Relation between sleep deprivation and nursing errors during the night shift

The aim of this study was to investigate the relationship between sleep deprivation and occupational and patient care errors among staff nurses who work the night shift. Whereas the aviation and trucking industries report that sleep deprivation increases errors, few studies have examined sleep deprivation association with occupational and patient care errors among nurses. A cross-sectional correlational design was used to evaluate relationships between sleep deprivation and occupational and patient care errors in 289 hospital night shift nurses. More than half (56%) of the sample reported being sleep deprived. Sleep-deprived nurses made more patient care errors. Testing for associations with occupational errors was not feasible because of the low number of occupational errors reported. Interventions to increase the quality and quantity of sleep among hospital night shift nurses are needed. Improved sleep among night shift nurses will reduce the impact of sleep deprivation on patient care errors.

Received from the Anesthesia Service, VA Palo Alto Health Care System, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California; the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; and the Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.HEALTHCARE delivery takes place 24 h a day, 7 days a week, and is colloquially termed a “24/7” operation. Anesthesia providers are required to deliver critical around-the-clock care to a variety of patients. This parallels the situation in many other domains that provide such services, e.g ., transportation, law enforcement, communications, fire fighting, technology, manufacturing, and the military. Even “convenience” industries (e.g ., gas stations and grocery stores) now provide uninterrupted access. These continuous operational demands present unique physiologic challenges to the humans who are called on to provide safe operations within these systems. Human physiologic design dictates circadian patterns of alertness and performance and includes a vital need for sleep. Human requirements for sleep and a stable circadian clock can be, and often are, in direct opposition to the societal demand for continuous operations.Recently, patient safety has taken center stage in health care. The Institute of Medicine's report “To Err Is Human: Building a Safer Health System,” revealed that medical errors contribute to many hospital deaths and serious adverse events. 1The response to this report was widespread and included the Quality Interagency Coordination Task Force's response to the President of the United States, “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.”∥2This report listed more than 100 action items to be undertaken by federal agencies to improve quality and reduce medical errors. One action promised by the Agency for Healthcare Research and Quality was “the development and dissemination of evidence-based, best safety practices to provider organizations.” In addition to the multiple recommendations to improve patient safety, the report from the Agency for Healthcare Research and Quality included a review chapter on sleep, fatigue, #and medical errors. **There is evidence that the issue of fatigue in health care is coming to prominence on a national level. In April 2001, Public Citizen (a consumer and health advocacy group) and a consortium of interested parties petitioned the Occupational Safety and Health Administration to implement new regulations on resident work hours (table 1). The primary intent of the regulations is to provide more humane working conditions, which the petitioners declare will result in a better standard of care for all patients. Also, the Patient and Physician Safety and Protection Act of 2001, which would limit resident physician work hours, was introduced in Congress. Recently, the Accreditation Council on Graduate Medical Education, the accrediting organization for residency training programs in the United States, has approved common program requirements for resident duty and rest hours that will take effect in July 2003. ††The potential impact of sleep loss and fatigue, specifically among anesthesiologists, has received only sporadic attention. 3,4The cognitive demands of intraoperative patient care requires an iteration of data collection, evaluation of its relevance to patient status, development and implementation of plans to maintain the desired patient status, and monitoring the outcome of interventions. These complex tasks require sustained attention or “vigilance” and are particularly vulnerable to the effects of fatigue. 5–8The purpose of this article is to review the physiology of prolonged work cycles and fatigue, to relate this to the work milieu of the practice of anesthesiology, and suggest economically feasible recommendations to mitigate the effects of fatigue.Sleep loss and disruption of circadian rhythm that result from arduous work schedules can lead to reduced safety, performance, and health. While some of these outcomes are well documented, much remains to be learned about the short- and long-term effects of sleep and circadian disruption. The following nonmedical examples of the safety, performance, and health risks associated with around-the-clock operations illustrate the increasing human and economic costs related to ignoring the effects of these physiologic disruptions.There have been several high-profile accidents where fatigue was identified as either causal or contributory. For example, although alcohol is often cited as the central reason in the Exxon Valdez marine grounding, the National Transportation Safety Board investigation identified fatigue as one of the probable causes of the accident. 9Similarly, circadian factors were identified as contributing to the errors that resulted in the nuclear accidents at Three Mile Island and Chernobyl. 10,11Fatigue resulting from the work–rest patterns of managers was also acknowledged as an important component of the flawed decision-making that contributed to the space shuttle Challenger accident. 12Fatigue-related accidents have been identified in every mode of transportation and can be found in many around-the-clock operational settings. Clearly, there are a variety of adverse outcomes such as economic costs, disrupted service, injuries, and even fatalities that result from these accidents. For example, the Exxon Valdez grounding was associated with environmental cleanup operations and legal cases involving billions of dollars, and Space Shuttle operations were suspended for several years after the Challenger disaster.Fatigue-related safety risks affect us at both individual and societal levels. A recent poll by the National Sleep Foundation indicated that one of two drivers reported having driven while drowsy in the past year, ‡‡and one of five acknowledged having “nodded off” while driving. Fatigue contributes to 100,000 crashes annually that result in 76,000 injuries and 1,550 fatalities, according to estimates by the National Highway Traffic Safety Administration. 13Recently, an international group of scientists estimated that fatigue is causal in 15–20% of all transportation accidents, that official statistics underestimate the scope of the problem, and that fatigue exceeds the combined contribution of alcohol and drugs in transportation accidents. 14Fatigue caused by sleep loss and circadian disruption can degrade performance and reduce many aspects of human capability. 15Known performance effects include reduced attention–vigilance, impaired memory and decision-making, prolonged reaction time, and disrupted communications. 16–20These degraded performance outcomes create a situation where there is increased risk for the occurrence of errors, critical incidents, and accidents. 15Fatigue also creates increased performance variability, with cyclic reductions in alertness and performance. 21Fatigued workers have a tendency to slow down work processes to maintain accuracy, a classic effect known as the speed-accuracy trade-off. 22It takes only a moment of reduced performance during a critical task to have a negative outcome. Even if a lapse in performance occurs during a noncritical task, the system vulnerability shifts to a less safe state.Fatigue-related accidents are sometimes considered to be a result of falling asleep. Performance gaps can be the result of these “microsleeps,” which are brief, uncontrolled, and spontaneous episodes of physiologic sleep. 