Feeling sleepy? Increasing evidence that sleep should be a health and safety priority Jillian...
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Transcript of Feeling sleepy? Increasing evidence that sleep should be a health and safety priority Jillian...
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, 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
PVT Reaction Time
Belenky et al (2003)
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
8h
6h
4h2 nights
1 night
Van Dongen et al., (2003) Sleep
Circadian Rhythms
I work at nightI see today with a newsprint frayMy night is colored headache greyDon'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
Sleep, circadian rhythms and shiftwork
The cost of sleep loss and fatigue in industry
Healthcare and error
Compensating for shiftwork
Any good news?
Injury and accident risk is affected by shift type and number of successive shifts – even day shifts!
Folkard & Tucker., (2003). Occup. Med.
Relative RiskShift Type
0.8
0.9
1
1.1
1.2
1.3
1.4
morning afternoon night
Shift Type
Rel
ativ
e R
isk
Relative RiskSuccessive Night Shifts
0.8
0.9
1
1.1
1.2
1.3
1.4
first second third fourth
Successive Nights
Rel
ativ
e R
isk
s
Relative RiskSuccessive Day Shifts
0.8
0.9
1
1.1
1.2
first second third fourth
Successive Days
Rel
ativ
e R
isk
also affected by time on shift and time since last break
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”
•Rail industry employees
•N=90, shifts=713
Work-related fatigue is common, even in industry with relatively well-developed fatigue management
Dorrian et al., (2011). Applied Ergonomics
Percentage of shifts with 1, 2, 3, 4 or 5 threshold crosses
•45% of shifts crossed at least one threshold
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
Sleep, circadian rhythms and shiftwork
The cost of sleep loss and fatigue in industry
Healthcare and error
Compensating for shiftwork
Any good news?
• 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)
The link between sleep loss and error is receiving increasing international attention
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
“while checking infusions, discovered heparin dose wrong”
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
• 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
Sleep loss, exhaustion, work hours and struggling to remain awake (STR) contribute to error
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
88% of people disagree or strongly disagree
S Agree=0
Agree
Neutral
Disagree
S Disagree
S Agree
Agree
Neutral
Disagree
S Disagree
S Agree
Agree
Neutral
Disagree
S Disagree=0
I get as much sleep as I need The amount of sleep I get is directly related to the hours I work70% of people agree or strongly agree
I think that fatigue is a problem in my workplace
10% of people disagree
Ferguson et al., (2005), SQC Report
The majority have experience of fatigue-related incident/accident
Potentially serious or fatal consequences were reported for 40% of incidents
YES
NO
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?
OFTEN
SOMETIMES
RARELY
• “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…”
Fatigue-related issues that impacted adversely on patient safety, were commonly reported
• 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”
incidents/accidents occurred on night shift or on the drive home
N=75
Long shifts, back-to-back work and time pressure were reported as issues
N=75
• 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”
• “…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???”
Under-staffing was also frequently raised in explanations
N=75
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.”
Informal team-based strategies were used to compensate for fatigue
Ferguson et al., (2005), SQC Report
Sleep, circadian rhythms and shiftwork
The cost of sleep loss and fatigue in industry
Healthcare and error
Compensating for shiftwork
Any good news?
Shiftwork is probably bad for the heart, almost certainly bad for the head and definitely bad for the gut ~Monk and Folkard, 1992
Shiftwork
Health effectsEating at biologically inappropriate times
Convenience or comfort eating
Disrupted family & social relationships
Shiftwork-related circadian disruption and sleep loss may lead to…
Changes in appetite hormones
Increased consumption of caffeine, alcohol, and nicotine
Changes in glucose metabolism
Light exposure at night influencing hormones
Reduced exercise
Behavioural & social mechanisms
Physiological mechanisms
Dorrian et al., (2011). Revista de Saude Publica, In press
Caffeine to cope with reduced sleep at work
• Reduced sleep and being at work was associated with increased caffeine intake
• 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
Sleep aids to cope with stress at work
Dorrian et al., (2011). Revista de Saude Publica, In press
Sleep, circadian rhythms and shiftwork
The cost of sleep loss and fatigue in industry
Healthcare and error
Compensating for shiftwork
Any good 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
Is it all bad news?
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
• 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…
Those who have more sleep look out for others
• 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
Current directions
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
Acknowledgements