Impacts of Shift Work on Sleep and Wakefulness

Contents

Introduction: The Sociology of Sleep
About the project
The participants
What we asked
Our findings

1. Impacts of shift work on sleep and wakefulness
2. Sleep and alertness in the workplace
3. Managing sleep and wakefulness

1. Managing sleep
2. Prescription medications
3. Managing alertness

1. Future

Conclusions and Recommendations

Introduction: The Sociology of Sleep

Sleep, in one form or another, is a biological necessity for all living creatures. While the exact functions of sleep are still being determined and debated in the scientific community, the effects of going without sleep for extended periods of time have been fairly well characterised. Getting enough sleep is regarded as essential for our health and wellbeing and short sleep on a regular basis has been associated with the development a range of serious health problems, from obesity to cancer (Cappuccio et al. 2008, Thompson et al. 2011). Sleep deprivation has been associated with impaired cognitive performance, decreased productivity in the workplace and an increase in accidents and errors (Alhola and Polo-Kantola 2007, Barger et al. 2005, Gaba and Howard 2002), highlighting the social costs and consequences of poor sleep.

Concerns have been raised that, as we move further towards a global 24/7 society, the length of time we spend sleeping is being curtailed in favour of waking activities and social opportunities (Williams 2011). Studies have found that although people do value sleep and link it to their general wellbeing, at the same time, sleep is often not given priority, instead being viewed as a ‘disposable resource’ or ‘expendable luxury’ (Dzaja et al. 2005: 69–70). Sleep deprivation is thought to be commonplace in contemporary western societies and it is frequently claimed that, on average, sleep duration is declining.

Although a still fairly nascent field of study, research into the sociology of sleep has begun to shed light on the social, cultural and political dimensions of sleep. Recent studies have shown how the meanings and values people attribute to sleep and the importance they give to it is likely to be gendered (Hislop and Arber 2003, Meadows et al. 2008, Venn et al. 2008) and to differ according to other socio-demographic and sociological factors including age (Venn and Arber 2011), socioeconomic status (Arber and Meadows 2011), occupation (Bryan 2011, Coveney, 2014) and substance use (Nettleton et al. 2011). As such, socially appropriate ways of ‘doing sleep’ (Williams 2007) and temporal and spatial patterning of sleep differ between social groups.

Recent large-scale surveys (Arber and Meadows 2011, Byran 2011, Chatzitheochari and Arber 2009) have drawn attention to the complex ways in which one's lifestyle, particularly in relation to work, impacts upon sleep. Shift work and long work hours (more than 48hours per week), in particular, have been associated with short sleep duration (that is, sleeping for 6 or fewer hours per diurnal day) and poor quality sleep (Bryan 2011). Work hours have also been linked to the development of sleep problems, the quality of sleep people get and the amount of time people spend asleep each day. For example, a recent study found that men actively negotiate the amount of time they are going to spend sleeping in relation to the amount of work they have to get done the next day (Meadows et al. 2008), thus demonstrating the extent to which employment is a key factor in the social patterning of sleep (Williams 2011). Sleep loss and fatigue are therefore prevalent problems in the modern workforce, particularly as long work hours and shift work become more common (Chatzitheochari and Arber 2009, Stoller, et al. 2009).

Sociological research into experiences of and expectations about sleep alerts us to how the broader social context, including lifestyle, work commitments, family responsibilities and the emotional labour attached to these social roles may influence sleep. Although there is much research to show that one's lifestyle and working patterns can have a significant influence on sleep duration and sleep quality, very few qualitative empirical studies have been conducted that focus specifically on the relationship between social context and subjective and embodied experiences of sleep. The aim of this study was to conduct an in-depth and qualitative analysis of the sleeping practices and subjective experiences of sleep across different social groups.

References

Alhola, P., & Polo-Kantola, P. (2007). Sleep deprivation: Impact on cognitive performance. Neuropsychiatric Disease & Treatment, 3(5), 553–567.

Arber, S., & Meadows, R. (2011). Social and health patterning of sleep quality and duration. In S. McFall & C. Garrington (eds) Understanding society: Early findings from the first wave of the UK's household longitudinal study. Colchester: ISER, University of Essex, pp. 88-98.

Barger, L.K., Cade, B.E., Ayas, N.T., et al. (2005). Extended work shifts and the risk of motor vehicle crashes among interns. New England Journal of Medicine, 352, 125–34.

Bryan, M.L. (2011). Measuring work: prospects for labour market research, in S. McFall and C. Garrington (eds) Understanding society: Early findings from the first wave of the UK's household longitudinal study, Colchester: ISER, University of Essex, pp. 35-42.

Cappuccio, F.P., Taggart, F.M., Kandala, N.B., Currie, A., Peile, E., Stranges, S., & Miller, M.A. (2008). Meta-analysis of short sleep duration and obesity in children and adults. Sleep, 31(5), 619-626.