8There can be significant performance reductions that are sufficient to create safety risks prior to and immediately after the occurrence of a microsleep. 23,24Slowed cognitive throughput, reduced memory, slowed reaction time, lowered optimal responding, and attention lapses can create an increased opportunity for errors to occur. 25Consider the circumstance where an anesthesiologist's response to an alarm is slowed and an inappropriate decision guides an incorrect action. The practitioner may have been “awake,” but fatigue-related performance decrements could be contributory to the occurrence of any error, incident, or accident that resulted from the action.The decrement in psychomotor performance resulting from sleep deprivation have been correlated with those resulting from the impairments associated with ethanol ingestion. 26Performance on a hand–eye tracking task declined such that the impairment was equivalent to a blood alcohol level of 0.05% after 17 h of wakefulness. At 24 h of sustained wakefulness, the impairment in psychomotor function was equivalent to a blood alcohol concentration of 0.1%, at or above the legal limit for driving in most states. These data could be useful to help quantify fatigue-related effects with a drug that the public and policy makers better understand.Specific clinical skills of importance to the practice of anesthesiology deteriorate as a result of fatigue. On a simulated monitoring task where subjects were asked to monitor and record the time of significant deviation of clinical variables (e.g ., heart rate, blood pressure), Denisco et al . reported lower “vigilance scores” in the group that had been on call. 27The ability to interpret electrocardiographic changes and to do simple mathematical calculations is compromised among sleep-deprived house officers. 28The speed and quality of intubation was diminished among emergency department physicians working the night shift as compared with their performance while working during the day. 29,30Many of the fatigue-related decrements in performance identified in residents are potentially worse in older physicians. Aging is associated with a tendency toward early awakening, an exaggerated dip in arousal midafternoon, and a decreased tolerance of late-night and shift work. 31The unique demands of night call on older anesthesiologists are more onerous than those found in other specialties. 32Among recently retired anesthesiologists, night call was identified as the most stressful aspect of anesthetic practice and the most important reason for retirement. 33,34Beyond the safety risks and performance decrements associated with sleep loss and circadian disruption, there are a variety of personal health concerns. Several studies have shown that long-term exposure to shift work represents an independent risk factor for the development of both gastrointestinal and cardiovascular diseases. 35–39A recent study found that women working the night shift had a 60% greater risk for breast cancer compared with women who never worked the late shift. 40There is evidence that some adverse pregnancy outcomes are related to working conditions. 41A meta-analysis of 29 studies, including more than 160,000 women, evaluated the association of physically demanding work, prolonged standing, long work hours, and cumulative “fatigue score” with preterm delivery, pregnancy-induced hypertension, and small-for-gestational-age infants. There was a positive association between physically demanding work and preterm births, pregnancy-induced hypertension, and delivery of small-for-gestational-age infants. Shift work alone was found to increase the incidence of preterm births. 41There is evidence that sleep restriction alters physiologic function. Significant detrimental effects on immune function can be found after a few days of total sleep deprivation or after several days of partial sleep loss. 42,43Sleep restriction of 4 h per night for six nights is associated with harmful effects on carbohydrate metabolism and endocrine function. 44This degree of sleep restriction resulted in abnormal glucose tolerance, decreased thyrotropin concentrations, increased evening cortisol concentrations, and increased sympathetic nervous system activity (as measured by heart rate variability). Sleep deprivation and circadian disruption affect cerebral metabolic and cognitive function. In a study of changes in regional cerebral glucose utilization (i.e ., positron emission tomography) during 85 h of consecutive sleep loss, decreases in cerebral metabolic rate were observed primarily in the thalamus and prefrontal and posterior parietal cortices. Alertness and cognitive performance declined in association with these brain deactivations. 45A recent study of aircrew members suggests there may be a linkage between long-term exposure to time-zone changes (i.e ., circadian disruption), temporal lobe atrophy, and deficits in learning and memory. 46Investigations using functional magnetic resonance imaging technology contradict some of the aformentioned findings and reveal compensatory changes of increased activation in the prefrontal cortex and parietal lobes during verbal learning after sleep deprivation. 47–50Studies show altered mortality with sleep loss and circadian disruption. Circadian disruption in hamsters and Drosophila reduce life span from 11 to 15%. 51,52A prospective investigation of more than one million individuals conducted by the American Cancer Society found that men who reported “usual” daily sleep times of less than 4 h were 2.8 times more likely to have died within a 6-year follow-up as men who obtained 7.0–7.9 h of sleep. 53The risk for women was increased by 48%. Conversely, men and women who reported sleeping 10 h or more per day had about 1.8 times the mortality rate of those who reported 7.0–7.9 h of sleep.The two primary determinants that underlie fatigue and interact in a dynamic manner are sleep homeostasis and circadian rhythms. 54An individual's level of alertness (e.g ., on the job) or potential for sleep (e.g ., during a rest period) will be determined by a complex interaction of these factors. Performance and alertness decrements may occur when either of these elements is disrupted. 55Factors other than fatigue, such as workload, environment, stress, boredom, motivation, and professionalism, also influence the ability to perform. 4In addition, there are large interindividual differences on the effects of fatigue. 56Sleep serves a vital physiologic need. 57Like other basic physiologic requirements such as food and water, sleep plays a fundamental role in survival. Sleep homeostasis is the balance between sleep need and quality and quantity of sleep obtained by an individual. On average, the adult human requirement for sleep appears to be greater than 8 h (8 h:14 min) per 24-h period. 58,59The range of sleep need varies from 6 to 10 h, and this requirement is probably genetically determined and cannot be “trained” to a different sleep need. 60Estimates suggest that most American adults obtain about 1–1.5 h less sleep than needed. §§This lost sleep accumulates to produce a “sleep debt.”8,58For example, an individual who obtains 1.5 h less sleep per night over a 5-day work week will begin the weekend with 7.5 h of sleep debt. This deficit is roughly equivalent to the loss of a full night of sleep and requires about two nights of at least 8 h of sleep for recovery. 20Sleep debts are not repaid hour for hour, but instead through an increase in deep sleep or nonrapid eye movement stages 3 and 4. 20A variety of factors can affect sleep quantity and quality. Perhaps some of the most dramatic changes in sleep occur as a normal function of aging. Approaching age 50 and beyond, sleep becomes more disrupted with frequent awakenings. There are reduced amounts of deep sleep, and sleep becomes less consolidated. 61Nocturia in men and menopausal symptoms in women are likely to contribute to sleep disturbances in older individuals. There are also age-related increases in complaints of insomnia and depression that negatively impact sleep. Sleep need does not necessarily decrease with age, and increased daytime sleepiness can be the consequence of reduced sleep quantity and quality. There have been no formal studies assessing whether these changes in sleep quantity and quality affect the performance of older anesthesia providers.There are approximately 90 known sleep disorders that have been described and classified in a diagnostic nosology. 