still think about it to this day." "…all day on Sunday I was like shaking, very shaky and overwhelmed and I kept thinking like wow, what happened, did it really happen? (she crossed several lanes and struck a bicyclist-without recollection).
The near-miss is not without consequence to the driver. The sense that a person is in imminent danger triggers the dramatic emotional/physical response of the sympathetic nervous system response called "fight or flight." This is followed immediately by the release of adrenaline and cortisol. Blood pressure rises and the heart rate accelerates. This response to imminent danger can leave lingering effects of shakiness, digestive upset and unclear thinking.

just need to get home
Many of the participants cited the need to "just get home after work." They were not motivated to pull off the road and take a nap or stop for a cup of coffee.
Instead, they tried playing the radio loudly, moving about in their seats, slapping their cheeks in order to stay awake long enough to get home. "Research has shown that most such activities (opening the window, increasing the volume of the radio, etc.) at best, can postpone sleep for only a few minutes. The only effective countermeasure against sleepiness is sleep, preferably combined with a caffeine drink" (Sagberg, Jackson, Kruger, & Williams, 2004). The following participant revealed that her need to get home super-ceded the laws to stop at stop signs and red lights. She ran through several lights and stop signs despite other motorists honking their horns at her. She recounted that on one level she was aware of what she was doing but she didn't care. When she thought about it later it frightened her. "I don't even remember how I got home but I know that I passed some red lights. I heard cars honking at me, but I was so sleepy that I didn't even react to it. It didn't even like scare me. It was just, "I need to get home" I was so sleepy that I didn't even react to it -it was just, I need to get home." "I'd drive fast going home and I mean I hate to say it, I mean good thing no cops have ever really pulled me over, just to get home and I just wanted to be home. I think that was my-my-my focus was just get home and so I can sleep." According to a recent report on drowsy driving by the (Centers for Disease Control and Prevention, 2013), drowsiness impairs decision making skills. Driving excessively fast or running stop signs and lights in order to get home were not routine behaviors for the participants when they were not driving drowsy. The associated sleep debt along with an overwhelmingly strong urge to sleep served to impair judgment with regard to personal and public safety.

not a night person
While there are nurses who seem to thrive on the night shift and would not consider changing to the day shift, for most people, staying awake through the night is struggling to fool the bodies' natural circadian rhythm. Deviations from the norm of nocturnal sleep leads to problems in the quality and quantity of sleep. During the daytime, sleep is of poorer quality and quantity than when taken at night (Arendt, 2010) . "Most permanent or long-term night shift workers do not adapt their circadian system to the imposed work schedule. A recent meta-analysis of 6-ulphatoxymelatonin rhythms in permanent night workers indicates that only a small percentage (<3%) shows complete circadian adaptation" (Arendt, 2010, pp. 13-14).
Throughout the interviews, many of the participants noted that other nurses seemed to adapt well to shiftwork and did not complain of falling asleep on their drive home.
"I'm not a night person. I realized after working night shift I'm not a night person at all." "I feel like I am one of the people who is more tired in the morning. I feel like everyone else when they leave work it doesn't look like...you know some people even go out to breakfast after work with each other. I can't do that. They go out and they have like Mimosas and they have breakfast on the waterfront. And they, I always get invited and I've never gone in the year I've been there because I just I wouldn't be able to drive home afterwards." "You know that, I mean some, some of my friends were completely okay with it, they didn't have any problems. I think I was probably, me and another girl were the ones that was struggling the most. You know they would, they would say oh you know I go home, take my family, spend time with my mom and then wake up, sleep for two or three hours before the night, the next day and I'm like God, how do you do that? How do you do that? "

