Jean, an emergency nurse with 15 years of experience, recently relocated from Florida to California, accepting a permanent position at a high acuity medical center. Working overtime to train a replacement, selling her home, and packing until the last minute had left her sleepless and stressed. Arriving the day before she was scheduled to start her new job, Jean had little time to adjust to the different time zone, yet alone the idea of working nights instead of days.
As she got into her car at the end of her first 12-hour shift, Jean mused, “It certainly has been a hectic month.” Driving to her apartment in the early morning light, she didn’t realize she was nodding offÃ¢Â?Â¦or that her car was easing over into oncoming trafficÃ¢Â?Â¦
Many healthcare professionals will attest that sleep deprivation (SD) from shift work may lead to occurrences that jeopardize not only themselves, but also their patients. Fatigue from long shifts can reduce attention to detail, affecting critical thinking and performance. Although sleep is not cumulative, SD is. The more hours a person works, the longer it takes to complete a task. More mistakes are made, and alertness is markedly decreased.
Jean discovered, firsthand, that lack of sleep poses risks not only while at work, but also when driving home. Producing a “drunken” effect, sleep deprivation is a leading cause of automobile accidents. This fact is underscored by results from the 2002 Sleep in America Poll, conducted by the National Sleep Foundation (NSF). Over half of its 1,010 adult respondents reported driving while drowsy, with 17 percent admitting to dozing off on the road within the past year. As noted by the National Commission on Sleep Disorders Research, falling asleep at the wheel is the most costly and devastating problem on American highways.
According to NSF, the percentage of individuals receiving less than six hours of sleep per night has steadily increased, from 12 percent in 1998 to 15 percent in 2002. At the time of the study, participants averaged 6.9 hours of sleep during weekdays and 7.5 hours on weekends. When asked if daytime sleepiness interfered with daily activities, 37 percent replied in the affirmative. Considering that people who get the least sleep include parents, males, individuals between 18 and 64, and those who work untraditional shifts, it is imperative for mobile professionals to recognize the symptoms of sleep deprivation and take steps to combat it before negative consequences result.
ETIOLOGY OF SLEEP
Historically, experts have thought sleep to be a passive state, initiated through withdrawal of sensory input. Presently, researchers believe the recession of sensory awareness is a factor in sleep. During this process, the creative part of the brain-the prefrontal cortex-shuts down. If sleep time is reduced, there is a decrease in the functioning of the prefrontal cortex, resulting in a lowered attention span and dampened critical thinking abilities. Experts consider the period of time from 2:00 to 4:00 a.m. as the highest risk. It is then when people reach the lowest point of overall activation, are likely to feel sleepy, and are most vulnerable to making mistakes.
Circadian rhythms, modulated by the hypothalamus, regulate all the major bodily functions, from temperature and hormones to heart rate. This 24-hour internal clock is linked to cycles of light and dark. Notes Alex Lukeman, PhD, author of Sleep Well, Sleep Deep, when circadian rhythms are operating without interference, individuals are in an easy and natural cycle of wakefulness and sleep, rest and activity, tiredness and alertness. If these rhythms are disturbed, persons are suddenly fatigued, facing sleeplessness and experiencing reduced mental capabilities.
STAGES OF SLEEP
Four stages of sleep exist within a cycle. In general, people undergo four or five cycles a night, with each lasting approximately 90 minutes. In stage 1, or “light sleep,” theta waves form, promoting relaxation, although individuals can be easily awakened. The percentage of total sleep time devoted to this level increases with age. Stage 2 is characterized by sleep spindles where brain waves increase in size and amplitude with bursts of electrical energy, while Stage 3 features slow-frequency delta patterns mixed with theta waves. During Stage 4, also known as “deep sleep,” theta waves disappear but delta waves remain. The most difficult time to awaken individuals, this level promotes deep relaxation with a small amount of muscle activity and reduced bodily function. As individuals age, the percentage of sleep time devoted to this stage decreases progressively.
