Alertness Management Research Articles

Motives for Caffeine Consumption Questionnaire (MCCQ): validity and reliability of Turkish version

ObjectivesThe aims of this study are to make the Turkish validity and reliability of the scale that explain why caffeine intake. Additionally, it is crucial to highlight that the adaptation of the scale involved a confirmatory factor analysis (CFA) to validate its structure and the need for this adaptation in the Turkish context.Materials and methodsThe study was carried out with a total of 200 university students, comprised of 93.5% female and 6.5% male participants, with a mean age of 21.74 ± 6.15 years who were actively studying in the faculties of the universities who accepted to participate voluntarily in the study were included. The Turkish version of the Motives for Caffeine Consumption Questionnaire (MCCQ) scale and the MCCQ was used as the data collection tools. To evaluate the statistical analysis findings, the margin of error was taken as 5%. The entire application was carried out with the R-project software. CFA was used to test the adaptation of the MCCQ scale from English to Turkish.ResultsThe alpha internal consistency coefficient for the whole scale was calculated as 0.959. Just like the original scale, the Turkish version shows a six-factor structure: habit, alertness, mood, social, taste, and symptom management. In MCCQ-TR, it showed a low level of positive correlation with Yale Food Addiction Scale (YFAS). For the final scale with 23 items and 6 sub-dimensions, it was determined that the fit indices were at an acceptable level, and the internal consistency was highly reliable for all sub-dimensions and the total scale.ConclusionsIt has been determined that the Turkish version of the MCCQ is a valid and reliable measurement tool to operationalize the motives of caffeine consumption and to reveal possible differences in the motives regarding gender, age, and the type of caffeinated products consumed. The use of CFA in adapting the scale ensures the robustness of the structural validity in the Turkish context, making this adaptation a valuable contribution to the field.

Findings from a systematic review of fatigue interventions: What's (not) being tested in mining and other industrial environments.

Fatigue negatively impacts mineworker health and safety. In this paper, we identify fatigue interventions tested on industrial shiftworkers and explore their effects and the factors that may influence application in an industrial setting such as a mine site. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. A structured, systematic search of the literature was conducted to identify relevant studies published between 1980 and 2020. Researchers independently conducted article screening and study quality appraisals against pre-established criteria, and then extracted data and conducted a narrative synthesis of the included studies. Seven intervention studies, out of 1651 articles initially screened, were retained for narrative synthesis. Four studies tested the alerting effects of bright-light treatment, one evaluated the effectiveness of blue-light blocking glasses at improving daytime sleep quality and nighttime vigilance, and two examined whether sleep hygiene and alertness management trainings improved sleep quality or alertness. There was substantial evidence for the use of bright-light treatments to improve night shiftworker alertness, but insufficient evidence to draw conclusions about the effectiveness of blue-light blocking glasses and sleep hygiene and alertness management trainings due to the small number of studies included. Shiftworkers were mostly male and employed in industrial subsectors such as production and manufacturing, oil and gas, and transportation. No mining-specific intervention studies were identified. Future research is needed to identify effective fatigue risk management interventions for the mining industry as well as best practices for implementing these interventions with mineworkers.

Cross-sectional analysis of sleep-promoting and wake-promoting drug use on health, fatigue-related error, and near-crashes in police officers

ObjectivesTo examine sleep-promoting and wake-promoting drug use in police officers and associations between their use and health (excessive sleepiness, stress and burnout), performance (fatigue-related errors) and safety (near-crashes) outcomes, both...

Recurrent On-Duty Sleepiness and Alertness Management Strategies in Long-Haul Airline Pilots.

