Shift Work and Sleep Disruption: Implications for Nurses’ Health
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HEALTHY NURSE Shift work and sleep disruption: Implications for nurses’ health Take steps to protect nurses and ensure patient safety. By Amy Witkoski Stimpfel, PhD, RN THE STANDARD Monday through Friday, 9:00 two states—non-rapid eye movement (NREM) AM to 5:00 PM work schedule has become a and rapid eye movement (REM)—which are thing of the past for many workers. The global measured using an electroencephalogram. In economy, expanded technology use, and com- healthy adults, sleep onset occurs through petitive labor markets have dramatically changed NREM sleep and is followed by REM sleep. when, where, and how work is done. The Then, NREM and REM sleep alternate prevalence of nonstandard work hours, flexible throughout the night in 90- to 120-minute cy- schedules, contract work, and shift work vary cles. Most sleep is NREM, which has four dis- by occupation, education, gender, race, and eth- tinct stages. The National Sleep Foundation nicity, but the U.S. workforce is made up of ap- recommends that healthy adults (26 to 64 proximately 157 million individuals, and esti- years) get 7 to 9 hours of sleep each night mates suggest that 20% work shifts. and that older adults (≥65 years) get 7 to 8 Because of the ubiquity of nurses across hours of sleep. care settings and the high-touch nature of bedside care, the health and safety ramifica- How is sleep regulated? tions of shift work on nurses and their patients The classic sleep model has two distinct is significant. When individual nurses and or- processes that overlay one another: sleep ganization leaders understand the basic prin- homeostasis (Process S) and circadian rhythm ciples of human sleep, the effects of shift (Process C). Process S is based on prior sleep work, and the implications for nursing prac- and wakefulness. As wakefulness is main- tice, they can take steps to mitigate health and tained, sleep pressure builds—the propensity safety risks. to sleep increases. After sleep occurs, that pressure diminishes until the next bout of Sleep essentials wakefulness begins and sleep pressure builds Sleep is as necessary for human survival as again. air, food, and water. Sleep is separated into Process C is governed by our central clock, MyAmericanNurse.com November 2020 American Nurse Journal 23 ness end of the spectrum (early lark) is an ear- Shift work and safety ly riser, performs best in the morning, and goes to bed early in the evening. Those who The effects of shift work–related sleepiness or fatigue are far reaching. fall on the extreme eveningness end (night Major public health and safety catastrophes have implicated either owls), go to bed late, get up later in the morn- nightshift work or shift work schedules as a contributing factor. Some ing, and perform best in the late afternoon of the most notable include the nuclear power plant accidents at Three and evening. Most people, however, display Mile Island and Chernobyl, the grounding of the Exxon Valdez oil tanker, an intermediate chronotype; they’re not an and the Space Shuttle Challenger accident. Specific to nursing, growing empirical evidence indicates nurses’ im- early lark or night owl, but fall somewhere in paired functioning during nightshifts and extended shifts. The implica- between. tions of nurses’ schedules and shift work are significant and include Unlike animal models, identifying human • needle sticks genes that regulate sleep and circadian • musculoskeletal injuries rhythms have been primarily limited to candi- date gene analysis. This approach focuses on • patient safety errors associations between genetic variation within • poor collaboration specific genes of interest rather than looking • decreased patient satisfaction. at the entire genome. More research is needed Researchers also have found an increased risk for drowsy driving to identify genes specific to sleep disorders to and motor vehicle crashes among nurses who work nightshifts. aid treatment decisions and develop best clin- ical practices. the suprachiasmatic nucleus (SCN) of the ante- What’s the connection between rior hypothalamus. This central clock oscillates circadian misalignment, shift work, in an approximate 24-hour period, thus the and disease? term “circadian rhythm,” which is derived from Shifts in sleep and wake patterns are affected the Latin words “circa” (about) and “dies” by changes in photic (light) and nonphotic (day). The SCN is affected by external stimuli, (eating, exercising) input. Bright light expo- such as eating and drinking, exercise, and tem- sure at night or a change in mealtimes can perature, but light is the strongest synchroniz- lead to circadian desynchronization. A main er. When the SCN is properly synchronized source of circadian desynchronization is shift with the daily light/dark cycle, other behav- work, which requires workers to be awake ioral (eating/fasting, sleeping/waking) and phys- when they normally would be asleep and iologic (body temperature, melatonin) rhythms asleep when they normally would be awake. will