62The causes for these disorders range from physiologic to psychological to environmental. Some sleep disorders are relatively prevalent in the population and have well-documented negative effects on waking alertness and performance. 63–65Often, the affected individual is unaware of their disorder, and the bed partner may be the first to identify the problem. Obstructive sleep apnea is a common example of a sleep disorder that has implications in operational settings. There are many health consequences associated with sleep apnea, but, in addition, it has been shown to be associated with a twofold to sevenfold increase in risk for automobile accidents. 66,67Consistent with this, Powell et al . demonstrated that individuals with mild to moderate sleep apnea had a decrement in performance equivalent to that of an individual with a blood alcohol concentration of 0.05–0.08 g/dl. 68Alcohol is the most widely used sleep aid, and its use is typically intended to provide relaxation or to promote sleep. 69However, alcohol is a potent suppressor of rapid-eye-movement sleep, especially in the first half of the night. 70As the blood alcohol concentration declines, there is a rapid-eye-movement rebound in the second half of the night, producing more rapid-eye-movement sleep with increased awakenings and a reduction in total sleep time. Therefore, although alcohol may be consumed as an aid to promote sleep, it actually has the potential to significantly disrupt it.Sleep can be measured both subjectively, using a variety of questionnaires, and objectively, using standardized physiologic measures. Generally, humans are inaccurate subjective reporters of alertness. 71,72Individuals can report being awake and alert, when physiologically they could be asleep in minutes. This discrepancy between self or subjective reports and physiologic levels of alertness can have significant operational implications. First, it indicates that verbal reports of subjective alertness are to an individual's for an individual with the subjective and report of being be less likely to an alertness (e.g ., or as in the on alertness that could the physiologic is important to that when an individual reports a subjective at either of the (e.g ., fatigue or it is more likely to the physiologic human circadian is in the of the and is an for 24-h rhythms. most and of the is while a of the is by the at night and is by to the direct for and exposure to affect the circadian The daily the to its 24-h The tendency of the circadian clock is to than 24-h day, is the physiologic to than work–rest In other of shift from days to to nights has a circadian physiologic but this has not been a to the of shift work. a range of and For example, it the 24-h daily and as well as alertness and performance levels. the of sleep are important and complex but are the scope of this article and are are for increased sleepiness at two times and circadian associated with the levels of and performance and vulnerability to errors, incidents, and accidents, occurs at about an example, it has been well that a in fatigue-related accidents, alcohol occurs roughly between 3 and of alertness occur at approximately and to a different work such as the night shift or time the circadian will occur for days as the to the new environmental (e.g ., the after through several time work creates a different by its disruption of the circadian individuals are working at night, circadian sleep, and when they to sleep during the day, the circadian clock is for wakefulness. Generally, studies have shown that does not occur prolonged exposure to night work. an the individual and is to daytime that maintain for a factors such as with and that can only be during daytime hours also a role in the to the rhythm to night work. study of during anesthesia has for a circadian in clinical performance among risk of was greater at night to and among this investigation is of a negative circadian effect on performance, it was by the of as well as by not including important such as patient and physician data from of anesthesiologists other that fatigue is by as a significant risk for patients. In two studies of anesthesia more than reported having an in medical that they to fatigue. et al ., using the critical of anesthetic errors, estimated that human a role in more than of anesthetic and that fatigue was an associated factor in of reported critical a of New anesthesiologists, reported that they their limit for safe continuous of and reported having a fatigue-related from reports of critical to the from to revealed that fatigue was listed as a contributing factor in reports data suggest that there is a association between fatigue and errors at circadian The from these studies are they are on but the of that quality of care is compromised and that some errors are to working while recently the effect of fatigue in the was of falling asleep while an the was that the had been by about falling asleep during was of medical and of of and The was on a as the of on the had using of accident (table the of errors and accidents that occur in the are likely to have fatigue as a contributing factor on work schedules is a well-documented association between long work hours or late work and an increased potential for from accidents. The risk of an accident increases with hour after the consecutive hour of work. effect is exaggerated when work hours occur on a late shift. injuries, among the most frequent of the injuries by anesthesia are occur during or of and are associated with from fatigue. residents and medical there is a greater risk of a exposure during night work than during have the described risks associated with drowsy driving to physicians. physicians are at risk for accident and as they after their duty In a study of an of residents h of sleep while on reported falling asleep at the compared with of These residents had as many for than the in and emergency have been reported to the of accidents, in many cases while driving after being on call. a more recent study of risk among anesthesia only accidents were which not from the this to the circadian effect during the effect of work hours on pregnancy outcomes in resident physicians has been These data reveal that there is an increased incidence of pregnancy-induced hypertension, small-for-gestational-age infants. study an association between preterm delivery and residents who worked more than 100 h per in other “24/7” health care has some where fatigue was identified as causal or contributory. most often example is the of which attention on work hours and of resident physicians. there has been much to whether was related to the providers who for a high-profile was in that recommendations to limit house work hours and to increase their These recommendations of the of the New Health (table Accreditation Council on Graduate Medical and its and program requirements for resident duty hours, and work were required to that training program formal for resident duty hours that and care of patients. The for that duty hours not be and on average, residents have least day of 7 of and be on call in the hospital no more often than every if these are residents are from anesthesia on the day after evaluation suggests that the of resident duty hours may not be the that alone patient outcome. and after implementation of the New regulations found that there were no differences in mortality rate of patient to care or of and that there were more having at least one et al . demonstrated that adverse were more common when house were for compared with times when a resident the patient was with the care. follow-up study revealed that the quality of during patient the quality of care. suggests that during some use of residents to house may the of more medical errors, but that these errors be in other is among studies on the effects of fatigue on the performance of have the in most of the studies (table is not that the of this of data are these is a studies in the used for fatigue or sleep loss. studies of partial sleep deprivation reveal that performance decrements occur if sleep is by as as h, et al . used 4 h of sleep on the night prior to performance to between and is no for the that sleep times of greater than 4 h be considered as other use study conditions. of in studies is the of a standardized to performance. A