feeling awful
The theme of "feeling awful" encompasses feelings of social isolation and a lack of physiological and psychological wellness. Shift workers do not have time for social activities. "Work is the central factor in creating sleep deprivation for shift workers. Their schedule revolves around work, which is frequently taking place at a time when their family and friends are asleep. To interact with these people, shift workers have to sacrifice something, usually sleep" (Nelson, Isaac, & Graham, 1998, Key Findings).
"And the other hard thing was um, still trying to socialize with people who have a regular day job. So you get off work on a Saturday morning and you want to go to bed because you're extremely tired but there's a birthday party going on. Or there is, you know whatever.. you're working you've got to put on a professional self so you-you are trying to be the best you can to project what you are at work. And then when you go-go home you vent everything out. It's the kids; you don't want to talk to them. It's your husband; you don't want to talk to, you don't want to see him. " Several of the participants working nights initially believed that the night shift would allow them to spend more time with their families. Instead, they found that their level of patience and desire to be social was low due to fatigue.
Healthy patterns of nutrition and exercise were compromised as well.
Participants spoke of either gaining weight from eating nutritionally deplete vending machine food or eating less overall and losing weight. Those who had exercised on a routine basis found it difficult to fit into their schedules.
"From personal experience I think your nutrition suffers. I see a lot of really poor eating habits on my night shift. You tend to want to eat sweet and savory foods at three in the morning. It's harder to eat something like a salad or a sandwich. Um, and you come home in the morning and you don't really have an appetite because your circadian rhythms are off. And so when that doesn't match up you don't have the same hunger schedule almost. So I actually found when I started nights I-I lost probably about ten pounds. Yeah, I wasn't eating healthy and I would go home and I was so tired I couldn't even make breakfast when I got home. Um, so on that level; on a fitness level you don't want to work out when you come home. You don't want to work out before you go to work because you're trying to maximize your sleep. So it really leaves you know three, three and a half days a week to exercise which you know we know as nurses is not enough for that thirty hours a week you're supposed to get." The participants discussed responsibilities related to work and family, their schedules are very tight, with little room to do much else.
"Um, and so I was tired, just completely exhausted. I had circles under my eyes, my … I was just overall unhealthier, dry skin, you find yourself crabby." I couldn't take care of myself, I couldn't, I could barely eat. I could, I was just very irritated most of the time you know? You just feel like you're not, you're not your best you know you're not, you're not doing the best you can because you're just very tired and you know your physical needs are not met so your mental needs are not met either, you know".
Several of the participants who were not married and did not have children were surprised at those nurses with families. They felt that they could barely care for themselves. Several of the participants lived at home with a parent who in essence took care of them by providing meals, transportation and the time to sleep uninterrupted during the day.
All twelve participants had either come off of the night shift or were planning to come off shortly. Two of the participants had left their night positions and relocated out of state in order to secure a day position. While all of the participants felt more comfortable on the night shift, they all either left or planned to leave as soon as they could in order to secure a day position. The compromise in their mental and physical well-being coupled with the fear of drowsy driving were strong motivators to change.
One participant continued to work occasional night shifts despite securing a day position. When probing questions were asked as to why, she answered; "I just feel like by the time we reach adulthood, it's more of a personal decision, a personal choice And we take the chances, you know I hate saying that, but um, you know, you hear other people telling stories about, oh you know, I fell asleep or-or even reading in the paper that a death is because someone fell asleep for a brief, brief, brief moment, it brings to mind oh, I've been in that position. But somehow, I still don't process it as you know what, I got to take action, so I'm not in that position anymore. It's like out of sight, out of mind, once I finish reading and the article is out of my sight, I still need the money and still pays me more. And nothing's happened yet".
In response to further probing questions, she relayed having worked the night shift as a child alongside her parents and siblings in a factory at night. Being from a large family and new to the United States, it was the only way for the family to get by.
She shared loving and fond memories of her family and knew that her parents were doing the best they could. Working nights was a way to provide for the family.