We examined whether long-haul airline pilots without recurrent on-duty sleepiness obtain more prior sleep and use more effective in-flight alertness management strategies than their colleagues with recurrent on-duty sleepiness. There were 51 pilots who flew at least twice from Helsinki to Asia. Of them, 44 flew at least twice back to Helsinki following 1 local night. On-duty sleepiness was measured by the Karolinska Sleepiness Scale (KSS), alertness management strategies by a diary, and sleep by a diary and activity monitor. Pilots who rated KSS ≥ 7 on each, some, or none of the flights were classified as "regularly", "sometimes", and "never" sleepy, respectively. This classification was performed separately for the outbound and inbound flights. On the outbound flights, 22% of the pilots were "never", 54% "sometimes", and 24% "regularly" sleepy. For the inbound flights, the respective distribution was 25%, 48%, and 27%. Compared to the "regularly" sleepy group, the "never" sleepy group obtained 54 min more night sleep prior to the outbound flights. For the inbound flights, the respective difference was 1 h 23 min. Also, the "never" sleepy pilots slept 31 min more between days off than the "regularly" sleepy pilots. The results of the in-flight alertness management strategies were mixed. The study demonstrates that pilots without recurrent on-duty sleepiness obtain more sleep than their colleagues with recurrent on-duty sleepiness. The result emphasizes the need to investigate whether the sleep of recurrently sleepy pilots can be increased and whether this increase would reduce their on-duty sleepiness.Sallinen M, Åkerstedt T, Härmä M, Henelius A, Ketola K, Leinikka M, Kecklund G, Sihvola M, Tuori A, Virkkala J, Puttonen S. Recurrent on-duty sleepiness and alertness management strategies in long-haul airline pilots. Aerosp Med Hum Perform. 2018; 89(7):601-608.

Effects of alertness management training on sleepiness among long-haul truck drivers: A randomized controlled trial

Education is a frequently recommended remedy for driver sleepiness in occupational settings, although not many studies have examined its usefulness. To date, there are no previous on-road randomized controlled trials investigating the benefits of training on sleepiness among employees working in road transport. To examine the effects of an educational intervention on long-haul truck drivers’ sleepiness at the wheel, amount of sleep between work shifts, and use of efficient sleepiness countermeasures (SCM) in association with night and non-night shift, a total of 53 truck drivers operating from southern Finland were allocated into an intervention and a control group using a stratified randomization method (allocation ratio for intervention and control groups 32:21, respectively). The intervention group received a 3.5-hour alertness management training followed by a two-month consultation period and motivational self-evaluation tasks two and 4–5 months after the training, while the control group had an opportunity to utilize their usual statutory occupational health care services. The outcomes were measured under drivers’ natural working and shift conditions over a period of two weeks before and after the intervention using unobtrusive data-collection methods including the Karolinska Sleepiness Scale measuring on-duty sleepiness, a combination of actigraphy and a sleep-log measuring sleep between duty hours, and self-report questionnaire items measuring the use of SCMs while on duty. The data analysis followed a per-protocol analysis. Results of the multilevel regression models showed no significant intervention-related improvements in driver sleepiness, prior sleep, or use of SCMs while working on night and early morning shifts compared to day and/or evening shifts. The current study failed to provide support for a feasible non-recurrent alertness-management training being effective remedy for driver sleepiness in occupational settings. These results cannot, however, be interpreted as evidence against alertness management training in general but propose that driver education is not a sufficient measure as such to alleviate driver sleepiness.

Why Do You Drink Caffeine? The Development of the Motives for Caffeine Consumption Questionnaire (MCCQ) and Its Relationship with Gender, Age and the Types of Caffeinated Beverages

Caffeine is the most popular psychoactive substance that is consumed worldwide. As motives influence behavior, investigation of the motivational background of caffeine consumption should help provide a better understanding of the popularity of caffeinated products. The present study aimed (i) to explore and operationalize the motives of caffeine consumption and (ii) to reveal possible differences in the motives regarding gender, age and the type of caffeinated products consumed. Motives for caffeine consumption were collected from regular caffeine consumers (N = 26) and were informed by a review of the relevant literature. Following this, a cross-sectional study was conducted on a convenience sample of Hungarian university students and working adults (N = 598). The participants completed the Motives for Caffeine Consumption Questionnaire and the Caffeine Consumption Questionnaire. Six motivational factors were identified: Alertness, Habit, Mood, Social, Taste and Symptom Management. Women had higher scores on Habit, Social, Taste and Symptom Management. Younger participants had higher scores on Alertness than the older group, and the older group had higher scores on Habit and Symptom Management. Five types of caffeine users were identified. Those who consumed (i) coffee, (ii) tea, (iii) energy drinks, (iv) coffee and tea and (v) mixed drinks. Several differences between the five groups were revealed across all motives except for Taste. The present study developed a robust psychometric instrument for assessing caffeine consumption motives. The factors varied in importance in relation to gender, age and caffeine consumption habits.

