Sleep quality

Sleep loss and decreased quality of sleep is another effect of shift work. To promote a healthy lifestyle, the American Academy of Sleep Medicine recommended that an adult have 7 or more hours of sleep per day.^[10] Each year, there are almost 100,000 deaths estimated in the U.S. because of medical errors.^[10] Sleep deprivation and sleep disorders are factors that contribute significantly to these errors.^[10] In the same article, the authors affirm that there is a high prevalence of sleepiness and symptoms of sleep disorders related to the circadian system in medical center nurses.^[10] In a study done with around 1100 nurses, almost half of them (49%) reported sleeping less than 7 hours per day, a significant increase compared to national figures, in which 28% of people claimed to sleep less than 7 hours per night.^[11] Having a lack of sleep can impact cognitive performance.^[1] For example, it might become difficult to stay focused and concentrate, and reaction times might also be slowed down.^[12][1] SWSD might interfere with making decisions quickly, driving, or flying safely.^[1] Sleep loss seen in shift workers greatly impairs cognitive performance, being awake for 24 hrs. straight results in a cognitive performance that is equal to a blood-alcohol of 0.10, which is over the legal limit in most states.^[6] All of these factors can affect work efficiency and cause accidents. Michael Lee et al. demonstrated that those working night shifts had a significantly higher risk of hazardous driving events when compared to those on a typical day shift schedule.^[13] Accidents in the workplace have been found to be 60% higher in shift workers.^[6] They can affect the individual's social life and cause a lack of well-being and happiness.^[1] Poor sleep quality has also been associated with decreased quality of life, based on a SF-36 assessment.^[14]

Sleep and alertness

Although SWD affects many shift workers, its manifestation is still unclear within the general shift-working population.^[15] A field study investigating the nature of SWD in an experimental (with SWD) and control (non-SWD) group of Finnish shift workers revealed decreased total sleep time (TST) and increased sleep deficit before morning shifts.^[15] Furthermore, the SWD group also exhibited decreased objective sleep efficiency, decrease in sleep compensation over the free days, increased sleep latency, and finally poorer sleep quality was recorded in the SWD group compared to the non-SWD group.^[15] Moreover, shift workers with SWD scored significantly higher on the Karolinska Sleepiness Scale (KSS) when assessed at the beginning and the end of morning shifts and at the end of night shifts, while having more attentional lapses at the beginning of night shifts.^[15]

Many studies have shown evidence of how partial and total sleep deprivation affects work productivity, absenteeism, fatal workplace accidents, and more.^[16][17] In a study by Akkerstedt et al., those who had a hard time sleeping in the past two weeks were at a greater risk for having a fatal workplace accident (RR=1.89, 95% CI 1.22–2.94).^[18] Other sleep disorders, like OSA which are risk factors for SWSD, have also been associated with low productivity, absenteeism, and accidents.^[19] At a cognitive level, sleep deprivation has been shown to cause decreased attentiveness, increased micro-sleeps, delayed psychomotor response, performance deterioration, neglect of activities, decline in working memory, and more.^[17]

Immune functioning

Partial and total sleep deprivation has been linked to an increase of pro-inflammatory markers,^[20] such as IL-6,^[21] and a decrease in anti-inflammatory markers, such as IL-10, that plays a role in tumor suppression.^[22] Chronic shift work has been associated with decreased immune function in nurses. In a study by Naigi, et al., over the course of a shift, nurses exhibited decreasing levels of Natural Killer cells, an innate immune response that plays a role in infectious disease and tumor suppression.^[23] Other researchers have found that less sleep at night increased the risk of developing the common cold.^[24] A supporting study by Moher et al. showed that shift workers were more likely to develop infectious diseases after exposure compared to daytime workers.^[25] A poorly functioning immune system may leave workers vulnerable for developing occupational illnesses. Sleep loss is also associated with an increase in TNF, a marker of systemic immune functioning.^[26]

Cardiovascular disease

Decreased sleep quality and duration have also been associated with other chronic illnesses, such as cardiovascular disease. Many studies have shown that prolonged sleeplessness and sleep disorders, such as OSA, increases systemic levels of CRP, a marker of cardiovascular disease.^[20] Many studies have shown that lack of sleep causes blood pressure to increase from the prolonged stimulation of the nervous system.^[26] The increase of inflammatory markers, like IL-6, up-regulate the production of CRP.^[26]

Cognitive Impact

Shift work sleep disorder affects many individuals, especially those within the medical field. Research done by The Journal Of Sleep Research^[35] examine the difference in cognitive function using sleep-deprived and well-rested nurses using autobiographical memory skills. The participants underwent the autobiographical memory test, as well as anxiety and depression inventories. The researchers found that a sleep-deprived group of individuals scored significantly higher in the depression score and remembered more negative than positive memories. The sleep-deprived group also scored significantly lower than the well-rested group in autobiographical memory and specific memories. This study is similar to the one done by the National Center for Biotechnology Information,^[36] which found that their hypothesis of sleep deprivation and the cognitive impact it has on nurses was strongly supported in 69% of shift workers. The impairment in cognitive performance, such as general intellect, reaction time, and memory, was statistically significant among the staff nurses due to poor sleep quality and decreased alertness while awake.

