The most appropriate management is sleep hygiene counseling. This patient has symptoms of shift work sleep disorder, in which sleepiness and fatigue occur during the nighttime work shift and insomnia occurs during the daytime sleep period. The first step in management is to address sleep-related behaviors and the sleep environment, referred to as sleep hygiene. Strategies that may be useful include caffeinated beverages and bright light exposure during the evening work shift; avoiding direct sunlight in the early morning (by using sunglasses and darkening the bedroom); avoiding exertion, eating, and alcohol prior to the morning sleep period; and, if feasible, considering a short (30-minute) nap overnight, perhaps during a meal break.

Modafinil, a novel stimulant, is approved for use in shift work sleep disorder. However, it should be considered only after conservative measures such as sleep hygiene counseling are tried. Modafinil is limited by cost and side effects, which include headache, anxiety, and (rarely) serious skin reactions.

Multiple sleep latency testing (MSLT) is a laboratory-based sleep test that objectively measures sleepiness and is used primarily as a diagnostic aid in testing for narcolepsy or idiopathic hypersomnia. MSLT should not be performed in sleep-deprived patients. There is no indication for MSLT in this patient.

Polysomnography is indicated when there is strong pretest evidence of a primary sleep disorder, such as sleep-disordered breathing. Because of this patient's lack of previous symptoms and association of her symptoms with her work schedule, there is low suspicion for an underlying sleep problem requiring diagnosis by polysomnography. However, if her symptoms persist following conservative therapy, in-laboratory polysomnography could be considered for a more comprehensive evaluation.

Hypnotic medications such as zolpidem have been used empirically to aid sleep initiation following a night shift, but their efficacy is not well known. Furthermore, there is increasing concern about side effects and complex behaviors (sleep driving and sleep eating) associated with hypnotics in patients who may be sleep-deprived. A short course of hypnotics could be considered, but only after conservative measures, such as sleep hygiene counseling, are attempted.