BackgroundThe SNORE (Sleep Deprivation among Night shift health staff On Rotation-Evaluation) study evaluated the effects of sleep deprivation on healthcare professionals working rotational night shifts. Given the association between sleep deprivation and cognitive impairment, this sub-study examined the prevalence of cognitive impairment and its relationship with sleep deprivation in a tertiary care hospital.MethodsA cross-sectional study included 293 healthcare workers (doctors, nurses, paramedics). Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) during day and night shifts. Sleep deprivation was evaluated via the Epworth Sleepiness Scale (EPSS) and self-reported sleep hours. Statistical analysis employed the Wilcoxon signed-rank test for shift-wise cognitive score comparison and multivariable logistic regression to explore the relationship between sleep deprivation and cognitive impairment.ResultsCognitive impairment prevalence during night shifts was 23.5%, with nurses showing slightly higher rates (26.2%). Cognitive scores were significantly lower during night shifts (median 28) compared to day shifts (median 29). Sleep deprivation was significantly associated with cognitive impairment (adjusted odds ratio [aOR]: 1.78 [1.01–3.16] for EPSS; 9.20 [2.16–39.23] for self-reported sleep hours). Male participants exhibited higher odds of impairment than females (aOR: 2.30 [1.19–4.47]).ConclusionSleep deprivation significantly impacts cognitive function in healthcare workers, with more pronounced effects during night shifts. These findings underscore the urgent need for interventions promoting sleep health and optimizing working conditions in healthcare settings.

