10 Steps to Insomnia Relief: When You Missed the Zebra… or the Horse

You bolt awake at 3am and realize: “I forgot to order a TB test on Patient X. I feel like such an idiot! He trusts me to know this stuff, and I missed it.” You moan and know you won’t be able to get back to sleep.

 What do you do?

a) Resign yourself to a poor night’s sleep and commence tossing and turning
b) Ruminate all night on how bad of a nurse practitioner and person you are
c) Get up, sign in to the patient’s chart and start documenting
d) None of the above

We all know the answer is “none of the above,” but that can be hard to remember when you feel anxious, frustrated and upset at yourself on top of being fully awake at 3am.

So what SHOULD you do?

Try this ten-step, twenty-minute insomnia-busting program for when you wake up after missing something major. It takes twenty minutes to calm down the sympathetic nervous system after bolting awake anyway, so you might as well get some use out of that time. Each step takes two minutes, though feel free to change that to whatever amount of time works for you. 

Step 1 – Take A Deep Breath or Ten

You MUST breathe. When we get emotional and self-judgmental, we breathe shallowly and ineffectively, robbing our brain of the oxygen it needs to start calming down and counteracting the burst of epinephrine and norepinephrine you just got.

3:00 am – 3:02 am

Step 2 – Get Out of Bed

Change your environment. You are too wired to go immediately back to sleep anyway, so you might as well get up. Go into a different room if possible, but avoid screens and bright lighting.

3:02 am – 3:04 am

Step 3 – Write a Paper Note to Yourself

DO NOT sign into the patient’s chart. In fact, avoid screens entirely. DO write yourself a brief paper note to get your immediate thoughts down, but save the heavy thinking until tomorrow, when you can do something about it. Put the note in your purse, lunch bag, or somewhere else you will remember to take it to work tomorrow.

3:04 am – 3:06 am

Step 4 – Wallow

Give yourself two minutes to wallow. You screwed up; it woke you up; it sucks. But it’s real, or at least the feeling is real, so you might as well admit it. Besides, you won’t be able to focus on anything else until you face it. Allow yourself two minutes only, and absolutely no more than five minutes. Set a timer if you have to, because you need to have an end point, or this step can last all night.

3:06 am – 3:08 am

Step 5 – Be Compassionate to Yourself

Cut yourself some slack. You are human, and even with your high level of education, we all make mistakes. Recognize that it’s okay, and you are okay, and you will do everything you can to rectify the situation later. But for now, just be kind to yourself.

3:08 am – 3:10 am

Step 6 – Recollect Past Successes

Remember that you have made “good calls” in the past and “caught” diagnoses and issues that you could have missed. You are doing a good job taking care of your patients, and your best to be there for them.

3:10 am – 3:12 am

Steps 7 & 8– Progressive Muscle Relaxation

Remember PMR, like we teach patients to do when they are having insomnia? Yeah, it’s hard to remember at 3:12 am, but your body is starting to calm down and is becoming amenable to relaxation exercises. Take as long as you need. Even if the PMR isn’t “working” right away, it is restful and helps clear the mind and body.

3:12 am – 3:16 am

Step 9 – Lay Down When You Feel Sleepy

Sleepy. Not tired. If you don’t feel sleepy, keep doing the Progressive Muscle Relaxation exercises, or do something else quiet that doesn’t involve loud noises, screens, or bright lights. You are going to feel tired, because it is “oh-stupid-o’clock” in the morning, but until you feel sleepy, dreamland will elude you anyway, so you might as well stay up.

3:16 am – 3:18 am

Step 10 – Fall Back Asleep

Easier said than done, I know, but at least now you have a chance at it. Be kind to yourself, and use whatever strategies work to go back to sleep. If you are not able to do so, know that mindful wakefulness is nearly as restorative as sleep.

3:18 am – 3:20 am


If you fell asleep, great! Enjoy dreamland; I’ll see you in the morning. If you are not asleep after 30-60 minutes, get up and repeat steps four through nine, and hopefully step ten, and wake up refreshed and ready to face the day.

Use these ten steps in whatever way works for you. Feel free to change the order of the steps, the timing, the steps themselves or anything else about it. If you are sleeping restfully, I am happy.

Take Care of You!