Sleep, alertness and alertness management among commercial airline pilots on short-haul and long-haul flights

Airline pilots’ sleep and on-duty alertness are important focus areas in commercial aviation. Until now, studies pertaining to this topic have mainly focused on specific characteristics of flights and thus a comprehensive picture of the matter is not well established. In addition, research knowledge of what airline pilots actually do to maintain their alertness while being on duty is scarce.To address these gaps in research knowledge, we conducted a field study on a representative sample of the airline pilots of a medium-sized airline. The sample consisted of 90 pilots, of whom 30 flew long-haul (LH) routes, 30 short-haul (SH) routes, and 30 flew both. A total of 86 pilots completed the measurements that lasted for almost two months per pilot. The measurements resulted in a total of 965 flight duty periods (FDPs) including SH flights and 627 FDPs including LH flights. During the measurement periods, sleep was measured by a diary and actigraphs, on-duty alertness by the Karolinska Sleepiness Scale (KSS) in all flight phases, and on-duty alertness management strategies by the diary.Results showed that SH and LH FDPs covering the whole domicile night (00:00–06:00 at home base) were most consistently associated with reduced sleep-wake ratio and subjective alertness. Approximately every 3rd FDP falling into this category involved a reduced sleep-wake ratio (1:3 or lower) and every 2nd a reduced level of subjective alertness (KSS rating 8–9 in at least one flight phase). The corresponding frequencies for the SH and LH FDPs that partly covered the domicile night were every 10th and every 5th FDP and for the pure non-night FDPs every 30th and every 36th FDP, respectively. The results also showed that the pilots tended to increase the use of effective on-duty alertness management strategies (consuming alertness-promoting products and taking strategic naps) in connection with the FDPs that overlapped the domicile night. Finally, the results showed that the frequency of flights involving reduced subjective alertness depended on how alertness was assessed. If it was assessed solely in the flight phase just before starting the landing procedures (top of descent) the phenomenon was less frequent than if the preceding cruise phase was also taken into account.Our results suggest that FDPs covering the whole domicile night should be prioritised over the other FDPs in fatigue management, regardless of whether an FDP is a short-haul or a long-haul. In addition, the identification of fatigue in flight operations requires one to assess pilots’ alertness across all flight phases, not only at ToD. Due to limitations in our data, these conclusions can, however, be generalise to only LH FDPs during which pilots can be expected to be well acclimatised to the local time at their home base and SH night FDPs that include at least 3h of flying in the cruise phase.

Sleepiness, sleep, and use of sleepiness countermeasures in shift-working long-haul truck drivers

Driver sleepiness is a prevalent phenomenon among professional drivers working unconventional and irregular hours. For compromising occupational and traffic safety, sleepiness has become one of the major conundrums of road transportation. To further elucidate the phenomenon, an on-road study canvassing the under-explored relationship between working hours and sleepiness, sleep, and use of sleepiness countermeasures during and outside statutory rest breaks was conducted. Testing the association between the outcomes and working hours, generalized estimating equations models were fitted on a data collected from 54 long-haul truck drivers (mean 38.1±10.5 years, one female) volunteering in the 2-week study. Unobtrusive data-collection methods applied under naturalistic working and shift conditions included the Karolinska Sleepiness Scale (KSS) measuring sleepiness, a combination of actigraphy and sleep-log measuring sleep, and self-report questionnaire items incorporated into the sleep-log measuring the use of sleepiness countermeasures during and outside statutory rest breaks. Drivers’ working hours were categorized into first and consecutive night, morning and day/evening shifts based on shift timing. The results reveal severe sleepiness (KSS≥7) was most prevalent on the first night (37.8%) and least on the morning (10.0%) shifts. Drivers slept reasonably well prior to duty hours, with main sleep being longest prior to the first night (total sleep time 7:21) and shortest prior to the morning (total sleep time 5:43) shifts. The proportion of shifts whereby drivers reported using at least one sleepiness countermeasure outside statutory rest breaks was approximately 22% units greater for the night than the non-night shifts. Compared to the day/evening shifts, the odds of severe sleepiness were greater only on the first night shifts (OR 6.4–9.1 with 95% confidence intervals, depending on the statistical model), the odds of insufficient daily sleep were higher especially prior to the consecutive night shifts (OR 3.5 with 95% confidence intervals), and the odds of using efficient sleepiness countermeasures outside statutory rest breaks were greater on the first as well as consecutive night shifts (OR 4.0–4.6 with 95% confidence intervals). No statistically significant association was found between shift type and use of efficient sleepiness countermeasures during statutory rest breaks. In all, the findings demonstrate marked differences in the occurrence of severe sleepiness at the wheel, sleep preceding duty hours, and the use of sleepiness countermeasures between different shift types. In addition, although drivers slept reasonably well in connection with different shift types, the findings imply there is still room for improvement in alertness management among this group of employees.