Chatzitheochari, S. & Arber, S. (2009). Lack of sleep, work and the long hours culture: evidence from the UK Time Use Survey. Work, Employment & Society, 23(1), 30-48.

Coveney, C.M. (2014). Managing sleep and wakefulness in a 24-hour world. Sociology of Health & Illness,36(1), 123-36.

Dzaja, A., Arber, S., Hislop, J.et al. (2005). Women’s sleep in health and disease. Journal of Psychiatric Research, 39(1), 55-76.

Gaba D.M. & Howard SK (2002) Fatigue among clinicians and the safety of patients. New England Journal of Medicine. 347, 1249–55.

Hislop, J. and Arber, S. (2003) Understanding women's sleep management: beyond medicalization‐healthicization? Sociology of Health & Illness, 25(7), 815-837.

Meadows, R., Arber, S., Venn, S., & Hislop, J. (2008). Engaging with sleep: male definitions, understandings and attitudes. Sociology of Health & Illness, 30,696–710.

Nettleton, S., Neale, J. & Pickering, L. (2011) Techniques and transitions: A sociological analysis of sleeping practices amongst recovering heroin users.Social Science and Medicine, 72(8), 1367-73.

Stoller, E.P., Papp, K.K., Aikens, J.E., Erokwu, B., & Strohl, K.P. (2009). Strategies resident-physicians use to manage sleep loss and fatigue.Medical Education Online, eISSN 1087-2981.

Thompson, C. L., Larkin, E. K., Patel, S., Berger, N. A., Redline, S., & Li, L. (2011). Short duration of sleep increases risk of colorectal adenoma. Cancer, 117,841–7.

Venn, S., Arber, S., Meadows, R. & Hislop, J. (2008) The fourth shift: exploring the gendered nature of sleep disruption among couples with children.The British Journal of Sociology,59(1), 79-97.

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About the project

The Medicated Sleep and Wakefulness Project is a social scientific investigation ofdevelopments and debatesregardingthe role of sleep medication inBritain today. The research examined issues regarding the medical, social and personal management of sleep problems with particular reference to the roles, meanings and uses of pharmaceuticals in everyday/night life. This involved multiple methods, including documentary research, interviews, and focus groups with key stakeholders in the field. Eighteen interviews were held with scientists and clinicians, pharmacologists, General Practitioners and representatives of patient organisations. A total of 99 people across 23 focus groups also took part in the study.

The research project was funded by the Economic and Social Research Council (ESRC) and ran from April 2011 to May 2014.It wasbased in the Department of Sociology at the University of Warwick, and undertaken in conjunction with Royal Holloway, University of London and Kings College London. The research was led by Professor Jonathan Gabe. Other members of the research team were Professor Simon Williams, Professor John Abraham and Dr. Catherine Coveney.

The participants

As part of the larger study, threefocus groups were held with 9 members of the West Midlands Ambulance Service (WMAS) between February and March 2012. Data contained within this report are based on the responses of these participants.Numbers are small, in part at least because of the problems of recruiting respondents who are working on shifts. Consequently we are not claiming that they are representative of WMAS staff. However, they do raise some interesting issues about the nature of shift work and its impact on sleep.

The identity of all participants has been anonymised and remains confidential. Participants have been assigned with an alpha - numerical code to identify them. This identifies which focus group they took part in, their gender and the order they first spoke during the session. For example, FG1 M1 identifies the first male participant who spoke during focus group 1.

Participants from WMAS were aged 25 – 54. Five were male and four female. All identified as being of White British ethnicity.

Four respondents were ambulance technicians and five worked as paramedics. The length of time that they had worked shifts in the ambulance service varied from 3.5 years to over 30 years. The average was around 12 years’ service. The type of shift pattern each individual worked also varied. Only one participant had a fixed shift pattern of working one night shift per week. One worked permanent night shifts. The remaining 7 participants described variable shift patterns, rotating between day and night shifts across 24 hours of the day, 7 days a week, 365 days a year.

Five of the participants said that they were currently using, or had in the past, used over-the-counter (OTC) or prescription medications to help them sleep.

What we asked

During the focus groups participants were asked to discuss the following topics:

1. Expectations around and experiences of sleep

• Understandings and expectations around sleep – what sleep is for, what good sleep is, how important sleep is to them
• Their experiences of sleep, sleepiness and sleep problems

1. Managing sleep and wakefulness

• Managing sleep and wakefulness in daily life– pharmacological and non-pharmacological strategies
• Relationships with medications– accepting/resisting medicine
• Seeking information and advice

1. Attitudes towards the uses of sleep and wakefulness medication in the workplace

• Moral judgements and discourses used to evaluate drug use
• Non-medical/ lifestyle uses –social and ethical issues

Our findings

1. Impacts of shift work on sleep and wakefulness

..I don’t believe I have a sleep pattern, I just sleep as and when I need to and it’s only very, very short periods at a time. I honestly thought that after many years of doing permanent nights that it would have changed and my body would have naturally adapted, but it hasn’t and I find a lot of people I work with are in the same boat”. (FG2 M1)

Sleep was valued highly by all of those who participated in the study. All considered sleep to be vital for health, wellbeing and ability to function both inside and outside of the workplace. Participants spoke about the body and brain needing sleep for recovery, rest and repair. Getting enough good quality sleep was viewed as key for mental health and general wellbeing.