don't know how to fix it
The 24-hour hospital is here to stay, but so is the pull of the sleep homeostat and the strong need to sleep when sleep deprived. All participants felt that drowsy driving is a big problem and potentially life-threatening for either themselves or others. In response to the interview questions below, I received several different responses, although many were followed with a disclaimer that it might not work. Several participants thought that nurses should be screened for their ability to adapt to the night shift. She couched the statement by adding that it might not be a viable solution in that the more senior nurses had worked nights and might feel that it was unfair to allow some not to work nights. "It'd be nice if the, if, this is really hard to say but, I guess we could ask management to consider that some people are just not adapted or suitable for the night shift. But I feel that there's a, there's a mentality that you know, if-if one generation has had to do it, then everybody else has to do it as well." This participant took some time off from work after striking a bicyclist in a fall asleep accident. She shared this story with her director and waited for things to change.
"Administrators need to evaluate employees to see if they are a day or night person. " The director had promised day shift after warning her how hard days would be for a new nurse. He never followed up with a day shift so she resigned, moved out of state, and returned to graduate school in hopes of securing a day position upon confirmation of her advanced degree. While a couple of the participants stated that their managers were open to listening and working with them to alleviate the strain of the night shift, most either were frightened to approach their managers, found them not helpful or just decided that it they needed to put in the hours until they were no longer considered an new graduate.
"No I didn't because I was scared um you know she would, you know think that you know my performance or this would affect my performance and then fire me. I went to school for my associate degree and then I had to ah, then I went for my bachelors and they were paying for, so I, I was scared and I was naive and I didn't know that I could ask for help .I just kind of thought you know I'll just suck it up, you know, I have another nine months to go." Unfortunately, many of the participants did not have positive feelings for their employers and did not feel they cared or were interested in the participant's problem with the night shift.
Several of the participants suggest car-pooling and had actually tried it but found it to be difficult with conflicting scheduled work dates. In addition, they found it difficult when they got off of work on time and had to wait for their carpool-mate who might be running late. Also, people are spread far geographically which poses a challenge to operationalizing carpools.
A suggestion made by several of the participants was to provide sleeping quarters for the nurses. While they did not believe that many would use them after their shift, they did think that napping during breaks was a viable solution. They stated that sleeping even during breaks was against hospital policy and knew of staff that had been terminated for sleeping during work hours.
"I know there are some hospitals have like sleeping areas, so on your break, uh … what we do, I know, technically you're not supposed to be sleeping on the job, but you know, we are entitled to a break, and on your break, you technically do, you know, you can go talk on the phone, you can go eat, um, so sometimes what I do is on my break, kind of in between, um, right in the middle of my shift, I will go away and, uh, you know, get to go my car and I'll go to sleep for, you know, half an hour, whatever. It's definitely helpful." "It was something that they knew we did but we weren't really supposed to be doing it. And um, at some of the hospitals we clocked out, at other's you didn't have to clock out for lunch. But they knew that it was like our protected time; we were off the clock. We weren't working; so it's now like we were sleeping while we were supposed to be working. But at one hospital I can think of specifically; I won't say the name. But it's here in Los Angeles County um, sleeping is forbidden. If you're on your break; it doesn't matter where you are.
And if you want to sleep you have to go to the parking lot and sleep in your car. The problem is the parking lot is about a twenty minute walk from the actual hospital because it's a very huge facility. And so if you wanted to go to your car and come back you couldn't. They only give you thirty minute breaks and you're not allowed to combine your fifteen minute breaks with your thirty minute lunch break. So you only get thirty minutes for lunch." Overall, the idea of sleep rooms, napping, and an evaluation for a nurse's ability to physically and mentally work the night shift were the suggestions that came through many of the interviews. Support for these suggestions is found in a qualitative study that explored napping on breaks during night shifts. They concluded that 10 out of 13 critical care nurses who napped regularly during breaks reported several benefits to napping, including improved energy, mood and decision-making, and vigilance (Fallis, McMillan, & Edwards, 2011).
In examining the suggestions by the participants that certain nurses are not well suited for shiftwork, researchers at Vanderbilt obtained DNA samples from participants to determine the extent to which circadian rhythms influenced their adaptation to the shiftwork. They identified the nurses' chronotypes in their human circadian genes and predicted who would adapt to nights and who would not (Salisbury, 2011). This type of genetic research is promising in that chronotypes might play a role in how well a nurse adapts to working nights and determining suitability for shiftwork.