2011 Critical Care Transport Workplace and Salary Survey

Critical care transport (CCT) leaders from 260 organizations were invited to participate in an online, hosted survey of industry compensation and workplace practices. Approximately 150 questions were presented to participants, soliciting a broad base of information on CCT organizations, personnel, compensation, and workplace practices, notably alertness and fatigue management. CCT organizational salaries are represented by common job class and reported by summary with minimum, middle, and maximum hourly rates in a national aggregate and by Association of Air Medical Services region.

Pilot Fatigue Survey: Exploring Fatigue Factors in Air Medical Operations

IntroductionHumans confront significant physiological challenges with sleep and alertness when working in 24/7 operations. MethodsA web-based national survey of air medical pilots examined issues relevant to fatigue and sleep management. ResultsSix hundred ninety-seven responses were received, with a majority of rotor wing pilots working 3/3/7 and 7/7 duty schedules. Over 84% of the pilots reported that fatigue had affected their flight performance; less than 28% reported “nodding off” during flight. More than 90% reported a separate work site “rest” room with a bed available. Over 90% reported no company policies restricting on-duty sleep. Approximately half of the pilots reported getting 4 hours or more sleep during a typical night shift. Approximately half reported that sleep inertia had never compromised flight safety. Over 90% reported that it was better to sleep during the night and overcome sleep inertia if necessary. DiscussionSurvey results reflected practices that can mitigate the degrading effects of fatigue, including the availability of designated work-site sleep rooms. As demands continue to evolve, the need remains for sustained efforts to address fatigue-related risks in the air medical transport industry. This includes further study of sleep inertia issues and the need for alertness management programs.

'Alertness Management in Aviation Operations: Enhancing Performance and Sleep'

Fatigue is an acknowledged safety risk in diverse operational settings. As a result, there has been growing interest in developing and implementing activities to improve alertness, performance, and safety in real-world operations where fatigue is a factor. A comprehensive Alertness Management Program (AMP) that included education, alertness strategies, scheduling, and healthy sleep was implemented in a commercial airline. An operational evaluation was conducted with 29 flight crewmembers, first when flying a standard schedule without AMP components (i.e., standard condition) compared with full AMP implementation, which included flying an innovative schedule that incorporated physiological sleep and alertness principles (i.e., intervention condition). The evaluation included objective measures of sleep quantity (actigraphy), psychomotor vigilance task (PVT) performance, and subjective reports of daily activities and sleep. The results showed that the 3.5-h educational CD improved pre-education test scores from an average 74% correct to a post-education average of 98%. Alertness strategies showed minimal changes, though the daily diary did not allow for refined evaluation of duration, frequency, and timing of use. The intervention condition was associated with significantly more sleep (1 h, 9 min; p < 0.01) during the trip period compared with the standard schedule. All performance metrics showed significantly better performance during the intervention condition trip schedule (p < 0.01) compared with the standard condition. This first-ever evaluation of a comprehensive AMP showed significantly improved knowledge, support for the use of alertness strategies, and increased sleep and performance during actual operations. The robust and consistent findings support the use of an AMP approach to effectively manage fatigue in operational settings.