The aim of this study was to estimate the association between insufficient sleep and prescription opioid misuse among US high school students. Participants were 6,884 high school students who self-reported on sleep duration and prescription opioid misuse in the 2019 Youth Risk Behavior Survey. Sleep duration was categorized by the Youth Risk Behavior Survey according to the American Academy of Sleep Medicine guidelines as follows: recommended sleep duration (8-9 hours) vs insufficient sleep (< 8 hours). Participants also reported whether they had any prescription opioid misuse during their lifetime and whether they had prescription opioid misuse within the past 30 days. Most (79.4%) participants reported sleeping less than 8 hours per night. Among all youth, 12.9% reported lifetime prescription opioid misuse and 6.2% reported current prescription opioid misuse. Prevalence of both lifetime and current opioid medication misuse was higher among those also reporting insufficient sleep compared to those reporting recommended sleep duration (14.3% vs 7.7%, P < .0001 for lifetime misuse and 6.6% vs 4.3%, P = .0091 for current misuse). In multivariate models, insufficient sleep was associated with an increased odds of lifetime prescription opioid misuse (adjusted odds ratios = 1.4; 95% confidence interval, 1.1-1.2; P = .006); however, we did not find an association between sleep duration and current prescription opioid misuse in multivariate analysis. Sleep duration is associated with lifetime opioid misuse among US youth. Longitudinal studies are needed to test whether causal relationships exist, and to understand biobehavioral mechanisms that underlie associations between sleep deficiency and opioid misuse in adolescents. Groenewald CB, Rabbitts JA, Tham SW, Law EF, Palermo TM. Associations between insufficient sleep and prescription opioid misuse among high school students in the United States. J Clin Sleep Med. 2021;17(11):2205-2214.