According to Sandra Fielo, EdD, RNC, author of “The Mystery of Sleep: How Nurses Can Help the Elderly,” a typical pattern within the sleep cycle for any age group is Stages 1 through 4, followed by Stages 3, 2, and REM (rapid eye movement) sleep. Occurring about an hour after individuals initially fall asleep, REM comprises 25 percent of total sleep time and is characterized by increased brain activity, reduction in muscle activity often to the point of paralysis, and variable vital signs. Throughout the night, the length of time devoted to REM sleep increases per cycle until the final phase lasts an hour. It is during this stage that individuals experience dreams. Images appear in the mind, while respiration, heart rate, and blood pressure rise and fall in response.
Though dreaming is believed to be significant, its exact function has not been determined. Dr. Lukeman states, “Scientific thought tends to dismiss meaning and emphasize a role in memory retention and learning.” It is also difficult to determine how long an individual dream lasts, explains John Harvey, PhD, a licensed psychologist and author of Deep Sleep. For the person dreaming, time perception can be quite distorted. He says that dreams may have multiple roles, including the neurological processing of the day’s sensory experiences and learning. Michael J. Breus, PhD, ABSM, faculty member of the Atlanta School of Sleep Medicine, in Atlanta, Georgia, notes it is difficult to determine whether dreams mean anything; however, it is known that recurring dreams likely revolve around themes that are meaningful to the individuals who have them.
While senses still function during every stage of sleep, they do so at a reduced level. According to Dr. Lukeman, a recent study at Johns Hopkins University indicates there may be several different areas of the brain that monitor and evaluate sounds when we sleep, ignoring some, waking us gently for others, or throwing us into a state of adrenaline panic when danger appears. Internal warning systems, however, can be thwarted by drugs, alcohol, exhaustion, or medication.
CHARACTERISTICS AND SYMPTOMS OF SD
More than a quarter of respondents to NSF’s poll believed their quality of sleep was poor, with 15 percent of those surveyed using prescriptions or over-the-counter (OTC) drugs a few nights a month to promote sleep. This four-percent increase in sleep aid use over the past year is reflected in the rising incidence of disorders such as insomnia, sleep apnea, and restless legs syndrome. According to the 2002 poll, 74 percent of participants reported symptoms of at least one of these conditions-up from 62 percent three years ago and 69 percent in 2001.
Insomnia is the most common complaint, with nearly three-fifths acknowledging “difficulty falling asleep, waking a lot during the night, waking up too early and not being able to get back to sleep, and waking up feeling unrefreshed.” A number of conditions can exacerbate insomnia, from congestive heart failure and pulmonary disease, to hyperthyroidism and esophageal reflux, to arthritis. Considered a symptom of an underlying problem-medical, lifestyle, psychological, or environmental-insomnia is more prevalent in women than in men.
Snoring and pauses in breathing-two signs associated with sleep apnea-were experienced by 37 percent and nine percent of participants, respectively. More men reported these symptoms, although an equal amount of males and females presented with restless legs syndrome. Overall, 16 percent of respondents reported “unpleasant, tingling feelings” in their legs a few nights a week, with individuals 65 and older being affected to a greater degree.
Additional sleep disorders that may lead to nighttime awakenings are periodic limb movements-a potential indicator for diabetes, kidney disease, or anemia-and narcolepsy. Jet lag and drowsy driving are two other conditions familiar to travelers that are associated with changing sleep patterns.
According to the recent NSF study, sleep deprivation is not only cyclical in nature, but also geographical. Half of the participants from the Northeast believe they receive more than adequate amounts of sleep, as compared with 37 percent of Southerners. Over three-quarters of respondents from the South are affected by sleep disorders. Reporting the highest percentage of daytime sleepiness, these participants are more likely to use prescriptions or OTC sleep aids to achieve states of relaxation. Other interesting findings: A higher number of Western respondents snore, while those in the Midwest have the least occurrences of sleep disorders.