CONCLUSIONS AND IMPLICATIONS
This study explored nurses' perceptions and experiences of falling asleep behind the wheel on the drive home after a worked night shift. By focusing the interviews on the experiences of falling asleep while driving home and eliciting suggestions for mitigating risks of drowsy and/or fall asleep driving after the night shift, this researcher was able to elicit details regarding the registered nurse participants' experiences and their suggestions.
What is clear and well-documented in the literature, are the inherent risks and dangers of driving drowsy and fall asleep accidents. The overwhelming physical urge to fall asleep when a substantial sleep debt has been incurred can only be remedied by sleep. This was validated by the participants as they described the failure of various strategies they used such as loud music, eating, slapping their cheeks, etc. as they attempted to fend off sleep during the drive home. "Putative counter measures to sleepiness, adopted during continued driving (cold air, use of car radio) are only effective for a short time" (Horne & Reyner, 1999, p. 289). Sleeping is the only way to combat sleepiness. The research on drowsy and fall asleep driving is clear with regard to the negative impact this behavior has on the safety of the driver and the greater driving public on the roadways. "Sleep related vehicle accidents are not only more common than is generally realized, but are more liable to result in death and serious injury owing to the relatively high speed of the vehicles on impact" (Horne & Reyner, 1999, p. 289).
The use of a qualitative descriptive research approach allowed this researcher to present the findings in a way that stayed close to the data with minimal interpretation. Sandelowski (2000), states "There is no mandate to produce anything other than a descriptive summary of an event organized in a way that best contains the data collected and what will be most relevant to the audience for whom it was written" (p. 339). A description of the phenomena is provided in eight themes that emerged from the data and obtained through semi-structured interviews.
There is no prior research study that describes the nurses' experience of fall asleep driving after the night shift. While this served to identify the gap in the literature, prior research studies served to form the basis of the literature review and aid in achieving a comprehensive understanding of the research problem. Conversely, this limitation served to identify the need for this research.
This study contributes to the literature as new information was obtained from the perspective of the participants. The participants felt that it was important to come forward and speak about this issue; to be a part of the change. In order to develop interventions to address this issue, the stories must come from them. As previously stated, there has been no qualitative research to date examining the experience of falling asleep behind the wheel after a worked night. There are no qualitative studies that elicited experiences from nurses in their own words. This study serves as a beginning step to close this gap. The themes that emerged from the participants' interviews provide much needed knowledge as to the experience of the shiftworker who has fallen asleep on the drive home after work.
One significant finding was the participants' perception of the lack of choice for new graduates with regard to shift selection. All participants with the exception of one discussed that they were not given a choice of shift for their first nursing position.
A study of new graduate nurses (West et al., 2007) validates the lack of choice experienced by new graduates as well as their discontent with shiftwork. "It is also commonly perceived that the effects of shift work contribute to the current New Graduate Nurses (NGNs) attrition rate" (West et al., 2007, p.23). Many participants expressed the fact that they had little to no choice but to work the night shift when they were new graduates and in essence, "put in their time" until they had gained enough experience and proficiency and were thereby deemed ready to move to the day shift. As a profession, we need to closely examine why the newest members of the nursing profession are placed on the shift with the least amount of clinical, education, and support resources. The night shift, despite having fewer available resources, was identified by all participants to be the shift that had the greatest amount of teamwork and support. This is an interesting finding that raises concerns regarding nurse staffing across shifts. If strong teamwork is an essential component of patient safety, that component should remain consistent 24 hours per day Participants also underscored their discomfort and reluctance with speaking to their nursing leaders regarding their struggle with shiftwork. Some of the participants recounted unpleasant exchanges with their nurse leaders regarding their difficulty with shiftwork and others stated that when they did speak with their nurse leaders, little if anything was accomplished. This information also raises a number of questions and concerns related to nursing administration. It is possible that nurse managers are not aware of the current literature related to the negative effect of shiftwork on their staff.
The fact that the participants were uncomfortable speaking with their nurse managers questions the level of trust between the mangers and their staff.
The nurses who participated in this study were deeply concerned for their safety and the safety of others on their drive home after their scheduled shift.
Participants described the experience of drowsy driving and falling asleep behind the wheel as frightening, terrifying, and scary. They discussed those first few moments of fright and disbelief when they realized they had arrived home without recollection of the parts of the drive or had passed their exit and had no memory as to how they had arrived where they were. Many nurses continue shiftwork despite a foreboding fear of involvement in a vehicular accident as well as persistent unpleasant physical and psychological effects of shiftwork. They fail to see any viable alternative options.
Some participants chose not to share their experiences with family and friends as they did not wish to frighten them or cause them to worry. This illustrates the lack of congruence that seems to exist between knowing the potential negative outcomes of this behavior and changing their behavior. .