Physicians, Heal Thyselves … With Caffeine?

Fatigue, Countermeasures, and Performance Enhancement in Resident Physicians

Lack of sleep another safety risk factor

ObjectivesTo determine attention performance of medical students after sleep deprivation due to night shift work.MethodsProspective cohort design. All seventh, eighth and ninth semester students were invited to participate (n= 209). The effectiveness and concentration indices (d2 Test for attention, dependent variable) from 180 students at 3 evaluations during the semester were compared. Eighth and ninth semester students underwent their second evaluation after a night shift. The independent variables were nocturnal sleep measurements.ResultsNo differences in nocturnal sleep hours during the previous week (p=0.966), sleep deprivation (p=0.703) or effectiveness in the d2 Test (p=0.428) were found between the groups at the beginning of the semester. At the beginning and the end of the semester, the d2 Test results were not different between groups (p=0.410, p=0.394) respectively. The second evaluation showed greater sleep deprivation in students with night shift work (p<0.001). The sleep deprived students had lower concentration indices (p<0.001).The differences were associated with the magnitude of sleep deprivation (p=0.008). Multivariate regression analysis showed that attention performance was explained by sleep deprivation due to night shift work, adjusting for age and gender. Students with sleep deprivation had worse concentration than those without.ConclusionsSleep deprivation due to night shift work in medical students had a negative impact on their attention performance. Medical educators should address these potential negative learning and patient care consequences of sleep deprivation in medical students due to night shifts.

Fatigue, Countermeasures, and Performance Enhancement in Resident Physicians

Background:SNORE (Sleep deprivation among Night shift health staff On Rotation- Evaluation) was a hospital-based observational study conducted to study the effects of sleep deprivation on healthcare professionals working night shifts on rotation.Aim:This study determines the burden of sleep deprivation and daytime sleepiness and also the relation between hours of sleep and Epworth sleepiness scale scores in the study population.Methodology:A comparative hospital-based observational study was conducted, including healthcare professionals working night shifts on rotation at a tertiary-level healthcare facility, using a semistructured questionnaire. Observations from 293 study participants are reported, selected based on stratified random sampling, after the exclusion of healthcare professionals with other factors which may interfere with sleep deprivation testing.Results:The mean age in years of the study participants is 27.9 ± 4.3, with female composition being 68.9%. The mean duration of self-reported hours of sleep during the night shift period was 5.43 ± 1.38 hours, and 82.3% of the study participants were found to be sleep-deprived (<7 hours of sleep). The mean Epworth sleepiness scale (EPSS) score is 6.25 ± 3.15 with the burden of sleep deprivation being 30.7% and the burden of excessive daytime sleepiness being 16.4%. EPSS scores were found to decrease with an increase in hours of sleep, with 61% lesser odds of scoring 8–24 on EPSS.Conclusion:This study highlights the significant burden of sleep deprivation among healthcare providers working rotational night shifts, emphasizing its impact on daytime functioning and wellbeing. The findings point to the need for strategies to improve sleep health in this population to enhance both personal and professional outcomes.