Patient Care

Shift work sleep disorder affects patient care within all aspects of the medical field. Research published in European Review for Medical and Pharmacological Sciences^[37] analyzed the correlation between the clinical risk management and the occurrence of medication errors and the effects of the shift work on inpatient nurses. The researchers reviewed 19 out of 217 research articles and focused on the impact of workload, shifts and sleep deprivation on the probability of making medication errors. They found that the main reason behind medication errors are stress, fatigue, increased workload, night shifts, nurse staffing ratio and workflow interruptions.

Circadian misalignment

Circadian misalignment plays a major role in shift work sleep disorder. Circadian misalignment occurs when there is no complete adaptation to a night shift schedule.^[39] The hormones cortisol and melatonin are an important part of the circadian rhythm.^[39] In circadian misalignment, cortisol and melatonin lack entrainment to a night oriented schedule and stay on a daytime schedule.^[39] Melatonin continues to peak at night during a shift workers awake time and decreases during a shift workers sleep time.^[39] Cortisol levels are lower during a shift workers awake time and remain higher during shift workers sleep time.^[39]

Assessments

There are different tools to assess shift work disorder.^[33] Patients can keep a diary.^[33] Some questionnaires could be useful as the Morningness-Eveningness Questionnaire.^[33] Actigraphy and polysomnography could indicate some interesting patterns.^[33] Further studies are needed to see if some phase markers as the body temperature rhythm or the melatonin rhythm are efficient to assess shift work disorder.^[33] Decreased sleep quality may be assessed using the Pittsburg Sleep Quality Index (PQSI).^[19]

Prescribed sleep/wake scheduling

Experts agree that there is no such thing as an "ideal" night work schedule, but some schedules may be better than others. For example, rotating shifts every two weeks in a forward (delaying) direction was found to be easier than rotation in a backward (advancing) direction.^[43] Gradual delays ("nudging" the circadian system about an hour per day) has been shown in a laboratory setting to maintain synchrony between sleep and the endogenous circadian rhythms,^[44] but this schedule is impractical for most real world settings. Some experts have advocated short runs (1 to 2 days) of night work with time for recovery; however, in the traditional heavy industries, longer (5 to 7 day) runs remain the rule. In the end, scheduling decisions usually involve maximizing leisure time, fairness in labor relations, etc. rather than chronobiological considerations. Shift workers can benefit from adhering to sleep hygiene practices related to sleep/wake scheduling.^[12] Symptoms typically only fully resolve once a normal sleep schedule is resumed.^[40]

Many night workers take naps during their breaks, and in some industries, planned napping at work (with facilities provided) is beginning to be accepted. A nap before starting a night shift is a logical prophylactic measure. However, naps that are too long (over 30 minutes) may generate sleep inertia, a groggy feeling after awakening that can impair performance. Therefore, brief naps (10 to 30 minutes) are preferred to longer naps (over 30 minutes). Also, long naps may interfere with the main sleep period.^[45]

In the transportation industry, safety is a major concern, and mandated hours of service rules attempt to enforce rest times.

Bright light treatment

The light-dark cycle is the most important environmental time cue for entraining circadian rhythms of most species, including humans, and bright artificial light exposure has been developed as a method to improve circadian adaptation in night workers. The timing of bright light exposure is critical for its phase shifting effects. To maximize a delay of the body clock, bright light exposure should occur in the evening or first part of the night, and bright light should be avoided in the morning. Wearing dark goggles^[46] (avoiding bright light) or blue-blocking goggles during the morning commute home from work can improve circadian adaptation. For workers who want to use bright light therapy, appropriate fixtures of the type used to treat winter depression are readily available^[47] but patients need to be educated regarding their appropriate use, especially the issue of timing. Bright light treatment is not recommended for patients with light sensitivity or ocular disease.

Melatonin treatment

Melatonin is a hormone secreted by the pineal gland in darkness, normally at night. Its production is suppressed by light exposure,^[48] principally blue light around 460 to 480 nm. Light restriction, or dark therapy, in the hours before bedtime allows its production. Dark therapy does not require total darkness. Amber or orange colored goggles eliminate blue light to the eyes while allowing vision.

Melatonin is also available as an oral supplement. In the US and Canada, the hormone melatonin is not classified as a drug; it is sold as a dietary supplement. In other countries, it requires a prescription or is unavailable. Although it is not licensed by the FDA as a treatment for any disorder, there have been no serious side effects or complications reported to date.

Melatonin has been shown to accelerate the adaptation of the circadian system to a nighttime work schedule.^[49] Melatonin may benefit daytime sleep in night workers by an additional direct sleep promoting mechanism. Melatonin treatment may increase sleep length during both daytime and nighttime sleep in night shift workers.^[28]

Medications that promote alertness

Caffeine is the most widely used alerting drug in the world and has been shown to improve alertness in simulated night work.^[50] Caffeine and naps before a night shift reduces sleepiness during the shift.^[28] Night shift medical field workers report the highest activity, along with the least amount of sleep. These individuals require medication/power naps to function at their best.^[51] Modafinil and armodafinil are non-amphetamine alerting drugs originally developed for the treatment of narcolepsy that have been approved by the FDA (the US Food and Drug Administration) for excessive sleepiness associated with SWSD.^[52]

Medications that promote daytime sleep

Obtaining enough sleep during the day is a major problem for many night workers. Hypnotics given in the morning can lengthen daytime sleep; however, some studies have shown that nighttime sleepiness may be unaffected.^[53] Zopiclone has been shown to be ineffective in increasing sleep in shift workers.^[28]