Methodological Implications
For this study, the researcher identified the lack of existing qualitative descriptive research of nurses' experiences falling asleep on the drive home after a scheduled night shift. While there are multiple studies that have examined drowsy and fall asleep driving, they are primarily from a quantitative point of view. In addition, there are no studies that include suggestions for mitigation of the risk in the voice of nurses who themselves have experienced the phenomenon. This study provides a foundation to begin to understand structures and processes that might affect implementation of interventions to mitigate the risk of drowsy or fall asleep driving by nurse shiftworkers. Initiatives or interventions that are a good fit with existing organizational goals and staff preferences are more likely to be adapted. This research adds knowledge from the perspective of the nurse that may serve to facilitate effective implementation, test new approaches and determine causal relationships between interventions and their impact. For example, in this study, participants suggested that car-pooling might be an alternative to driving drowsy and fall asleep driving.
However, the participants were quick to cite the reasons that it was not operationally feasible.
It was important to provide a description of the phenomenon that was lacking in the existing body of literature as well as suggestions from those who have experienced the phenomenon in order to heighten awareness of the phenomenon and also to provide an initial review of the feasibility of interventions. This study augments the existing literature on nurses and fatigue in that the focus is on nurse safety after the work shift is completed. Many of the existing studies of nurse shiftworkers focus on the effect of nurse fatigue during worked hours on patient safety.
Selection of a qualitative descriptive research methodology allowed the researcher to present the data in a way that holds true to the qualitative description by remaining close to the data. For all of the women who participated in this study, the use of in-depth semi-structured interviews gave the participants the opportunity to discuss the phenomena using their own voice. Most importantly, the study gave the participants a chance to be heard.
In the discussion of the findings in Chapter 4, the voice of the participant is commonly used in juxtaposition with comments from the researcher. Paraphrasing was avoided and actual quoted text was utilized to provide the reader with the voice of the participant. The interview process afforded the researcher the opportunity to gather extensive and comprehensive data that would have otherwise been inaccessible.
The qualitative methodology allowed for in-depth information and reasons or explanations as to why the participants worked the night shift, a comprehensive account of their experience with fall asleep driving, and their suggestions for correction of the phenomena. During the interview, the participants were asked to reconstruct the events of a time when they fell asleep behind the wheel. They were asked to describe the event as it unfolded. This reconstruction of an event could not have been accomplished without in-depth interviews.
A strength of the use of qualitative description lies in the fact that there are no theoretical strings attached, thereby allowing the analysis to remain close to both the data and the participant's point of view (Neergaard et al., 2009;Sandelowski, 2000)..
As one participant stated, "Just like when you have addicts and they talk about you know, their recovery and fess up and-and put a face to it. I think that's what, and that's part of the reason why I agreed to do this, is because I was thinking, you know, by saying it out loud, I'm processing it and realize that just like I have my story, there's other people that have this and there's got to be a work around it.
And so just sharing the story would be the first step."

