Theoretical Framework
a. The study framework is not clearly identified; however, a tentative theory is proposed since a tentative theory “has had minimal exposure to critique by the discipline, and has had little testing” (Burns & Grove, 2009).
b. The discussion of the conceptual framework is limited to the model of impaired sleep. The linking of the concept of impaired sleep to independent variables of the Fatigue countermeasures program for nurses (FCMPN). The major study concepts include: sleep deprivation (inadequate sleep), sleep disruption (fragmented sleep), lifestyle situation, and health related issues.
Variables Identification and Definition
Independent Variables: Feasibility of an FCMPN intervention for patient and nurse safety
Conceptual Definition: “The model of impaired sleep (Lee et al., 2004) guided the intervention for evaluating the feasibility of an FCMPN for improving sleep duration and quality while reducing daytime sleepiness and patient care errors… Performance accomplishment was achieved by ‘educating’ the staff about fatigue, sleep, and circadian rhythms; neurobehavioral and health effects associated with sleep loss or deprivation; and misconceptions about sleepiness” (Scott, et al. 2010, p. 250, 253). Operational Definition: “A one-group pretest-posttest repeated measures approach was used. Participants provided data 2 week before the FCMPN, 4 weeks after receiving the intervention, and again at 3 months after intervention (Scott, et al. 2010, p. 250).
Dependent Variables: Fatigue Countermeasures Program for Nurses (FCMPN)
Conceptual Definition: The FCMPN is conceptually defined that sleep deprivation and sleep disruption can lead to sleep loss and poor sleep quality as shown in Figure 1 (Scott, et al. 2010, p. 252). Operational Definition: FCMPN was calculated from data from the participants’ daily logbooks (self report sleep times), Pittsburgh Sleep Quality Index (PSQI) by Buysse, et al. (1989) a 19 item computed global sleep quality score, and Epworth Sleepiness Scale (ESS) by Johns (1991) an eight common situation scale (Scott, et al., 2010, p. 250).
Sleep Duration Conceptual Definition: Sufficient sleep that is followed by a spontaneous awakening and leaves one feeling refreshed and alert for the day. Operational Definition: Sleep duration were measured with the total sleep duration, work day sleep duration, non-work day sleep duration, and night shift sleep duration.
Sleep Quality
Conceptual Definition: Persistently interrupted or uninterrupted sleep with or without difficulty falling asleep. Operational Definition: Sleep quality was measured by the PSQI scores.
Daytime Sleepiness Conceptual Definition: Insufficient sleep during the night that leads to daytime sleepiness. Operational Definition: Daytime sleepiness was measured before the intervention, 4 weeks post intervention, and 12 weeks post interventions using the logbooks.
Drowsiness and Sleep Episodes at Work Conceptual Definition: Feeling drowsy or sleepy at work due to sleep quality and duration. Operational Definition: Drowsiness and sleep episodes at work were measured pre-intervention frequency, 4 weeks post intervention frequency, and 12 weeks post intervention frequency.
Drowsy Driving and Motor Vehicle Crashes Conceptual Definition: Drowsy driving and motor vehicle crashes can stem from driving with less sleep as usual, yawning frequently, trouble keeping your head up, unable to remember the last few miles driven, missing exits or traffic signs, and swerving or tailgating. Operational Definition: Drowsy driving and motor vehicle crashes were measured by logbooks during the initial data collection, 4 weeks post intervention, and 12 weeks post intervention.
Errors, Near Errors, and Intercepted or Discovered Errors Conceptual Definition: Errors, near errors, and intercepted or discovered errors mainly “involved medication administration, patient care procedures, physician order processing, and transcription issues” (Scott, et al. 2010, p. 255). Operational Definition: Errors and near errors were measured using logbooks pre intervention, 4 weeks post intervention, and 12 weeks post intervention periods.
Clinical Assessment Conceptual Definition: Not clearly defined but is implied as a need for future investigations and studies. Operational Definition: “Involve adopting effective fatigue countermeasure both at home and work” Scott et al. (2010, p. 253) to prevent fatigue, review of self reported sleep duration and quality, daytime sleepiness and drowsiness at work and while driving, and errors on the job.