Background: It has always been suggested that sleep deprivation has a deleterious effect on the ability of health workers who are involved in multitude of life-saving tasks, which often require more attention and concentration. The Centers for Disease Control and Prevention and the national health portal (Government of India) have now recognized sleep deprivation as a public health epidemic. Materials and Methods: A cross-sectional study was done including health-care professionals working night shifts on rotation at a tertiary level health-care facility, using a semi-structured questionnaire to test the status of their sleep deprivation, cognitive ability, and quality of life as a pilot study. Stratified random sampling was used to select the study participants and health-care professionals with other factors which may interfere with sleep deprivation testing were excluded. Data were analyzed using IBM-SPSS, and required statistical tests were applied (Pearson Chi-square, Fisher exact, Spearman correlation, and Wilcoxon signed-rank test). Results: About 95.12% of participants reported &lt; 6 h of sleep post night shifts, of which 51.2% were found to show signs of sleep deprivation. Of this 51.2%, 28.57% were also found to have lower cognitive function scores, and statistically significant lower cognitive scores were observed during night shifts than during day shifts. The median value of the Montreal cognitive assessment (MOCA) score during the night shift was 27 (interquartile range [IQR] = 4) and the median value of MOCA score during the day shift was 29 (IQR = 1). A poor QOL was observed in 17.07% of the study participants, and it was found to have a significant positive correlation with hours of sleep obtained. Conclusion: The results from the present study points towards a significantly high burden of sleep deprivation among health-care professionals working rotational shifts (51.2%). This warrants a need for further evaluation on larger populations and adoption of comprehensive measures including preventive and promotive aspects like sleep counselling and yoga/meditation for management.

To evaluate the effectiveness of a broad, literature-based night shiftwork intervention for enhancement of emergency physicians' (EPs') adaptation to night rotations. A prospective, double-blind, active placebo-controlled study was conducted on 6 attending physicians in a university hospital ED. Three data sets were collected under the following conditions: baseline, after active placebo intervention, and after experimental intervention. In each condition, data were collected when the physicians worked both night and day shifts. Measurements included ambulatory polysomnographic recordings of the main sleep periods, objective performance tests administered several times during the subjects' shifts, and daily subjective ratings of the subjects' sleep, moods, and intervention use. The subjects slept an average of 5 hr 42 min across all conditions. After night shifts, the subjects slept significantly less than they did after day shifts (5 hr 13 min vs 6 hr 20 min; p < 0.05). The physicians' vigilance reaction times and times for intubation of a mannequin were significantly slower during night shifts than they were during day shifts (p = 0.007 and p < 0.04, respectively), but performances on ECG analysis did not significantly differ between night and day shifts. Mood ratings were significantly more negative during night shifts than they were during day shifts (more sluggish p < 0.04, less motivated p < 0.03, and less clear thinking p < 0.04). The strategies in the experimental intervention were used 85% of the time according to logbook entries. The experimental and active placebo interventions did not significantly improve the physician's performance, or mood on the night shift, although the subjects slept more after both interventions. Although the experimental intervention was successfully implemented, it failed to significantly improve attending physicians' sleep, performance, or mood on night shifts. A decrease in speed of intubation, vigilance reaction times, and subjective alertness was evident each time the physicians rotated through the night shift. These findings plus the limited sleep across all conditions and shifts suggest that circadian-mediated disruptions of waking neurobehavioral functions and sleep deprivation are problems in EPs.

&lt;sec&gt;&lt;st&gt;Introduction&lt;/st&gt; Usually night and shift work have been associated with insomnia and fatigue. The current industry model implies the existence of many groups of night workers. For this reason we consider of interest to conduct a systematic review to evaluate the relationship between shift or night work as risk factors for health. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Objectives&lt;/st&gt; Evaluate the relationship between shift or night work as a risk factor for health and performance for working. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Methodology&lt;/st&gt; Literature review from Pubmed database (01/10/2015) with keywords (“sleep disorder or insomnia”) and (occupational or workplace) and active filters: last 5 years, human, Spanish, English or French. 571 publications were found, of which 141 were selected from title critical lecture (3 independent reviewers, and articles were selected if 2 or 3 of the 3 reviewers agree). Critical lecture of abstracts for 5 reviewers was performed and 35 of the 141 were selected. 6 of 141 papers were not found. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Results&lt;/st&gt; In this review, a relationship between shift and night work with loss of sleep (OR 1.17-4.1) and increased accidents (OR 1.62) is observed. Time control, sleep 2–3 hours during the night shift, and working maximum 3 consecutive night days, are also seen as protective factors. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Conclusions&lt;/st&gt; Night and shift work is related to insomnia and fatigue, which leads to a reduced work capacity and increased accidents; although it seems that it does not lead to premature ageing. It would be desirable to identify profiles of night workers (owls) and evaluate the effects of the double presence with these types of work, especially in women. There is controversy as to whether these jobs can cause anxiety disorder and/or depression. &lt;/sec&gt;

