Sleep and your health care provider
Sleep has been the subject of study for many years. Through the years we have discovered it's purpose and gained an understanding of its importance. However, many people still don't get enough of it. This can be due to an illness, disorder, Jet lag or even their day-to-day schedules. One area of interest, specifically, is how sleep affects individuals in the health care industry. As many know, the work schedules of health care providers on average is hectic and requires unusual hours to be worked. This work schedule increases fatigue and decreases cognitive function of health care providers, leading to a negative impact on patient safety and care.
Cognitive function is closely related to the amount of sleep a person receives on a daily basis. An average adult should get between 7-9 hours of sleep to function at his or her best. Although in some cases this isn't always feasible. Humans are equipped with biological clocks that control biological rhythms that effect sleep patterns. (Goel 2013) There are four biological rhythms that regulate bodily functions. These rhythms are known as the circadian, diurnal, ultradian and infradian rhythm. Each has its own function on the human body. However, the circadian and diurnal rhythms are the two rhythms that play major biological roles in an individuals sleep cycle. (Hedge 2013)
The circadian rhythms are physiological, psychological and behavioral changes that occur over a 24-hour period and are effected by natural internal factors within the body. The diurnal rhythm is an extension of the circadian rhythm, so it acts in the same manner but it is affected by external causes such as cycles of light and dark as well as social contact. The circadian rhythm is controlled by a group of cells located in the hypothalamus of the brain. This part of the brain is known as the Suprachiasmatic nucleus (SCN). This group of cells responds to light and dark and signals the diurnal rhythm when it is time for the body to wake up or go to sleep. After the diurnal rhythm is signaled, the circadian rhythm is signaled, which then sends signals to other parts of the brain that control hormones, body temperatures, levels of alertness, reaction times and other functions that make us feel awake or sleepy. For example, when the diurnal rhythm responds to light it causes the circadian rhythm to send signals to decrease the output of the hormone melatonin, which is associated with the onset of sleep. Therefore, when light is scene the body will feel more awake and when light is absent the body will feel sleepier. (Goel 2013)
An individual should listen to and follow his or her body's signals of when to go to sleep and when to wake up. This will help keep their body's circadian rhythm balanced. When the biological clock is not followed the circadian rhythm will become disrupted. This disruption can lead to weight gain, impulsiveness, delayed thinking and reaction times, poor executive function and poor emotional control. Author Iliad Karasoreos, PhD, of Rockefeller University stated, "These disruptions are not only a nuisance, they can lead to serious health and safety problems." (Stimpfel, Sloane, Aiken 2012) The circadian rhythm can become disrupted when there is a rapid change to sleep patterns. Such as not getting enough sleep or waking up and going to bed at different hours.
The circadian rhythm does have the ability to adjust and resynchronize but it is a challenging task for the body due to internal and external stimuli. The circadian rhythm can only shift 1-2 hours a day which means resynchronization can take up to several days depending on how drastic the shift in time. (Goel 2013) For instance, when a worker transitions from a day time shift to a night time shift, even after three to five shift, which is about a full work week the body still will not be 100% adjusted. The body will only be adjusted enough to make it easier on the person to stay more awake throughout the night. But he or she will still not be fully functional. For this reason, it is important for people to stick to a constant schedule. Although it's not always possible do to shift work, such as the shift work of medical residents, physicians and nurses.
Shift work is considered to be a schedule outside side of the average 9-5 work schedule typically worked in America. These shifts can be overnight, anything more than eight hours of work time or schedules that constantly rotate. These schedules do have many advantages but they also come with many risk factors. One of the main more serious risk factors is the disturbance to sleep, which can lead to excessive sleepiness or fatigue. Fatigue can lead to a plethora of problems not wanted in the work place, especially in the health care the setting. Some of these problems are irritability, lapse in memory, decreased empathy, slower reaction times, compromised problem solving and reaction times as well as many others. Some researchers suggest that the symptoms of fatigue are just a problematic as individuals that are inebriated. Sometimes the symptoms of fatigue caused by shift work are refereed to as "industrial lag." (Price 2011)
Shift work can be found across many field and industries. One of the most common field shift work is scene in is health care. This is mainly duo to the 24/7 medical care that needs to be provided all around the country. This mean nurses, doctors and medical resident/students are subject to the effects of shift work. On average hospital nurses work 8-12 hours a daily. They will either work in the day or night or at some hospitals they may even rotate between day and night shifts. Most nurses work 3-5 day a week but on some occasions the may even work six days a weak. Some nurses may have an on call requirement which means they are not formally on duty but they must be available to assist in a medical emergency when needed.
Physicians also experience shift work. The work schedule of fully certified physicians does vary depending upon the specialty, location and if the physicians work in a private practice or a hospital. However, the average hours worked amongst physicians in America considering all factors is approximately 59.6 hours a week. Like nurses, some doctors may be required to be on call for a certain amount of days out of the week and they may rotate between day and night shifts. (Eddy 2005)
Medical residence and students are also familiar with shift work. These individuals may even exhibit more severe symptoms of fatigue than nurses and physicians. The average resident works roughly 90 hours a week. They also work shifts known as heavy call rotations. These heavy call rotations consist of residents being on call two to three days a week with, one 24 hours day off out of a 7-day period. Within this rotation they are required to experience both day and night shifts. (Lockley, Barger 2007)
These work schedules pose a disruption to the workers circadian rhythm, which can lead to unruly systems exhibited in the work place. Nurse, Laura A. Stokowski, when interviewed stated " [when working the night shift] you have to find the time to get good sleep during the day or you cannot make it through the night. You feel sick to your stomach and your body shuts down no matter how hard you try to stay awake." These extreme work schedules are hard on a person's body and mind. Nurses, doctors and residents working with these disruptions may also lead to poor patient care and safety.