Sample and Setting
a. Sample Inclusion and Exclusion Criteria: The participants are nurses with fatigue at work and the sample criteria are: Inclusion criteria were “full-time staff nurses practicing on the selected units… advanced practice nurses, nurse managers, or nurses in specialized roles such as discharge planning were not eligible” (exclusion criteria) to participate (Scott, et al. 2010, p. 252).
b. Sampling Method: “A prospective design with a one-group pretest-posttest repeated-measures approach was used… Baseline data were collected for 2 weeks before the intervention (Study Weeks 1-2). Subsequent data collection occurred during the 4- week period (Study Weeks 4-7) after the intervention given during the third week, with a final data collection period 12 weeks after intervention (Study Weeks 15-16)” Scott et al. (2010) to evaluate the FCMPN intervention.
c. Sample Size: A total of 47 staff nurses participated in the intervention. A power analysis was done to determine the sample size needed for the study. According to Cohen (1988), a sample size of 30 participants would be needed to provide a power of .80 to detect a medium effect size with a Type 1 error rate of .05 in a study with three repeated measures with an average correlation of .50. Given that 47 nurses provided data for the entire study period, there are sufficient power to examine the feasibility of the FCMPN and changes in our selected variables of interest” (Scott et al. 2010, p. 254).
d. All subjects met the criteria to participate. No subjects refused to participate.
e. Original Sample Size: A total of 62 staff nurses enrolled in the intervention, but only 47 nurses responded and completed the interventions across the entire study.
f. Institutional Review Board (IRB) and Informed Consent: “The institutional review board at Grand Valle State University and each participating data collection site approved this study protocol” Scott et al. (2010, p. 254), however, informed consent was not identified in the study.
g. Setting: The settings took place on nursing units and at home. Nurse Managers in each unit provided sleep recliners for scheduled naps during breaks.
Measurement Methods
Table of Study Measurement Methods
Study Variables Author and Name of Measurement Method Type of Measurement Method Reliability or Precision Validity or Accuracy
Sleep duration Logbook (self-report sleep times) Logbooks No reliability or precision Initial intervention (M=6.23 hr, SD=1.83 hr); 4 weeks post (M=7.55 hr, SD=1.95 hr); 12 weeks post (M=7.08 hr, SD= 1.69 hr)
Sleep quality Buysse et al. (1989)/Pittsburgh Sleep Quality Index 19-items global sleep quality score (0 to 20) with higher scores indicative of poor sleep quality Reliability: Global scores greater than 5 have sensitivity for good and poor sleepers
Reliability: Cronbach alpha of .69 to .81 in various studies. Cronbach alpha coefficient of .70 in this study Initial intervention (M= SD=2.70); 4 weeks post (M=8.47, SD=2.57, p=.67); 12 weeks post (M=7.65, SD= 2.54, t-2.24, p=.03)
Daytime sleepiness Johns (1991)/Epworth Sleepiness Scale (ESS) 8-items situation score of never dozed, slight, moderate, and high (0 to 2) Reliability: A score greater than 10 indicate abnormal sleep and over 16 suggest pathological sleepiness
Reliability: Cronbach alpha of .73-.88, stability (r=.82) with reliability of .71 in this study Initial intervention 9.02; 4 week 8.33, 12 weeks 8.85
Vigilance(inability to remain alert) Drowsiness and unplanned sleep episodes at work and while driving Logbooks No reliability information provided. No validity or accuracy
Risk for accidents and errors Logbook (accident or error data) Logbooks No reliability information provided. No validity or accuracy
Short term memory Logbook (error description) Logbooks No reliability information provided. No validity or accuracy
Problem solving and coping Logbook (error description) Logbooks No reliability information provided. No validity or accuracy
Statistical Analysis and Results
a. Analysis Techniques: The sample was described with frequencies, means, percentages and standard deviation as depicted in Table 1 Demographic Summary of Study Participants (Scott, et al. 2010, p. 252). The PSQI scale was described using internal consistency coefficients. The EPS was described with both internal consistency reliability and stability. A one group pretest-posttest repeated measure was used overtime with a 2 weeks pre-intervention, 4 weeks post intervention, and 12 weeks post intervention.
