Feeling sleepy? Increasing evidence that sleep should be a health and safety priority

Feeling sleepy? Increasing evidence that sleep should be a health and safety priority Jillian Dorrian, School of Psychology, Social Work and Social Policy

Sleep, circadian rhythms and shiftwork The cost of sleep loss and fatigue in industry Healthcare and error Compensating for shiftwork Any good news?

Sleep • Sleep is a symptom of caffeine deprivation • ~Author unknown • The amount of sleep required by the average person is five minutes more. • ~Wilson Mizener

Impairment adds up across a week – even getting a bit less sleep than usual Belenky et al., (2003) JSR

Impairment really adds up across 2 weeks – 2 weeks of 6h is as bad as 2 full nights awake 4h 2 nights 1 night 6h 8h Van Dongen et al., (2003) Sleep

Circadian Rhythms I work at night I see today with a newsprint fray My night is colored headache grey Don't wake me with so much ~REM, Daysleeper

Consequences of Sleep Loss and Circadian Disruption • Impaired hand-eye coordination • Slower response time • Lowered visual discrimination • Reduced alertness • Increased error rates • Reduced logical reasoning • Short-term memory problems • Reduced concentration • Frustration and irritability • Impaired decision making • Injuries and accidents • The effects are measurable and meaningful

Injury and accident risk is affected by shift type and number of successive shifts – even day shifts! also affected by time on shift and time since last break Folkard & Tucker., (2003). Occup. Med.

Work-related fatigue is common, even in industry with relatively well-developed fatigue management • Rail industry employees • N=90, shifts=713 • THRESHOLDS • <5h sleep in 24h prior to work • <12h sleep in 48h prior to work • >10h work in a shift • >16h of wakefulness • Fatigue rating of “extremely tired” • or “completely exhausted” • 45% of shifts crossed at least one threshold Percentage of shifts with 1, 2, 3, 4 or 5 threshold crosses Dorrian et al., (2011). Applied Ergonomics

Fatigued train drivers use more fuel and don’t control their speed as effectively representing: $3512 weekly $182,655 yearly Just for this section of the corridor! Why? –late and heavy braking leads to increased speed variability, which results in reduced driving efficiency and safety Dorrian et al., (2007). J Sleep Res

The link between sleep loss and error is receiving increasing international attention • Healthcare workforce critical shortfall • As in the US, adverse events in Australian Healthcare have come under recent scrutiny • Relationship between work hours, attentional failures and medical errors in doctors (Lockley et al., 2004; Landrigan et al., 2004) • Relationship between work hours and medical error in nursing (Rogers et al., 2006)

US nursing error probability increases with increasing time awake, and decreasing hours of prior sleep Data from Rogers, al., (2004). Health Affairs

Australian nurses reported a variety of errors and near errors, including those made by others Dorrian et al., (2006). Chronobiology International

Less sleep leads to: (1) increased likelihood of error, (2) reduced likelihood of catching someone else’s Dorrian et al., (2006). Chronobiology International

Nurses frequently reported moderate to high levels of stress and exhaustion • Moderate to high levels of stress, physical, and mental exhaustion on 30-40% of shifts. • Nurses reported trouble sleeping on 30% of work days compared to 20% of days off. • Struggling to remain awake (STR) was reported on one in three workdays • Stress and exhaustion were significantly higher, and sleep duration was significantly lower on work days compared to days off (p<0.01) Dorrian et al., (2008), Applied Ergonomics

Sleep loss, exhaustion, work hours and struggling to remain awake (STR) contribute to error • Evidence for a relationship between reduced sleep, work hours, exhaustion, struggling to remain awake at work, stress and errors • Errors were predicted by STR and stress • STR was predicted by exhaustion, sleep and shift length Dorrian et al., (2008), Applied Ergonomics

Less sleep on night and morning shifts, more drowsy driving following night shifts • Evidence for a relationship between reduced sleep, work hours, exhaustion, struggling to remain awake at work and drowsy driving • Drowsy driving was predicted by STR, exhaustion and number of consecutive shifts Dorrian et al., (2008), Applied Ergonomics

Fatigue is a problem, participants report inadequate sleep & an effect of work hours on sleep I get as much sleep as I need The amount of sleep I get is directly related to the hours I work 88% of people disagree or strongly disagree 70% of people agree or strongly agree 10% of people disagree I think that fatigue is a problem in my workplace Ferguson et al., (2005), SQC Report

The majority have experience of fatigue-related incident/accident Have you been involved in a fatigue-related accident (or near miss) at work, or know of someone that has? If yes, how often does this type of event occur? Potentially serious or fatal consequences were reported for 40% of incidents

Fatigue-related issues that impacted adversely on patient safety, were commonly reported • “Patient care is directly affected by level of fatigue in care-givers.” • “…I was standing by the bed of a patient and almost fell on them when I went to sleep.” • “During training I fell asleep in the OR waiting for a biopsy” • “Death of a baby that was supposed to be fasting. I gave permission for the mother to feed…”

incidents/accidents occurred on night shift or on the drive home • 18% of fatigue-related incidents occurred on nightshift • “both on 3rd night duty, medication error, mathematics wrongly calculated” • “…a man died through bleeding because a senior doctor wouldn't come in at night” • A further 17% occurred while driving home • “…driving home after night shift, fell asleep at the wheel. Hit 2 pedestrians…pedestrians seriously injured” • “Driving home after a night shift and woke drifting onto other side of road.” • “fell asleep at wheel, overturned car, ended up with head injury /concussion” N=75