Researcher Qualifications
The researcher has extensive experience doing shiftwork, has personally experienced a fall-asleep accident after a worked night shift, and has twenty years of experience in nursing leadership. Disclosure of this information with the participants prior to the beginning of the interview served to diminish the fear of being judged or dismissed. This was critical in facilitation of the interview situation. While the researcher's first-hand experience was invaluable, it was important to remain open to new learning and revelations during the study process to allow for a growth of knowledge.
The researcher's background experience with the phenomena as noted above may be alternately viewed as a limitation of the study. The awareness of prior understanding was consciously noted by the researcher and served to minimize that risk. In addition, the data analysis was validated by Drs. Dufault and Ferszt.
Driving when drowsy and/or falling asleep behind the wheel is viewed as "impaired driving. " According to Kuhar, (SafeNY, 2013, para. 8), "The state of drowsiness itself is a significant impairment while driving and has been shown in several studies to be as dangerous as driving drunk. In driving performance testing, 17 hours of sustained wakefulness was equivalent to driving with a blood alcohol content of 0.05%." Those who knowingly drive drowsy or fall asleep driving are only too aware of the feelings of impairment and the associated stigma. The researcher maintained an approach of appreciative inquiry along with a non-judgmental attitude towards the participants and their responses during the interviews. The process of Appreciative Inquiry employs a particular way of asking questions that encourage positive thinking and employee-to-employee interaction. The researcher was attuned to avoidance of any subtle stigmatizing attitude or expressions during the interview process knowing that this would limit the level of comfort in sharing on the part of the participant. .
As a final and most important qualification, this researcher espouses the virtues of humility, patience, and perseverance. In the acquisition of new skills, it is important to call upon these virtues in facilitate movement to completion of the study. These qualities are the key to the success for novice researcher. Humility is critical in asking for guidance and support from the knowledge and content experts. It is critical in the feelings of discomfort that accompany the practice of a new skill, e.g., interviewing participants.
Patience as a qualification was important in that it allowed the researcher to be immersed in the data and not resort to primary closure in the process of analysis. The emergence of themes takes time and cannot be rushed. The virtue and capacity for perseverance served to propel the study forward and maintain the energy and momentum.
Despite a multitude of competing priorities, the researcher internalized the importance of the study and maintained a sense of urgency to the work at hand. The researcher was fully committed to the aim of the research study and has personal and professional interest in the topic