Over the past two decades there have been several studies conducted regarding the relationship between the schedules of health care providers and medical errors. The Harvard work hours, health and safety group lead by Rogers and Scott conducted two studies focusing on nurses shift work. In one of their studies they discovered that 34% of the nurses that worked more than 12.5 hours were three times more likely to make a medical error than the nurses that worked 8-hour shifts. In the second study conducted. A sample of 502 nurses that worked 12.5-hour shifts was used and the findings showed that 67% of the nurses had two times more medical errors than the nurses that worked a regular 8-hour shift.
In studies that focused on physician's schedules on medical errors the conclusions were similar to that of nurses. On behalf of the ACGME, Philibet analyzed 60 studies on the effects of sleep deprivation and physicians. The analysis concluded that the physicians that worked or were on call for more than 24 hours had a 10% decrease in overall performance. (Lockley, Barger 2007) In another study conducted on a group of surgeons demonstrated that over four consecutive night shifts those surgeons were at a higher risk of medical errors than the surgeons that worked 12-hour shifts during the day. (Mandawat 2015)
In research that focused on medical students, resident and interns the findings were even more severe than the focused research on nurses and physicians. One of the studies compared residents working 16-hour overnight shifts to residents that worked the same amount of hours during the day shift. The findings showed that the resident that worked the overnight shift had two times more as many failures regarding attention to details. The results also showed that 36% of the residents committed serious medical errors. In another study conducted on interns 2006 by the National Academy of science found that interns that worked just three hours more than their coworkers had 22% more critical errors that increased that chances of morbidity and mortality. (Stimpfel, Sloane, Aiken 2012)
These research results indicate that the schedules of medical professionals can cause serious medical issues to the patients they treat. A group of john Hopkins patient safety experts, over an eight-year span, calculated that there are over 440,000 death per year due to medical errors in the U.S alone. This makes medical errors the third most leading cause of death in America. It is estimated that out of the 440,000 deaths caused by medical errors approximately 100,000 of those errors are due to resident, nurse and physician sleep deprivation or fatigue. These results also raise red flags for medical policy makers and safety advocates to research more into this issue and discover plans of action to reduce these percentages. (Daniel 2016)
Not only is patient safety affected by the fatigue and sleep deprivation induced by the shift work but patient care and satisfaction may also be compromised. An American Medical Association study released last fall revealed that physicians who feel overworked, over scrutinized or overburdened with unfulfilling tasks can suffer continually from a growing sense that they are neglecting the professional priorities that really matter-their patients. (Stimpfel, Sloane, Aiken 2012)
All of the evidence from current research suggests that shift work does lead to a decrease in performance for a substantial amount of workers in the health care industry. Nurses that work more than 12-hour shifts are 2.5 times more likely to make medical errors. Doctors that worked night shift have 10% more chance to make medical errors than the doctors that work the day shift. Residents that work more than 16 hours and rotate between day and night shifts have a 36% chance of making critical medical errors. These findings are now forcing health care policy makers to make decisions about how to address this dilemma. It's a complicated decision because health care is need 24/7 but it is biologically difficult for people to work during the night and still have full cognitive function. Bottom line the work hours of health care providers are unsafe to the workers and the patients. Do reduce the risk these schedules create health care policy makers need to create limits as to how many hours a nurse, doctor and resident can work within a day. There should also be set times provider for these workers to take nap if shorter shifts are not feasible. As well as provided information about the signs of fatigue and sleep deprivation and ways to cope with them. Eventually with new policy there will be a decrease in the number of medical errors induced from fatigue and sleep deprivation.
Daniel, Michael. "Study Suggests Medical Errors Now Third Leading Cause Of Death in the U.S.
Eddy, Richard, MD. "Sleep Deprivation among Physicians." BC Medical Journal. BCMJ
Goel, Namni et al. "Circadian Rhythms, Sleep Deprivation, and Human Performance." Progress in molecular biology and translational science 119
Hedge, Alan. "Biological Rhythms." Cornell University
Lockley, Steven L., PhD, and Laura K. Barger, PhD. "Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance."
Mandawat, Anant, MD. "The Effects of Sleep Deprivation on Surgeons - and Their Patients."
Olson, Eric J., Lisa A. Drage, and R. Robert Auger. "Sleep Deprivation, Physician Performance, and Patient Safety."
Price, Michael. "The Risks of Night Work." American Psychological Association. Vol 42
Stimpfel, Amy Witkoski, Douglas M. Sloane, and Linda H. Aiken. "The Longer The Shifts For Hospital Nurses, The Higher The Levels Of Burnout And Patient Dissatisfaction." Health affairs (Project Hope)