Sekundenschlaf, Schläfrigkeit und Verkehrstüchtigkeit beim Schlafapnoe-Syndrom

Especially during monitoring activities or car driving needing high vigilance, episodes of microsleep are extremely dangerous. Microsleep can be described by observing behaviour patterns or electrophysiological parameters. An early recognition of these episodes is desirable. In the automobile industry intensive development is ongoing to register sleepiness and subsequent microsleep during driving to avoid accidents. The monitoring of eyelid frequency and diameter of the pupil (eye tracking) are most promising. Compared with a reference population, the accident risk of patients with sleep-related breathing disorders is more than two-fold higher. But up to now there are no definitive criteria--neither subjective nor objective tests such as, for instance, driving simulators--to predict driving impairment. By means of screening examinations, patients with obstructive sleep apnoea syndrome (OSAS) should be detected because therapy with CPAP normalises the accident rate. A further measure to reduce the risk of accidents is the so-called alertness management where techniques are communicated to detect and avoid sleeping episodes.

Alertness management strategies for operational contexts

This review addresses the problem of fatigue (on-the-job-sleepiness) attributable to sleep loss in modern society and the scientifically proven strategies useful for reducing fatigue-related risks. Fatigue has become pervasive because many people work non-standard schedules, and/or they consistently fail to obtain sufficient sleep. Sleep restriction, sleep deprivation, and circadian desynchronization produce a variety of decrements in cognitive performance as well as an array of occupational and health risks. A number of real-world mishaps have resulted from performance failures associated with operator sleepiness. In some cases, fatigue/sleepiness is unavoidable, at least temporarily, due to job-related or other factors, but in other cases, fatigue/sleepiness results from poor personal choices. Furthermore, some individuals are more vulnerable to the effects of sleep loss than others. Fortunately, fatigue-related risks can be mitigated with scientifically valid alertness-management strategies. Proper work/rest scheduling and good sleep hygiene are of primary importance. If sleep time is available but sleep is difficult to obtain, sleep-inducing medications and behavioral circadian-adjustment strategies are key. In fatiguing situations such as when sleep opportunities are temporarily inadequate, limiting time on tasks, strategic napping, and the potential use of alertness-enhancing compounds must be considered. To optimize any alertness-management program, everyone must first be educated about the nature of the problem and the manner in which accepted remedies should be implemented. In the near future, objective fatigue-detection technologies may contribute substantially to the alleviation of fatigue-related risks in real-world operations.

Underestimating the societal costs of impaired alertness: safety, health and productivity risks

Modern society now operates on a 24/7 global basis, with around-the-clock requirements that often ignore sleep, circadian rhythms, irregular work schedules and geographical time zones. Despite overwhelming evidence, there is gross underestimation and very little acknowledgement of the risks and costs related to sleep loss, circadian disruption, sleep disorders, reduced alertness and performance. Understanding the specific factors that impede our progress in addressing impaired alertness as an important societal issue could lead to raised awareness of the risks and costs and subsequent implementation of change. Effecting change requires an understanding of the complexity of the issue and a multidimensional approach. Real world data and outcomes are required to determine the exact extent of the health and safety risks related to impaired alertness. More public awareness of the potential hazards of impaired alertness is needed among the general population to increase societal knowledge and appreciation. Physicians need to be educated about the importance of detecting impaired alertness in their patients and should be aware of the range of actions needed to help these individuals so that they do not cause harm to themselves or others. A comprehensive approach using scientifically based alertness management principles and practices offers society an opportunity to operate 24/7 while reducing the risks and costs associated with impaired alertness.

Sleep loss and fatigue in medical training.

The effects of sleep loss and fatigue in the context of medical training is a topic that has generated considerable interest, as well as controversy, over the past two decades. The sleep deprived state in medical trainees potentially impacts on a variety of domains relevant to medical care, including performance on neurobehavioral and work-related tasks, mood and affect, learning, risk for and commission of medical errors, and the health and well-being of medical students and residents. The following review provides a summary of research conducted on this topic in the past decade, including the relation of sleep loss and fatigue to medical errors and the quality of patient care. Those few studies that have analyzed the use of operational alertness management strategies, countermeasures, and educational interventions to address and mitigate the effects of sleep loss and fatigue are also reviewed. There is clearly a need for additional research to further explore the complex interaction between sleep and fatigue and medical care, and to support the development and implementation of regulatory policies based on sound science.