Implications for Nursing Research
This study begets a priority for research to further knowledge development regarding drowsy/fall asleep driving. "Nursing exists to provide high-quality nursing care to individuals in need of health-promoting, health-sustaining, and health-restoring strategies" (Webb, 2013, p. 108). While Dr. Webb's statement infers that those "individuals" are patients, certainly the profession of nursing has a responsibility to care for the profession and its members as well.
In order to be integral in the development of nursing knowledge, a research study must seek to answer questions that are considered significant and relevant. This research study is significant to front-line staff nurses, nursing leaders and hospital administrators. It is posited that this study will be utilized by nurse scientists to identify interventions that mitigate the risk of drowsy/fall asleep driving in nurse shiftworkers that could form the basis for a research agenda.
Priorities for nursing research were identified via a review of the literature along with interviews with the participants. Potential areas for future research include: 1.) Conduct research to evaluate the effectiveness of restorative napping.
While restorative napping has had promising results in some research studies, organizational barriers exist in the form of policies or unwritten policies. In a study of 13 critical care nurses who completed semistructured interviews exploring napping "…participants identified a number of personal, safety, and patient safety factors that support the need for a restorative nap during the night shift" (McCann, 2008, para. 3). Research as to the effect of a nap during the night shift on the nurses' ability to drive home safely after work should be examined. As mentioned earlier, organizational barriers and negative attitudes towards "sleeping on the job" must be challenged with rigorous research and the development of best and safe practices to effect safe driving practices.
2.) Clinical Research related to screening for physical and mental ability to work the shift.
Many of the participants stated they believed that they were not physically able to work the night shift. They offered anecdotal evidence that they were unlike other nurses who appeared unaffected by shiftwork. In fact, they were perplexed by their own inability to adapt to shiftwork. According to a study by Schmidt, et al. (2009) examining sleep pressure, which increases with the length of time an individual is awake, certain individuals were identified as more susceptible to sleep pressure while others had greater stamina against the build-up of sleep pressure. Individuals who identify themselves as "early birds" had greater difficulty fending off sleep as they sleep pressure increased.
Failing to take into account the individual differences among nurses' physiological ability for shiftwork and reliance on prescribed staffing patterns and must be examined.
Research can be used to influence policy to mitigate the risk of driving drowsy/falling asleep after the night shift. Use the voices of the shiftworkers in this study as a basis of urging the development of policies addressing the risk of drowsy/fall asleep driving after the night shift.
This research can serve to heighten awareness about nurses struggling to stay awake while driving home. The addition of this knowledge to the literature can serve as a catalyst in impacting change.
A more immediate priority is the focus on the issue at hand -nurses falling asleep behind the wheel on their commute home after the night shift. While further research is necessary, there is a need for immediate attention to this safety issue.
Nurses must speak up and share their stories with colleagues and nursing leaders. The issue of fatigue is gaining the attention of regulatory agencies in terms of its effect on patient safety. The results of this study show that in addition to patient safety, nurse safety is at also at risk.
In discussions with registered nurses (in addition to the study participants), drowsy driving or fall asleep driving after the night shift is a ubiquitous phenomenon.
The practice continues every morning as nurses complete their night shift and drive home. This research not only provides a significant contribution of knowledge to the nursing profession, but also acts as a springboard for further research of the efficacy of the participants suggested interventions with the goal of decreasing the potential danger and risk this phenomenon brings.

Implications for Nursing Administration
The intended audience for this study is nurses, nursing leaders, and hospital administrators. It is hoped that the results of this study will serve as a "wake-up call" if you will, to the need for safe options. For the most part, the participants were either frightened to approach their nurse managers or did not consider doing so. Nursing leadership should be required to attend training in sleep hygiene, and sleep physiology so that they can optimize scheduling to ensure adequate rest between shifts and be alert to nurses who are leaving work and are in danger of drowsy and/or fall asleep driving. Sleep is a serious issue that needs to be treated as a priority for the well-being of employees.
Nursing leadership and the shiftworkers share accountability to ensure options for nurses who struggle to stay awake during the drive home after a worked night shift. Nursing leaders and hospital administrators must review the evidence and consider policies and/or procedures to identify those individuals who are physically unable to engage in shiftwork without physical detriment. We have no screening process for those who are asked to work the night shift. This bears further investigation.
Shiftworkers should also undergo training for sleep hygiene. Sleep hygiene is a variety of practices that are necessary to have normal, quality sleep. In addition, staffing policies should be in place and have a provision for offering a place to sleep or transportation home for a sleep-deprived worker. The researcher hopes that by sharing the words of the participants, nursing leaders will be moved to action. Often research is presented in dense data in the form of spreadsheets that are categorized and calculated. This study offers the reader a story. A story told in the voices of nurses who hope that nursing leaders and nursing researchers are paying attention and will take action. Quasi-statistical analysis methods using numbers to summarize data with descriptive statistics Stay close to the data-low level interpretation (if using qualitative software such as NVivo, the use of "Invivocoding" procedures works well here.

TABLES
Goal of the anlaysis strategy is to understand the latent variable (useful for concept classification and instrument development)

Outcomes
Straight description of the data organized in a way that "fits" the data (eg.chronologically by topic, by prevalence, etc.) Note. In Sandelowski, 2000 andSullivan-Bolyai, Bova, &Harper, 2005.     Feel panicked and jolted awake. But then oddly enough, you feel still sleepy, for a little, you know. There were times when I would pull into my driveway and be so exhausted that I couldn't even make it into the house.