All of those who took part in our focus groups found shift work had a direct negative impact upon their sleep, in terms of reducing sleep quality, quantity oraltering their preferred sleep patterns. Shift work was considered to be an “unnatural environment”, particularly night shift work where participants thought that by staying awake at night and trying to sleep during the daytime, they were attempting to function against the natural rhythm of their body.

Night shift work was implicated in a reduction in the time participants were able to spend asleep and the quality of sleep they were able to get. Participants found it difficult to sleep during the daytime after working a night shift. They reported thatit wasa problem switching off after a shift and described struggling to fall asleep and to stay asleep, often sleeping in shorter periods of ‘broken sleep’ for around 3 -6 hours in total. Many participants also found it difficult to wake up once they had fallen asleep and described having to set several alarms to ensure that they were up and ready for their next shift. Although describing individual sleep needs and patterns, all expressed how they would like to get more sleep. For most, the amount of sleep they were able to get during periods of night shift work was not considered sufficient.

Changing shift patterns were thought to have a more detrimental impact on sleep than working night shifts.It was common for respondents to state that they found it difficult to sleep when changing from night shifts to day shifts, often finding themselves lying awake in bed unable to sleep. In particular, quick turn-around times between night and day shifts were thought to be hard to cope with, with participants saying it was difficult to turn their body clock around from being awake during the daytime to staying awake during the night, and vice versa. Most felt that it took several days to adjust and to ‘feel normal again’, likening this to experiencing jet-lag. Those working relief shifts were perceived to be hit the hardest by this, having no time for their bodies to readjust to new patterns of sleep and wakefulness.

“Early in my career, I was all right while I was single and then just a married person. It was quite easy because I slept whenever I got tired, so sleeping in the day was fine. Since having children, their routine is a lot more structured and, therefore, doesn’t matter what you’ve been doing they get up at the same time every day and keep you awake during that time, obviously. So, actually, recovering after a run of any shift, really, whether that be an early shift because they are just as bad for me if I have to get up at, you know, an hour or two hours before the kids would normally get up then I’m just as ruined as I am doing a night shift. I can see how much better I feel when I’ve not been doing shifts and when I’ve been getting up the same time every day, going to bed the same time. Now that I’ve moved into family life it makes it a lot more difficult to deal with sleep and when I can actually get to sleep”. (FG1 M1)

Although some participants thought that they were able to catch up on this missed sleep by sleeping for longer on their days off, most felt that they never fully recovered from the sleep loss resulting from shift work. They described feeling constantly sleep deprived and perceived this lack of sleep to build up through successive years.

Those with families seemed more affected by sleep loss associated with shift work than those who lived alone and did not have family responsibilities. The impact on families and family life was thought to be considerable. Catching up on sleep after wakeful nights was often not possible due to the demands and obligations of being a mother, father or partner, providing care for others, spending time with children and partners and other responsibilities that come with these roles such as household chores and school runs.

2. Sleep and alertness in the workplace

FG2 F1 [on a night shift] everything just is five times as hard, even just basic coordination, sometimes, using our equipment.On a normal day shift, if I’d had a relatively decent kip before, I might be ok with certain pieces of kit and then if you try to do the same thing on a night shift nothing works, you know, this is too heavy, that’s too ... that doesn’t fit, this is... and everything becomes so short fused.

FG2F2 Yeah, everything weighs a ton […] everything becomes so much harder. So, things that we find we can do without thinking about during a day shift become quite taxing during a night shift. Even being able to stay awake while driving is phenomenally difficult. Sometimes I am convinced I’ve had about 10 micro sleeps on the way from one standby point to another because they seem to think that it’s great sport to make us just drive around all night! […] I always drive second half and I’m always off my feet by then, but I think to myself, I could probably cope better with driving than actually dealing with the patient because I can’t actually speak to the patient right now because I can’t string a sentence together.

FG2F3 I just get really tired and I don’t think I’m recovering enough to make a difference for my future shifts […] I continue with my shifts and I just feel even more tired and more drained. It impacts emotionally as well as physically in the sense that things can become slightly more sensitive when I am feeling very tired. I become more intolerant […] my speech is terrible, I can’t get my words out properly, or they will come out but they will be in a completely mixed part of the sentence, you know, and you can see people going... “All right, ok...” and they are having to work to try and understand and it’s ever so embarrassing. Even patients, you can see them going [sigh].