By Gary Evans
Sleep disturbance is an all-too-common problem for healthcare workers (HCWs), particularly if caused by alternating work shifts from day to night. While the workplace system is the primary driver of insomnia, there are steps HCWs can take to reduce the effects, which can be considerable. But has the pendulum swung too far?
“If you go back 15 to 20 years ago, it was all about the individual,” says Dave Lu, MD, MSCI, MBE, an emergency department physician at the University of Washington School of Medicine.
Sleep disturbance can lead to burnout and a panoply of adverse effects, but healthcare workers were advised to practice mindfulness training and meditation and become more resilient.
“There was appropriate pushback from providers because that was not the root of the problem,” Lu says. “Since then, it has become all about the work system and removing obstacles that cause burnout. But it shouldn’t be exclusively a workplace or system-based [issue] — there is still a role for the individual to do something.”
Lu recently published a commentary arguing the role of individual actions dropped out of sleep discussions as the paradigm shifted from self to system as the primary cause of insomnia.
“I am not saying the individual has the bulk of the burden,” Lu tells Hospital Employee Health. “Far from it. It is still a systems problem and that needs to be the target. But maybe a small percentage should be based on the individual, so you are not just waiting for your workplace to make you feel less burnout.”
In the commentary, Lu noted that “even theoretically perfect workplaces with ideal conditions for sleep health may not ultimately improve healthcare workers’ sleep behavior or results.”1
“It still depends on the person,” Lu explains. “There are individual components that still contribute to burnout. It’s a small percentage, but it is not nothing.”
Sleep and Burnout
Lu’s commentary accompanied a study that linked sleep problems to burnout, including symptoms like emotional exhaustion. The analysis included 126 emergency department workers and found that poor sleep quality and insomnia symptoms correlated with established measures of burnout.2
“The sleep-burnout relationship is likely bidirectional,” the authors hypothesized. “Healthcare workers’ poor sleep may also be associated with factors unrelated to occupational demands (e.g., personal stressors and family obligations).”
Regarding shift work, the American College of Emergency Physicians (ACEP) reports in a guidebook on wellness that a diagnosis of Shift Work Disorder must meet the following criteria:
- “Significant insomnia or excessive sleepiness that interferes with functioning and is associated with a work schedule that overlaps the usual sleep period”;
- “Symptoms must be associated with a shift work schedule over at least one month”;
- “Misalignment between the body clock and environmental clock manifested by loss of a normal sleep-wake pattern has been documented by a sleep log or diary, and laboratory or sleep recordings”;
- “Sleep disturbance that is not explained by another sleep disorder; a medical, neurological, or psychiatric disorder; medication use; or substance abuse disorder.”3
“Unfortunately, [shift work] is kind of the nature of the beast,” Lu says. “There are some creative things you can do here and there to lessen the impact, but shift work is very disruptive to your circadian rhythms as you flip from days to nights. One day I’ll be starting at 6 p.m., the next day I’ll be working from 2 p.m. to 10 p.m., then the next day I will be working from 10 p.m. to 6 a.m. But the individual still plays a role. If you have young children, long commutes, an [existing] sleep disorder — that is all on the individual. There is very little your employer can do to give you a perfect schedule. It illustrates the intersection between the workplace and individual actions.”
According to ACEP, biological and social problems associated with rotating shifts include higher risk for peptic ulcers, heart attack, divorce, substance abuse, accidents, and depression. “The adverse effect of constantly rotating shifts is the single most important reason given for premature attrition from the specialty,” ACEP reported in the wellness guidebook.
For these reasons, ACEP recommended, “Be selfish with your sleep. Let family and friends know that you are out of commission until a certain time and request that they avoid texting or calling during your sleep times. Put a sign on the door that says, ‘Day Sleeper. Do Not Disturb and Do Not Open the Door.’”
Other ACEP recommendations for HCWs struggling with sleep include:
- Create a dark and cool sleep room at home. If soundproofing is not possible, consider earplugs and eye shades.
- A split-sleep period used by some HCWs calls for sleep for three to four hours immediately before and three to four hours immediately after a night shift. The rationale is that at least part of each sleep episode is during the circadian period when sleep is expected.
- A healthy diet and exercise are recommended, but exercising within two hours of intended sleep time may delay the onset of sleep.
- Do not consume caffeine four hours before going home to decrease time to restful sleep. Melatonin has been shown to hasten resetting of circadian rhythms.
REFERENCES
- Lu DW. Sleep and burnout among health care professionals — the role of the individual. JAMA Netw Open 2023;6:e2341882.
- Shechter A, Firew T, Miranda M, et al. Sleep disturbance and burnout in emergency department health care workers. JAMA Netw Open 2023;6:e2341910.
- American College of Emergency Physicians. From Self to System — Being Well in Emergency Medicine. 2023.
Sleep disturbance is an all-too-common problem for healthcare workers, particularly if caused by alternating work shifts from day to night. While the workplace system is the primary driver of insomnia, there are steps healthcare workers can take to reduce the effects, which can be considerable. But has the pendulum swung too far?
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