Regardless of the types of contributing factors that lead to SD, its symptoms are clear: difficulty getting up in the morning, a feeling of tiredness throughout the day, irritability, lack of energy, memory problems, and decreased concentration. According to the NSF research, people who sleep less than six hours per day are also more likely to be tired, sad, stressed, and/or angry. Dozing off for a minute or two in the daytime is another common characteristic. Those individuals who experience vivid dreams during short naps are prime candidates for an SD diagnosis.
In addition to reduced efficiency, sleep deprivation slows down recovery processes and impairs host defenses, increasing susceptibility to infection. It influences the potential for developing other disorders as well. In particular, losing sleep heightens the risk for type II diabetes, moodiness, and obesity.
Shift workers affected by SD experience a greater incidence of diarrhea, constipation, ulcers, and heartburn. As if this were not enough, their risk of cardiovascular disease is increased by 30 to 50 percent. Women shift workers, reports Dr. Harvey, are more vulnerable to reproductive problems, from disrupted menstruation and difficulty conceiving, to miscarriages and premature births.
HOW SD AFFECTS TRAVELERS
Dr. Harvey, who also serves as director of psychology at Allied Services Rehabilitation in Scranton, Pennsylvania, reports that more than 40 percent of Americans admit they stay up later than they should. Whether reasons revolve around work schedules, computers, television or radio, or simply the use of electric lights, one thing is clear: Sleep needs differ from individual to individual. Some claim to be fully functional on four to five hours of sleep, when others have difficulty operating on nine to ten. Since the actual number necessary to fulfill the sleep function is still unknown, it is more difficult to quantitatively measure sleep deprivation. According to current literature, SD seems to be determined best in terms of tasks impaired.
With regard to healthcare professionals, sleep deprivation has been implicated in deadly medication administration errors and decision-making processes during critical patient assessments. Studies have shown that night shift workers have the highest incidence of fatigue due to SD. Personnel working 12-hour shifts average only 6.9 hours of sleep per night. Notes Dr. Harvey, those already spending long hours in the practice setting who are called in to deal with emergencies are often sleep deprived and prone to making mistakes that may put their patients at risk. Ralph Pascualy, MD, medical director of the Swedish Sleep Medicine Institute in Seattle, Washington, adds, “Although healthcare workers usually perform well in emergencies, the danger comes with routine tasks like checking charts.”
For nurses, in particular, current research has indicated a relationship between extended shifts and generalized performance. Overtime often comes at the expense of sleep. A 1992 study, conducted by the American Journal of Public Health, found that nurses in Massachusetts who worked variable schedules (including mandated overtime shifts) were twice as likely to report an accident or error and two-and-one-half times as likely to notify supervisors of near-miss accidents.
Generalized findings from NSF’s poll can also be applied to the healthcare setting. The study demonstrated that sleep deprivation occurs in many environments, with nearly two-fifths of respondents reporting less than seven hours per weeknight and 68 percent sleeping fewer than the eight hours recommended for superior health, performance, and safety.
MODIFYING CIRCADIAN RHYTHMS
While internal biological clocks are geared to sunlight hours, with cycles signaled by light and dark, individuals can adapt to untraditional shifts. Modifying an individual’s circadian clock is possible to a certain degree, states Dr. Lukeman, but adjusting rhythms take time. The body’s clock will adapt naturally to a different time zone, for instance, but it may take days or weeks-not within the typical shift rotation change.
Classically, says Dr. Breus, professionals on untraditional shifts need to keep the same schedule even when they are not working. Dr. Harvey concurs, reflecting that nurses who work nights will fair much better if they maintain healthy lifestyles and set up regular schedules so they get adequate rest during the day. Julie Silvertooth, RN, from Harborview Medical Center in Seattle, Washington, agrees. Working nights for nine years, she has just switched to days and offers this advice: “Avoiding sleep deprivation is difficult, especially for night shift workers. Looking back on my experience, I don’t think I was every really ‘undeprived.’ However, I did find that a consistent schedule, supportive family members and friends, and a healthy lifestyle helped me adjust. Accepting less overtime can also increase sleep time and reduce the potential for illness.”
