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Too many hours, too little sleep

by Mary Duffy

There’s a lot of talk these days  about how detrimental it is for hospital patients to have their sleep interrupted.

Given all we know about the health ramifications of short-changing sleep, it’s a topic that deserves discussion. But there’s another sleep issue with implications for patient welfare that’s not getting nearly enough attention, says sleep expert Ann E. Rogers, PhD, RN, FAAN. That’s nurse fatigue. Rogers, the Edith F. Honeycutt Chair in Nursing at Emory University’s Nell Hodgson Woodruff School of Nursing in Atlanta, says it’s a critically important issue because it affects the health and safety of nurses, their patients and the public.

The long hours (75 percent of nurses work a 12-hour shift), the rotating shifts, the propensity to work through breaks and the stress of the job create the perfect storm for sleep deficiency in nurses, says Rogers.

“Our studies show that nurses devote half their free hours sleeping. In other words, if you have 12 hours free between shifts, you sleep about six hours.” But who has 12 hours free between shifts? On average, nurses put in an extra 50 minutes after their shift officially ends, so the hours on duty are much closer to 13. Tack on the commute time (on average, about 25 minutes each way), do the math and you’ll find there’s not a lot of time left over for shut-eye. In fact, using Rogers’ formula, that leaves about 10½ hours of free time after a 12-hour shift, and that means well under six hours of sleep. Not enough when seven to nine is the recommended amount. On top of that, “Sleep loss is cumulative,” explains Rogers. “So nurses who work 12-hour shifts on consecutive days and are sleep deprived become more and more affected cognitively.”

On the face of it, the sensible solution would seem to be a return to the eight-hour shift, but as Rogers explains, that’s not likely to happen.

“Nurses like the 12-hour shift, and while they don’t like mandatory overtime, they don’t want any restrictions on their ability to work overtime.” One study showed that 80 percent of nurses are happy with current scheduling policies. Results from the same study, however, showed that levels of job dissatisfaction and burnout increase with an increase in the shift hours.

While the evidence clearly points out that the extended hours nurses work pose a threat to patient safety and to their own health, there are ways to mitigate some of those effects.

Most importantly, says Rogers, recognize your own limitations, make sleep a priority and don’t accept an extra shift when you should be catching up on sleep.


Safety Last?

It’s been more than a dozen years since Ann E. Rogers’ landmark study—The Working Hours of Hospital Staff Nurses and Patient Safety—found that nurses who work more than 12½ hours at a stretch are three times more likely to make a patient care error than those who work eight hours. A few years after its publication, the Institutes of Medicine sounded the alarm about the correlation between nurses’ extended hours and insufficient sleep, and the subsequent threat to patient safety.

In 2011, The Joint Commission issued a “Sentinel Event Alert” (reserved for “events [that] signal the need for immediate investigation and response”). Both organizations made evidence-based recommendations, but nothing has changed. There are no limits to the number of hours nurses can work, and no institutionalized fatigue risk-management systems in place. Now, the American Nurses Association (ANA) has convened an expert panel (which includes Rogers) to address the issue. “It usually takes 10 to 15 years after the research for change to be implemented, and we are there now,” says Rogers, who’s hopeful that the guidelines the ANA develops will ignite action.


Why a Good Night’s Sleep Is a Necessity, Not a Luxury

All systems no-go: Sleep plays a pivotal role in keeping your endocrine, metabolic and immune systems functioning properly. Deep sleep triggers the release of growth hormone, which in adults helps repair cells and tissues and boosts muscle mass.

Starved for sleep: Our bodies go into starvation mode when sleep deprived. So glucose—the fuel we run on—gets diverted away from your energy-hogging prefrontal cortex, and you start storing fat and craving sugary food. Oh, and since the executive function isn’t running at full speed, your self-control fades and your emotional reactivity is heightened. (One study even found that people who cheat sleep are more likely to act unethically at work.)

On the face of it: New studies show that cheating sleep can affect your skin (and not in a good way) and shorten telomeres—in other words, it ages you. Studies also find that short sleepers are more likely to be sedentary, to smoke and to drink to excess.


Taking Care on a 12-Hour Shift

When duty calls for an extended shift, play it safe by following these tips:

Ration your coffee. Caffeine should be on a PRN basis, especially if you work the night shift. By caffeinating yourself judiciously, says Rogers, you’ll be getting maximum effect when you need it most—those times when you’re dragging at work. And you should close the coffee bar at least four hours before you go to sleep.

Prioritize your duties. When possible, restrict the cognitive heavy lifting to those hours when you’re wide-awake—the first few hours on shift. If the action slows down just as you’re slowing down, don’t let yourself fall asleep (unless, of course, you’re allowed to nap during breaks). Get up, have a snack, stay where it’s brightly lit.

Take your breaks. A recent University of Pennsylvania study shows that nurses often work through lunch. Anecdotal evidence suggests they are reluctant to take breaks because it would impose on colleagues who’d have to cover, says Rogers. Other studies have shown that working 12 hours without a break, even when you’ve gotten adequate sleep, can affect your cognitive skills.