Long shifts, back-to-back work and time pressure were reported as issues • Long work hours • “24-hour shifts, totally buggered” • “Had been on deck for 36 hours straight” • “Doing the list after being on duty in emergency situation all night” • Time pressure, rushing • “Death in transit from peripheral to tertiary facility. ED dr asked to make decision on 15-min knowledge of 5/7 admission at 0400 of 2nd consecutive night shift.” • “Lots of pressure with emergencies and theatre was stacked” • “Poor communication as tired and rushed” N=75

Under-staffing was also frequently raised in explanations • “…staff member should have gone home, but that would have left inadequate staff to look after the patients. Therefore all the patients were put at risk” • Inadequate numbers of nursing staff, ward staffed for routine night duty not assist at a theatre procedure.” • “Two patients involved in a motorbike accident, head-on collision. Needed emergency treatment. 2pm Sunday treated both patients til 5-6am. Elective operating list beginning at 8am in private hospital - only surgeon of this type. Cannot remember what happened during the list.” • “…What’s worse a tired doctor or no doctor???” N=75

Informal team-based strategies were used to compensate for fatigue • Team-based strategies: • defer decisions until later or to someone else • double checks by self or someone else • advise someone that you are feeling tired • acknowledge the issue, increase communication • Some teams acknowledge fatigue, others do not: • “Probably the most important workplace issue at present.” • “Depends entirely on the team, some do better job of managing it than others.” • “People don’t recognise fatigue as a reason.” • “Don’t really talk about sleep with colleagues. People often fall asleep in the talks and meetings that we have.” Ferguson et al., (2005), SQC Report

Shiftwork Shiftwork is probably bad for the heart, almost certainly bad for the head and definitely bad for the gut ~Monk and Folkard, 1992

Shiftwork-related circadian disruption and sleep loss may lead to… Behavioural & social mechanisms Convenience or comfort eating Reduced exercise Increased consumption of caffeine, alcohol, and nicotine Disrupted family & social relationships Health effects Light exposure at night influencing hormones Eating at biologically inappropriate times Changes in appetite hormones Changes in glucose metabolism Physiological mechanisms

Caffeine to cope with reduced sleep at work • Reduced sleep and being at work was associated with increased caffeine intake Dorrian et al., (2011). Revista de Saude Publica, In press

Sleep aids to cope with stress at work • Sleep aid use reported by approx 60%, with 20% using prescription meds at least once during study • Using alcohol as a sleep aid at least once during the study was reported by 44% of nurses and 9% of midwives • Evidence for a relationship between being at work, stress levels and sleep aid use Dorrian et al., (2011). Revista de Saude Publica, In press

Is it all bad news? • Sleepiness, stress and exhaustion are common • There is evidence that this is linked to reduced efficiency and increased likelihood of error and drowsy driving • Circadian influences and workload may be important in this relationship • There is also evidence that compensatory behaviours are used to deal with sleep loss, particularly at work, and also with stress • Shiftworker health may be negatively influenced via social/behavioural and physiological mechanisms

Less sleep leads to: (1) increased likelihood of error, (2) reduced likelihood of catching someone else’s Dorrian et al., (2006). Chronobiology International

Those who have more sleep look out for others Dorrian et al., (2006). Chronobiology International

Those who have more sleep look out for others • In teams (2 or more) • Increased communication • Double-checking • Transfer to less safety critical duties • Cover for each other to allow naps/extended rest breaks • Individuals • Speed/accuracy trade-off • Efficiency/safety trade off • Open communication about fatigue, acknowledging it as an issue

Those who have more sleep look out for others • People generally look out for and help each other, particularly in workplaces where the discussion of fatigue is open and encouraged • Not just fatigue-reduction, but fatigue-proofing • Currently, most fatigue proofing strategies are informal • Investigating these informal strategies will allow those that are successful to be shared, and even made part of formal practice • It’s important to note that teamwork is also likely to be influenced by fatigue and error profiles can change • But, there’s no team to help during a drive home from night shift alone in a car…

Current directions • We know that shiftwork can cause problems for performance and safety • The focus now is really on how best to cope with it as individuals and as teams • The researchers are currently working on: • Identifying informal fatigue management strategies • Error profiles and fatigue • Teamwork and fatigue • Compensatory strategies for dealing with shiftwork • Shiftwork and health

Acknowledgements J Dorrian, S Ferguson, J Paterson, D Dawson, N Lamond, S Baulk, Frank Hussey: Centre for Sleep Research, School of Psychology, Social Work and Social Policy, UniSA J Pincombe, C Grech: School of Nursing and Midwifery, UniSA C van den Heuvel: Paediatrics, Women’s and Children’s Hospital AE Rogers: University of Pennsylvania School of Nursing

Feeling sleepy? Increasing evidence that sleep should be a health and safety priority