Feel panicked
Um, so I'd fall asleep for an hour and a half, two hours sometimes, and wake up, and be like, "Oh, I'm asleep." there are times where I got home and I had to sleep in the car I couldn't even get up to go in the house Table 9 Not a Night Person I've been there because I just I wouldn't be able to drive home afterwards.

Meaningful Units Condensed Units
Because I know there's some -some nurses that I work with and, you know, they've been a very long time nights they drive extremely far and they're not going straight to bed, they're just going straight to an area to pick up their children andand, you know, I honestly don't know how they make it.
Some nurses I work with they drive far and don't go right to bed  This study aims to answer the question: What is the experience of falling asleep behind the wheel on the drive home from a worked night shift? My hope is to illuminate the issue of night nurses and drowsy driving and shift work. This researcher hopes that the study will benefit night shift nurses and improve standards in this area. I would like to invite all staff nurses who have fallen asleep at the wheel driving home from a worked night shift. Anyone who chooses to take part will be requested to sign a consent form to partake in a 45-60 minute audio-taped interview which will be held at a time convenient to you and in a private meeting area or conference room. Be advised that participation is voluntary and that you have the right to withdraw from the study at any time and any data obtained will be removed from the database. Any information gathered from this study will remain confidential. Thank you for taking the time to read this letter. Should you wish to take part in this study, or have any further questions prior to making a decision, please feel free to contact me at 617-279-3119 or ssargent81@gmail.com. If you do decide to participate, please contact me either via phone or email. A gift card to Starbuck in the amount of $25.00 will be provided for each participant. Kind regards, Shirley Sargent PhD (c), RN Appendix D

Informed Consent
The University of Rhode Island College of Nursing White Hall 2 Heathman Road Kingston, RI 02881

CONSENT FORM FOR RESEARCH
You have been invited to take part in a research project described below. The researcher will explain the project to you in detail. You should feel free to ask questions. If you have more questions later, Shirley Sargent, RN the person mainly responsible for this study, 617-279-3119 will discuss them with you. You must be at least 18 years old to be in this research project.

Description of the project:
My name is Shirley Sargent, RN. I am currently working on a research study in nursing at the University of Rhode Island. My proposed study for my dissertation aims to explore the experiences of nurses who have fallen asleep behind the wheel on the commute home after a worked night shift. This study aims to answer the question: What is the experience of falling asleep behind the wheel on the drive home from a worked night shift? My hope is to illuminate the issue of night nurses and drowsy driving and shift work. What will be done? If you decide to take part in this study here is what will happen: Anyone who chooses to take part will be requested to sign a consent form to partake in a 60 to 90 minute audio-taped interview which will be held at a time convenient to you and in a private meeting area or conference room.

Risks or discomfort:
The subject of discussion, driving drowsy and/or falling asleep behind the wheel, may be uncomfortable for you. If you experience any anxiety related to describing your experience with drowsy driving, including describing any accidents you may have had, you may discontinue the interview at any time.

Benefits of this study:
This researcher hopes that the study will benefit night shift nurses and improve standards in this area.

Confidentiality:
Any information gathered from this study will remain confidential and anonymity will be maintained throughout the study. Your part in this study is confidential. None of the information will identify you by name. Any electronic data will be password protected and encrypted. Once the audiotapes have been transcribed, they will be kept in a locked file in a locked office available only to the researchers at the College of Nursing, White Hall, University of Rhode Island. Data will be stored for three years following completion of the study, and then it will be destroyed. Your part in this study is confidential within legal limits. The researchers and the University of Rhode Island will protect your privacy, unless they are required by law to report information to city, state or federal authorities, or to give information to a court of law. Otherwise, none of the information will identify you by name. Data entered into a computer database will have number identifiers only.
Decision to quit at any time: Be advised that participation is voluntary and that you have the right to withdraw from the study at any time and any data obtained will be removed from the database.