Curtail consecutive shifts. Limit the number of consecutive days of an extended shift to two or three at the most, suggests Rogers.

Leave on time. To combat sleep deprivation, Rogers and other experts advise limiting work to 12 hours per 24-hour period. If the culture at your hospital or unit makes that impossible, then work to change the culture.


The Side Effects of Insufficient Sleep

10 That Can Affect Your Health

Lack of sleep can put you at higher risk for:

  • hypertension
  • stroke
  • cardiovascular disease
  • diabetes
  • obesity
  • muscular skeletal injuries
  • needle sticks
  • depression
  • increased pain
  • auto accidents


10 That Can Also Affect Patient Care

The Joint Commission outlined these as patient-safety factors:

  • inability to stay focused
  • reduced motivation
  • compromised problem solving
  • confusion
  • irritability
  • memory lapses
  • impaired communication
  • impaired information processing and judgment
  • diminished reaction time
  • indifference and loss of empathy


Plan for a Good Night’s Sleep

Here are 10 simple steps to help you get more ZZZs:

  1. Sync up with your circadian clock. Daylight is key to regulating sleep patterns. Expose yourself to natural light each morning.
  2. Get some exercise. In one study, people who said they worked out vigorously also reported they slept better. Another study of 155,000 adults indicated that any exercise is good for your sleep. Those who reported walking, gardening, golfing or doing any exercise within the previous month were one third less likely to report problems sleeping, and half as likely to report daytime sleepiness. Research indicates that exercise might also help relieve sleep apnea.
  3. Make sleep a priority. The wash, those bills, this week’s Homeland—none are more important than your sleep. Period.
  4. Lights out. Since light cues the body to stay awake, make your bedroom as dark as possible. (Blackout shades or an eye mask, anyone?) Sleep experts also recommend banishing the television, tablet, computer, phone and anything with LED lighting from the room. In fact, your bedroom should be reserved for two activities—sleep and sex.
  5. Keep it cool. Your bedroom should be cool but comfortable, dark and quiet.
  6. Go for comfort. Indulge with luxurious linens, cozy PJs, a comfy mattress (if it’s sagging in the middle, it’s time for a new one) and pillows that offer support.
  7. Establish a ritual. Just as children settle down to sleep with a bedtime story, adult bodies also respond to cues. To condition your body to become sleepy, establish a relaxing nighttime routine, one that starts 30 to 60 minutes before you head to bed. It doesn’t matter what it is—as long as it’s not stimulating. An hour before bedtime, shut down the computer, turn on the soothing music, take a warm bath, sit in candlelight, have sex, do whatever it is that will help you relax. Avoid bright light and stress-inducing thoughts.
  8. Set a bedtime. And a wake time. Your body likes consistency.
  9. Lay off the stimulants. For at least four hours before bedtime, institute a prohibition on caffeine (even if you can fall asleep after a double espresso, caffeine can affect melatonin production and the quality of your sleep).  Also, while alcohol may make you fall asleep, it has a stimulant affect after your blood alcohol level drops, so it can disrupt your sleep.
  10. Surrender to sleep. That means letting go, not worrying about anything. Attitude counts. If you go to bed believing you’ll fall asleep, you’ll have a better chance of quickly nodding off.

“Nurses who work more than 12½ hours at a stretch are three times more likely to make a patient care error.”


Under the Influence

You wouldn’t think of going to work tipsy, would you? Well, from a neurobehavioral standpoint, being awake for 17 consecutive hours is like having a blood alcohol level of 0.05—the legal limit for driving in many countries. Awake for 24 hours? That’s similar to someone with a blood alcohol level of 0.10 (grounds for arrest for a DUI in the United States.). Drowsy driving is second only to drunk driving as a cause of car accidents in the U.S. “Unfortunately we don’t have a breathalyzer for sleepiness,” says Ann E. Rogers, the Edith F. Honeycutt Chair in Nursing at Emory University’s Nell Hodgson Woodruff School of Nursing.

Did you know? The National Highway Traffic Safety Administration estimates that 1,550 fatalities and 40,000 nonfatal injuries per year are caused by drivers who’ve had too little sleep.


What About the Night Shift?

The human body was built to be awake during the day and asleep at night. You pay a price when you try to fool Mother Nature with a counterclockwise approach to your circadian rhythms. A slew of studies indicate that working the night shift is hazardous to our health. Besides the side effects that are part and parcel of short-changing sleep, shift workers also may be at higher risk for some kinds of cancer. All the more reason to be vigilant about sleep.


Not Just Nurses

The Centers for Disease Control and Prevention has labeled insufficient sleep a public health epidemic. An estimated 50 to 70 million Americans have chronic sleep difficulties, and nearly 30 percent of adults get less than six hours of sleep a night, according to surveys.

 

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