Sleep in a 24/7 World

Hospitals are a 24/7 operation and shift work is a critical part of that service. Dr Maree Barnes, Sleep Physician and President of the Australasian Sleep Association has extensive clinical experience with sleep disturbance and shares her insights into how shift work can be sustainable in the hospital setting.

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There is a lot of sleep disturbance that occurs in hospitals with nurses and interns commonly on shifts that run from 8 to 10 hours.
There has been recognition recently about the problems with sleep deprivation on medical staff in terms of error making and poor patient outcomes so that many hospitals have changed the way they roster their junior doctors to allow more recovery time between shifts and less sleep deprivation.
For nurses, the main issue is the necessity of wards to be managed 24 hours a day so someone has to work mornings, afternoons and during the night. Shifts need to be managed well to ensure the delivery of excellent patient care and to minimise the impact on the health and wellbeing of the nursing staff.
There are ways of doing this and certainly in my experience, hospitals are very open to rostering appropriately and modifying the working environment to ensure that nurses are as well supported as they can be. Over the past ten years there have been great advances in our understanding of the importance of sleep and hospitals are using better rostering practices to improve staff performance and wellbeing.
Shift work is a challenge for everybody.
Research on the impacts of poor sleep on junior medical staff shows that they are more prone to having road traffic accidents on their way home from a night shift. It also shows that poor sleep is responsible for more errors in the management of patients.
The length and number of shifts that medical staff and nurses are expected to do is impacted on by location and the number of staff that are available. In a smaller hospital, nurses may work longer shifts.
Rotate it forward
We know from not only hospital shift workers but also from those working in the mining industry or trucking, that wherever there is a 24 hour need for people to be on staff, the best way to manage rotating shifts is to rotate them forward. This means that a person starting on a morning shift will move to an afternoon shift and then to a night shift rather than going backwards.
This forward cycling seems to fit best with the way our internal body clock works and allows people to adapt better to changes in the times they are expected to be awake and asleep and enables them to sleep better when they are at home and to be more alert and productive at work.
Light frequencies showing promise
As we are progressing with our research, we are gaining a better understanding of the way to manage alertness and productivity in all shift workers including nurses. The Australasian Sleep Foundation and the Institute for Breathing and Sleep at the Austin Hospital, Melbourne is currently taking part in research funded by a government grant held co-operatively by a number of organisations around the country including universities, hospitals and industry.
The focus of our research is to ascertain how to best manage sleep in hospital staff and one of the things we are investigating is artificial light.
We know that particular frequencies of light are more likely to send a signal to the brain that ‘there is daylight and it’s time to be awake’, than others. What we call ‘alerting light frequencies’ or those that promote vigilance, are in the blue light spectrum. This research is in its early stages and we hope that the results could make a real difference to the working environment for hospital staff.
The Institute for Breathing and Sleep is about to commence a project that will look at the types of sleeping problems that nurses may have, then provide solutions to these issues. A shift work disorder is only one of many sleep disorders that can affect nurses and there may be other issues such as insomnia or sleep apnoea influencing the quantity and quality of sleep. We are hoping that this research will help us to create a tailored package of health care so we can treat whatever sleep problems a nurse may be experiencing and reflect on how this improves their overall health and wellbeing.
The personal cost
It is vital that we find effective solutions to sleep disorders amongst our shift working hospital personnel to ensure that they are as alert, productive and healthy as they can be. Poor sleep has a professional impact but the personal impact of sleep disorders is also very well documented.
We know that disordered sleep results in mood changes and can cause interpersonal problems. A person who is not sleeping well is less able to engage happily with their family and co-workers and is at greater risk of depression and other mood disorders. Poor sleep can also impair a person’s memory and their ability to problem-solve.
I remember when I was an intern in smaller peripheral hospitals where we had fewer staff and we would be on duty for 24 hours for 4 or 5 days in a row. By the end of it I wondered how we all survived! There is more awareness now about the implications of long work hours and shift work and research has clearly shown us that you don’t get the best out people in terms of patient care when they are not well rested.
Guidelines for designing shifts that work
There are two basic guidelines for how to manage shift work. The first is shift management. The hospital needs to manage shifts well by ensuring people are rostered appropriately with adequate time off and that shifts are rotated forward. The second comes down to the individual. Anyone working shifts needs to ensure that the people they live with understand that when they are at home they need to sleep undisturbed, in a quiet, dark and comfortable environment. Even though a person who has worked a night shift is at home during the day, they can’t engage in normal daytime activities.
While employers do have a responsibility to ensure their employees are in a safe and healthy work environment, employees need to ensure that when they are at home they go to sleep. They need a dark room to sleep in quietly, free from phones and computers that may disturb their sleep. Just as you wouldn’t wake someone at 1am to help you find the butter in the fridge, it’s not OK to wake a shift worker during the day unless there is an emergency.
Getting 7 or 8 hours of good quality sleep is not an optional activity - it’s an absolute necessity both for a shift worker’s productivity and their own personal health. Too many people think that they can get home at 3am, sleep for a few hours, then get up at 7am and get the kids off to school. That is just not going to work, either for themselves or the family.
By not taking care of your sleep, your health can suffer. Patients with insomnia have an increased risk of developing cardiovascular disease, for example, high blood pressure. There is a trial underway at the moment at the University of Pittsburgh looking at whether treating insomnia helps to lower blood pressure. There are many health consequences of having insufficient or poor sleep.
The final word
The advice I would give anyone working shifts is that you need to make time to sleep. No matter what time you get home, if it’s 6pm or 6am, ensure that you have your meal at least two or three hours before going to bed and give yourself some wind-down time. Ensure that your sleeping environment is quiet, dark and protected from disturbance and observe the three pillars of health; diet, exercise and good quality sleep.
For nurses struggling to adjust to a shift cycle, I would recommend you talk to your nurse unit manager. If your shifts have been optimised and you are still having sleep problems, consult a sleep psychologist. A sleep psychologist can be of enormous benefit in helping you to improve the quantity and the quality of your sleep.

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“Just as you wouldn’t wake someone at 1am to help you find the butter in the fridge, it’s not OK to wake a shift worker during the day unless there is an emergency.”

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The issues are to ensure that;

• Staff on rotating shifts are managed well;


• The working environment is conducive to nurses being awake and


• Nurses are able to sleep well and adequately when they go home.

Dr Maree Barnes
Dr Maree Barnes, President of the Australian Sleep Association (ASA), graduated in medicine from the University of Melbourne and undertook postgraduate training in Respiratory and Sleep Medicine at St. Vincent’s Hospital Melbourne, which was completed in the US. On her return to Australia, Dr Barnes took up a research appointment at the Austin & Repatriation Medical Centre and the Institute for Breathing and Sleep.
Dr Barnes’ current research focuses are: improving and simplifying the approach to the diagnosis and treatment of sleep apnoea, with an emphasis on involving community health practitioners; evaluating the cardiovascular risk associated with sleep apnoea; the risks of sleep disordered in pregnancy and the relationship between mood disorders and sleep disorders. In addition to these research interests, Dr Barnes runs a busy Sleep Clinic, has appointments to both the Senior Medical Staff at Austin Health and the University of Melbourne Department of Medicine.