Too many hours, too little sleep

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From the Spring 2014 issue of Scrubs

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.

Some experts recommend abolishing the 12-hour shift. Where do you stand on extended work hours? Weigh in here!

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.