Alertness management in long-haul flying

The introduction of ultralong-haul aircraft in recent years has highlighted the need for alertness management advice to be available to flight and cabin crew. British Airways has for some time provided classroom training but, more recently, has developed Alertness Management Advice Cards to provide route- and time-specific advice for the management of rest and sleep by long-haul crews. Using a framework based on the Airbus Industrie publication `Coping with Long-Range Flying', British Airways created a set of cards and accompanying information booklet specifically for its Boeing 777 routes and a trial of 40 flight crew members was undertaken to assess the usefulness and acceptability of the concept. Subjects found the advice cards easy to use and helpful and the information booklet clear in outlining the physiology of sleep, alertness and circadian rhythms. Following the study, further advice cards were developed to cover the entire British Airways long-haul network and the complete Alertness Management package comprises a General Information section summarising the classroom teaching together with 30 Advice Cards covering 42 different route schedules grouped by direction of travel, time of departure and length of the layover. The cards contain general and specific advice including recommendations for light exposure, rest patterns and meal times presented in written and diagrammatic forms. Examples of sections from the Advice Cards together with results of the initial study will be presented and discussed.

Assessing nighttime vigilance through a three-letter cancellation task (3-LCT): effects of daytime sleep with temazepam or placebo

Nocturnal sleepiness is a common complaint suffered by night-shift workers, especially in conditions of an abrupt shift of the wake–sleep cycle. Alertness management strategies can minimize the adverse effects of sleep loss and circadian rhythm desynchronization and promote optimal vigilance in operational settings. Within these strategies, one possibility is to use short periods of “prophylactic sleep” (before long periods of work), which can be facilitated by hypnotics. Vigilance can be evaluated by means of several tests which, sometimes, imply procedures and devices not easily employable in operational settings. In such conditions pencil and paper tests of vigilance can be very useful in the assessment of attentional performance degradation due to sleep loss and/or inversion of the sleep–wake cycle. In this study we evaluated the sensitivity of a three-Letter Cancellation Task (3-LCT) in revealing nighttime variations of vigilance in a laboratory simulation of acute night shift, after a diurnal sleep with placebo (PLC) or temazepam (TMZ). Nocturnal levels of vigilance were also assessed using the Maintenance of Wakefulness Test (MWT) and the Multiple Sleep Latency Test (MSLT). All tests were administered four times at 2-h intervals during nighttime after a daytime sleep. Results show that the 3-LCT is sensitive to variations of vigilance occurring during a laboratory simulation of acute night shift. We also found some effects of TMZ, which in the first nocturnal session caused a slowing down of visuoattentive performance. Nocturnal variations of vigilance detected through the 3-LCT were similar to those revealed by means of MSLT, while the ability to maintain wakefulness was substantially spared during the night.

Alertness management: strategic naps in operational settings.

Managing fatigue in complex operational settings requires attention to multiple factors, including hours of service, scheduling, education and training, counter-measures, technology, and research. Alertness-management strategies can be used to promote safety, performance, and productivity in operational settings. These strategies can involve both preventive (used prior to duty/shift) and operational (used during duty/shift) approaches. Studies have demonstrated the effectiveness of naps to improve subsequent performance and alertness. Strategic naps can be used effectively to promote performance and alertness in operational settings. Two potential negative effects of naps, sleep inertia and effects on subsequent sleep periods, are discussed. Sleep inertia can involve sleepiness and decreased performance immediately upon awakening from a nap. It should be a consideration prior to implementing nap strategies in work environments. A study of planned rest periods in long-haul flight operations demonstrated the effectiveness of in-flight naps to promote performance and alertness during subsequent critical phases of flight (descent and landing). Empirical evaluation of alertness-management strategies during regular operations will be critical to their implementation. Combining strategies may be the most effective approach to managing fatigue engendered by 24-h operational demands. Other considerations prior to implementing alertness-management strategies in operational environments are discussed.

Alertness management in industry.

Abstract Alertness management is of interest in industry because of its criticality to production rate, quality control, and operator safety. Alertness management includes: (a) elimination of factors conducive to alertness decrement, (b) addition of conditions or procedures which enhance alertness, (c) reduction of the consequences of alertness decrements, and (d) personnel monitoring when necessary. The criteria for evaluating the controlling elements in the task, physical environment, social environment, and procedures which may lead to decrements in alertness are discussed. Monitoring procedures are described and recommendations suggested which should lead to improved alertness management in the industrial situation. An alertness checklist is presented for use in analyzing particular job situations.