b. The data analysis linked to the study purpose and/or objectives, question, and hypotheses. The purpose of the study “was to evaluate the feasibility of fatigue countermeasures program for nurses (FCMPN) for reducing fatigue and patient care errors. Specific goals of the study included an evaluation of hospital staff nurse sleep patterns and alertness before and after the implementation of an FCMPN and a comparison of the frequency and type of errors and near errors reported by hospital staff nurses before and after the implementation of an FCMPN. It was hypothesized that adoption of a standard fatigue intervention program used in many other industries would improve nurses’ alertness and therefore decrease the number of near errors or actual patient care errors” (Scott, et al. 2010, p. 251).
Findings
a. Link of findings to the study framework: “These preliminary findings suggest that it is possible to implement fatigue countermeasures that have potential to mitigate fatigue, improve sleep, and reduce errors among hospital staff nurses” (Scott et al. 2010, p. 257).
b. Expected findings: “Significant improvements were noted immediately after the intervention. Nurse participants averaged an increase in their sleep time by 50 minutes. Compared with the minimum amount of sleep obtained at baseline (1.50 hr), the minimum amount of sleep in the 4- and 12-week post intervention periods increased to almost 4 hr” (Scott, et al. 2010, p. 254).
c. Unexpected findings: “Significant improvements were not found in daytime sleepiness scores, the severity of daytime sleepiness appeared to decrease. Nevertheless, it is important to note that daytime sleepiness remained severe among 18 of 47 nurse participants” (Scott et al. 2010, p 256).
d. Consistency of the study findings: Studies have been done with pilots’ alertness at the cockpit over 10 years, including physicians, flight and traffic controllers during space shuttles. The logbooks and scales were easy to use which is evident in 47 of the nurses completing the study.

Study Limitations
Generalizations: “The use of convenient sampling and a pre-experimental research design limits the generalizability of this study… there were sufficient statistical power to examine the variables of interest in a one-group repeated measure design” (Scott et al. 2010, p. 257).
Nursing Implications: The researchers defined the clinical application of the study finding. “This is the first study to develop and test a fatigue countermeasures program designed specifically for hospital staff nurses. Furthermore, it addresses the recommendations of the 2004 Institute of Medicine report, Keeping Patients Safe: Transforming the Work Environment of Nurses (Institute of Medicine, 2004), which calls for fatigue management education for nurses, as well as the development and testing methods to reduce fatigue among night shift workers” (Scott, et al. 2010, p. 257).
Recommendations for Further Research: “Recent studies have documented that risk for error is significantly higher when nurses work more than 12 consecutive hours, work beyond their scheduled shift time, work more than 40 hours in a week, and obtain insufficient sleep” (Scott, et al. 2010, p. 256). “There are no studies to evaluate the efficacy of this type of fatigue countermeasure program among nurses. Neither has anyone tested the efficacy of a more comprehensive fatigue management program that includes efforts to improve fatigue management knowledge, sleep hygiene, and changes in specific work related behavior” (Scott et al. 2010, p 251).

References
Burns, N., & Grove, S. K. (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence (6th Ed.). St. Louis, MO: Saunders Elsevier.
Buysse, D. J., et al., (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193-213.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd Ed.). Hillsdale, NJ:
Lawrence Erlbaum.
Groves, S. K. (2007). Statistics for healthcare research: A practical workbook. St. Louis,
MO: Saunders Elsevier.
Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academic Press.
Scott, L. D., Hofmeister, N., Rogness, N., Rogers, A. E. (2010). An Interventional Approach for
Patient and Nurse Safety: A Fatigue Countermeasures Feasibility Study. Nursing
Research, 59 (4), 250-258.