The Multiple Sleep Latency Test (MSLT) is an important tool in the evaluation of excessive daytime sleepiness. It is indicated for the diagnosis of narcolepsy and the evaluation of idiopathic hypersomnia.1 However, the MSLT results can be affected by a variety of extraneous variables that must be controlled or minimized to obtain interpretable diagnostic data.2 Prior sleep deprivation is the most worrisome and difficult to monitor extraneous variable. The article “Nightly Sleep Duration in the Two-Week Period Preceding Multiple Sleep Latency Testing” in this edition, examines this issue by comparing sleep duration from self-reported average nightly sleep time, sleep logs, and actigraphy. Results showed that subjective estimates of sleep time were longer than the time measured by actigraphy. Moreover, actigraphy was the only measure that showed a low but significant correlation with MSLT results. It was suggested that actigraphy might be a better way of measuring sleep duration before the MSLT. This article touches on several basic questions surrounding prior sleep duration and the MSLT. The first question is when should an MSLT be performed? It is common for sleep duration to vary across the week with partial sleep deprivation on work nights followed by “catch up” on the weekend. This pattern was evident in the participants in this study, who also reported about 4 naps (range 0–14) per week. Not surprisingly, the patients slept the longest (7.4 hr) on the polysomnogram (PSG) night when given the opportunity. Having this information, a clinician should consider a diagnosis of insufficient sleep and recommend increasing sleep time to eliminate excessive daytime sleepiness before performing an MSLT. If this is not effective, an MSLT would be warranted if the history could support a diagnosis of narcolepsy. In practice, however, estimates of sleep durations in the week prior to MSLT are not usually obtained, so the clinician is not aware of the potential role of sleep deprivation. This study dramatically demonstrates what clinicians could be missing. Although military personnel with truncated sleep opportunities are not typical patients, it is well established that most Americans are sleep deprived.3 The next question is how should prior sleep time be measured? This study compared actigraphy, a single subjective estimate of sleep duration, and sleep time from measured line lengths on sleep logs. Actigraphy showed the shortest total sleep time (0.5–1.5 hr less) in the 2 weeks prior to MSLT compared to the other measures. On the PSG night, actigraphy also showed shorter sleep duration than sleep measured by PSG. Sleep log estimates were not obtained on the PSG night. These data make it difficult to draw conclusions because the measures are not really comparable, and data are not available for all measures. This last question is how much sleep is adequate? Adequate sleep is a requirement for correct interpretation of MSLT, but it is not defined.4 Indeed, it cannot be defined because it varies among individuals. Confusion arises because a minimum of 6 hours of sleep in the preceding PSG is required in the International Classification of Sleep Disorders-2 for performing the MSLT.1 This lower limit is not the same as adequate sleep. The lower limit was derived from the fact that narcolepsy patients often have very fragmented sleep and may not be able to get more than 6 hours of sleep at night. Six hours was not intended as an adequate amount of sleep in most cases, since most adults need 7–8 hours of sleep, while teenagers and some adults need more. Adequate sleep should allow a person to function well throughout the day without falling asleep or fighting sleepiness. Unfortunately, the sleep clinician will not know how many hours of sleep are adequate for a patient by looking at sleep duration in the weeks prior to the MSLT. The answers to these questions are still largely unknown. However, it is clear that a thorough sleep history combined with information about the prior week's sleep duration from any measure can help the clinician answer all of these questions. Moreover, given the large sleep debt in the country, a reasonable first step in most cases would be to prescribe increased sleep time for a week or two before deciding to do an MSLT. This may be beneficial to the patient, could provide valuable clinical information, and help assure more “adequate” prior sleep if an MSLT is performed.

Sleep, Circadian Rhythms, and Psychomotor Vigilance