align. In addition to the SCN, other periph- Most shift workers have different wake/sleep eral clocks function in the body’s organs and schedules on work and non-workdays be- tissues (such as the liver and adipose tissue), cause of family and social responsibilities, as well as in metabolic pathways. Coordinated putting them in a chronic state of circadian central and peripheral circadian rhythms are misalignment, which can lead to serious essential for virtually all biologic processes. health consequences. Across peripheral organ systems, circadian disruption has been linked What are the genetic components to cancer (breast, prostate, colorectal), mood of sleep? disorders (depression), cardiovascular disease Individual differences in human sleep need (coronary heart disease), metabolic dysfunc- are well documented. However, sleep need tion (impaired glucose tolerance), and de- follows a Bell curve, indicating that most peo- creased fertility. Nursing is primarily a female ple require the recommended 7 to 9 hours of profession, making the links between night- sleep each night and few people require a lot shift work (even for only a few years) and more or a lot less sleep. breast cancer and reproductive issues particu- Several heritable sleep phenotypes (chrono - larly concerning. types) have been identified. They’re common- Shift work sleep disorder (SWSD) is charac- ly described in terms of morningness and terized by circadian rhythm disruption as a re- eveningness (diurnal preferences, sleep–wake sult of social and work schedules that lead to activity pattern, and morning and evening excessive sleepiness and/or insomnia. Sleep/ alertness). Someone on the extreme morning- wake disturbances also may cause significant 24 American Nurse Journal Volume 15, Number 11 MyAmericanNurse.com distress or impairment in mental, physical, ber of allowable consecutive shifts (no more and social functioning. Approximately 20% to than three in a row) and shift lengths (< 12 30% of shift workers experience symptoms hours). Ensuring that the time off between consistent with SWSD; however, more popu- shifts is at least 11 hours helps the body re- lation-based studies are needed to determine cover and allows for adequate sleep between the exact prevalence. If switching to a stan- shifts, and nurses should have at least 3 days dard dayshift schedule isn’t possible, sleep off after working nightshift. When rotating medicine providers can diagnose and treat shifts, nurses should be scheduled using a SWSD with both behavioral (bright light, exer- clockwise or forward rotation so that they cise) and short-term pharmacologic (mela- move from day, to evening, to nightshift. tonin, stimulants) interventions. (See Shift Managers should provide shift work aware- work and safety.) ness education that includes topics such as sleep hygiene, chronotype and shift work, Practice recommendations strategic use of naps while working or on-call, Work-related interventions to eliminate or re- and how to recognize signs of excessive duce the effects of shift work can be imple- sleepiness in colleagues. Management also mented by individual nurses, managers, and should provide screening and referral to sleep organizations. medicine or occupational health for evalua- tion of SWSD. Free resources, such as the Na- Individual nurse interventions tional Institute for Occupational Safety and Overall sleep hygiene is important for all nurs- Health Training for Nurses on Shift Work and es. The ideal sleep environment is cool (68° F Long Work Hours (cdc.gov/niosh/docs/2015- to 72° F), dark (blackout shades or an eye 115/default.html), can be used in these staff mask can be used during the day), and quiet development sessions. (white noise machine or ear plugs can help Organizations also might want to consider reduce ambient noise, especially during the providing taxi vouchers or other incentives day). To reduce exposure to sleep-suppress- and support to promote safe commuting for ing blue light, the environment should be free nurses working extended or nightshifts. from electronics (tablets, phones, and TVs). Nurses commuting home from the nightshift Promote healthy sleep should consider wearing blue light–blocking Sleep is a crucial biologic need. Adequate sunglasses and using phone apps that reduce sleep quality and quantity are necessary for blue light stimulation. optimal neurobehavioral functioning and on- Healthy eating is important for good sleep, the-job performance. Nurses traditionally as is limiting food intake 2 to 4 hours before don’t receive adequate, if any, pre-licensure bed. Caffeine, alcohol, and nicotine can im- education on sleep or shift work. To protect pair sleep quality and shouldn’t be used 3 to nurses and the patients in their care, individu- 4 hours before sleep. als and organization leadership must take Nurses who work nightshifts need to make steps to promote schedules that limit circadian additional modifications to optimize their disruption and develop policies and practices sleep. They should try to sleep directly after to monitor workers for signs of sleep disor- their shift.