Circadian rhythms, notes Dr. Breus, may be altered through pharmacological and behavioral methods such as light therapy, exercise, melatonin, or zolpidem tartrate (Ambien), but cautions that strict regulation of medications by a sleep specialist is essential to making the changes permanent. Other drug therapies, according to Dr. Fielo, include triazolam (Halcion) or amitriptyline (Elavil) for short-term, intermittent use. These modalities must be monitored carefully and are contraindicated in individuals taking medications like diphenhydramine (Benadryl) that have anticholinergic properties.
Encouraging an environment that fosters sleep is an integral part of care plans for sleep-deprived patients and clinicians alike. To ensure proper inpatient care is provided, travelers should review diets and drug use for potential SD triggers during physical and psychosocial assessments. Additionally, professionals must inquire about physiological responses during sleep to rule out breathing pauses, leg movements, or other disorders. Information gleaned from patients and family members about recent lifestyle changes, sleep patterns, or chronic health conditions can also be beneficial in devising customized treatment regimens.
Mary Paskow, RNC, employed at Overlook Hospital in Summit, New Jersey, offers a number of suggestions on how nurses can help patients avoid SD by making their environments more conducive to sleep. For example, professionals in acute care settings can strive to decrease noise, control lights, encourage visitors to leave on time, and assist with necessary routine evening care. By taking vital signs early in the shift, nurses can ensure patients receive uninterrupted sleep.
Other expert recommendations that may also be applied to healthcare professionals include setting routine schedules for sleeping and waking, and keeping nap times short, or avoiding them altogether. For every age group, naps longer than 20 minutes may disrupt nocturnal sleep patterns and promote increased grogginess. Making sure sleeping areas are dark, cool, and quiet are other suggestions. Eliminating smoking, avoiding heavy meals and alcohol in the evening, and limiting caffeine-in foods, drinks, and medication-at least four hours before retiring are behavioral changes that can improve sleep habits as well. Substituting herbal teas and implementing exercise regimens or relaxation techniques are additional successful approaches.
Perhaps the most important consideration for travelers is the choice of work schedules. Mobile clinicians have the greatest opportunity to exercise control in their careers, opting for specific days of the week and shift preferences. Given that the majority of traveling professionals work nights, insiders suggest scheduling no more than four such 12-hour shifts in a row, while maintaining the same sleep/wake routines seven days a week. To increase their ability to adjust effectively, travelers should not select schedules that combine day and night shifts.
WHAT THE FUTURE HOLDS
Several research studies and clinical trials are underway to examine the neurological effects of sleep deprivation. Specific studies for sleep disorders and independent research into insomnia and restless legs syndrome are ongoing. Visit www.centerwatch.org or www.sleepfoundation.org/clinicaltrials/trialresource.html to discover several trials nationwide evaluating the impact of night and rotating shift work – many of which are currently accepting applications for participation.
BECOMING AN ADVOCATE
It is estimated that upwards of $150 billion is spent annually on lost productivity, fatalities, and lawsuits resulting from the effects of sleep deprivation. Although there has been public outcry regarding the levels of fatigue that contributed to recent disasters, including Exxon Valdez, Chernobyl, Three Mile Island, and Challenger, the majority of people in this country are still not fully aware of the condition’s magnitude-or its potential implications.
The National Commission on Sleep Disorders Research offers six recommendations to address this public health threat, including establishing a national center to coordinate education and research and strengthening ongoing programs. Other guidelines mandate creating sleep disorder offices within all federal agencies and making them accountable for coordination efforts, while enhancing training and career development for sleep investigators. In particular, the commission advocates educating healthcare professionals-most notably at the primary care level-about sleep disorders and SD, as well as implementing campaigns to improve public awareness.
Travelers have the responsibility to educate coworkers, patients and their families, and members of their new communities on the seriousness of sleep deprivation. By detailing the potential consequences to patient care and quality standards, as well as the increased likelihood of hazards outside the work environment, clinicians can promote solutions that improve sleep patterns and encourage individuals to devote more time to rest. Just as important, they have the opportunity to proactively improve their own sleep patterns, adopt a healthy lifestyle, and, in turn, enhance their professional practice.