Jack, an anesthesiologist, never saw the light pole he wrapped his BMW around while he was driving home after a long shift at the hospital. The police investigation and autopsy revealed he had fallen asleep at the wheel, a not uncommon occurrence among health care personnel. Colleagues said Jack had resigned himself to a work and call schedule that made him feel chronically “dead tired.” This time being tired had left him dead, and his hospital bereft of a valuable staff member.
Today’s health care worker sleeps 6.8 hours on week nights, one hour less than recommended. The 24/7 workplace takes part of the blame. We sleep an hour less than 50 years ago. Staying awake for 24 hour shift is equivalent to being legally drunk—a 0.1 blood alcohol level. 1
Repeated long work shifts and disruption of circadian rhythms can be fatal to patients and physicians alike. Physicians who are asked to respond to a medication order in the middle of the night might give the wrong dosage. Medical staff are at particular risk for adverse events when sleepy. Interns have 2.3 times the risk of a motor vehicle crash while driving home after an extended shift based on a study of 2,737 residents. 2
Work hour guidelines from the Accreditation Council of Graduate Medical Education (ACGME) have made minimal impact. Shifts are limited to 30 hours and work weeks to 80 hours. Prior to the new rules, the average was 32 hours a shift and 72 hours a week. It is not only young residents who are at risk. Sleep loss and shift work present additional hazards for the older workers who have slower reaction times, less resiliency, medical conditions and a greater likelihood of taking medication that may contribute to somnolence. 3
Twenty three million Americans are shift workers and 6-7 million are in the health care field and over 30 percent of health care personnel are in jobs that require extended hours or shift work that compromise the normal circadian rhythm. The adverse effects are profound. Lack of sleep predisposes to medical errors, auto accidents, impaired productivity, decreased work performance, and poor health. 1
There is strong evidence that shift work contributes to sleep disorders and that shift and night workers obtain less sleep than day workers. 5 The sleep deprived are more likely to suffer from obesity, diabetes, cardiovascular, psychiatric and gastrointestinal disease, and impaired immunity. 6, 7
One study of 79,000 nurses over a four-year period found a dose response relationship between coronary artery disease and shift work even after adjusting for risk factors such as smoking, BMI, hypertension, lipids, alcohol use and physical activity. 8 Night work worsens seizure disorders, post-myocardial infarction, asthma, and management of diabetes because metabolism, insulin resistance and the absorption of medication are altered. 9 Weight gain (the average was 15 pounds) was more common in night shift than day shift nurses tracked for five years. 10
There is strong evidence to support an association between shift work and poor pregnancy outcomes (low birth weight and prolonged gestation), as well as an increased risk of breast cancer adjusted for age, age at first birth of first and last child and number of children. 11, 12 Psychiatric conditions are more frequent in shift workers, including depression, substance abuse, divorce, family violence and sexual dysfunction. 13
Certain measures help delay the effects of sleep deprivation— short term. Caffeine, nicotine and modafinil—a wakefulness drug or “performance enhancer” used for narcolepsy and fatigue related to depression and multiple sclerosis—have been used as alertness aids. Unfortunately, negative side effects occur with higher doses and chronic use. Caffeine-related heart rhythm disorders are not uncommon. One large Starbucks beverage contains 1,000 milligrams of caffeine. In contrast the standard cup of coffee is only 100 milligrams. Modafinil increases vigilance and improves night time sleepiness, but contributes to insomnia. 4
Health care staff are often sleep bulemics, they binge and purge. Workers may go several nights with minimal sleep and then sleep longer on the weekend. Many will take another’s shift and “double up” with two eight hour shifts (a 16-hour work day) or work more shifts in a row in order to have a longer weekend. Unfortunately, if you only sleep four hours you are 20 percent less effective for your next work shift. 1 If you burn the candle at both ends, you get burned by more adverse events, including the risk of higher errors, accidents and less productivity.
It is not just the night or shift worker that is of concern. Up to 75 percent of Americans have difficulty with sleep a few nights every week, according to a National Sleep Foundation survey (2005). Sleep disorders include: insomnias, parasomnias such as REM (rapid eye movement) behavior disorder, sleep walking and sleep talking, and conditions that cause sleepiness during the day like narcolepsy and sleep apnea.
Health care work is not entirely to blame for lack of sleep. Personal habits contribute to disrupted sleep. Before bedtime exercise (elevates the heart rate) and stimulant use (nicotine and caffeine), alcohol ingestion (a diuretic that leads to nocturnal bathroom visits) and warm ambient temperature contribute to poor sleep.
Management can assist with two initiatives. The first is an employee education campaign about how to improve sleep hygiene at home and at work. Here are some suggestions:
The second management effort is to revise work schedules to conform to the latest science. Hospitals will always be a 24/7 operation. However, the following measures can be adopted to decrease the incidence of sleep deprivation and its related negative effects on worker health and productivity, and the bottom line.
For surgical residents, consider dedicated day and night teams led to improve patient care, reduce fatigue and enhance life quality, though residents and attendings are concerned about negative effects on continuity of care. 14, 15 A nursing schedule intervention that provides only two shifts, more weekends and fewer consecutive shifts reduces cardiovascular risk factor biomarkers. 16
There are contraindications for shift work all managers should be aware of, and your employee health staff can screen.
Finally be aware of the personal needs of your staff. Many chose shift work because of child care. A relative or neighbor who works during the day is available in the evening as a low or no cost babysitter when the worker is on the job. Pay differentials that favor night work are another factor. Hospital consolidations and shutdowns have caused more senior nurses who “did time” at nights, and who earned day shift work to be thrown back on evenings—and now they are older and less resilient.