Awake, Alert, and Ready to Work

Sleep technicians are not immune from the disorders they treat. In fact, sleep professionals, who are surrounded by sleep disorders daily, may fail to notice the signs and symptoms of a sleep problem in themselves. The very nature of the work of sleep professionals, which often calls for rotating shifts or night shifts, can put them at risk for shift work sleep disorder (SWSD). For the sleep professional, recognizing and coping with sleep deprivation can be challenging, but by employing the right strategies and having the necessary support team, sleep-deprived sleep professionals can endure the challenge of shift work and be successful in their profession.

DEFINING THE PROBLEM

In the United States, nearly 6 million full-time employees work night shifts on a regular or rotating basis, and approximately one quarter of these night shift workers are estimated to have SWSD.¹ The disorder is frequently found in people who work between 10 pm and 6 am. Night shifts for sleep professionals usually start at 6 pm and end at 8 am or are from 7 pm to 7 am, crossing through the hours common in those who suffer from SWSD.

While not all people who work night shifts develop SWSD, shift workers do have to learn to cope with fighting the body’s natural wake-sleep pattern. Many biological processes, including sleep and wakefulness as well as feeding and metabolism, have a 24-hour rhythm. The circadian rhythms that underlie these patterns are controlled in the brain by a molecular clock that has a period of approximately 24 hours. Exposure to light and darkness, in addition to light intensity and alterations in sleep patterns, can affect the timing of the circadian clock. Sleep technicians who work during the night might find it difficult to sleep during the day, since they are working against the nature of the circadian clock.

“Human beings are designed to be day-functioning,” says Marcel Hungs, MD, PhD, assistant professor of clinical neurology and director, Center for Sleep Medicine, at the University of California, Irvine, who is also a Diplomate of the American Board of Psychiatry and Neurology. “Physiology predisposes people to sleep at night when it is dark and to be alert in the daytime. Sleep technicians are required to work at night against natural physiology. Working against natural physiology increases the potential for physical and emotional stress because the body has to adapt to circumstances for which it was never designed.”

Further complicating the issue of sleep patterns of such professionals as Registered Polysomnographic Technologists (RPSGTs) is working split shifts when an employee may work from 6 am to 10 am, have a break until 4 pm, and work until later in the evening. Others work three 12-hour shifts followed by 4 days off. This arrangement can cause difficulty because the employee can have trouble adjusting to a set schedule of awake hours and sleep hours. Still some technicians might be working every other day, which can increase the strain on maintaining workplace wakefulness. “I’ve heard of some places (not accredited labs) where they might have [sleep technicians] work Monday, Wednesday, and Thursday, so their days and their nights are going to be really off,” says Nancy Sacks, RPSGT, Mission Sleep Disorders Institute, Mission Viejo, Calif.

SLEEP DEPRIVATION AT WORK

Heavy sleep deprivation can impact work performance. Sleep-deprived technologists may have difficulty concentrating, which can endanger the patient being studied. “You’ve got a person’s life here, and we’ve got some people who are really ill,” Sacks says. “You need to be watching for any arrhythmias or if they stop breathing.” Many patients who are tested for OSA also suffer from obesity or heart disease. Due to the dangers posed by such patients’ health problems, close monitoring is of utmost importance. If a technician is dozing on the job, a patient’s life could be at stake.

Sleep deprivation also can cause irritability, which can be problematic when dealing with difficult patients. “Inadequate rest impairs the ability to think, handle stress, maintain a healthy immune system, and modulate emotions,” Hungs says. Many patients do not want to be in the sleep lab or are in the sleep lab in an effort to solve a serious health problem related to a number of complications, including cardiovascular disease. Other patients are going to the lab for testing, not because they want to go of their own free will, but because a family member or bed partner has insisted. Regardless of the situation, when patients are frustrated or uncooperative, they need encouragement and support. When technicians are burdened by irritability stemming from tiredness, they cannot deliver care at their maximum potential.

Hungs says that sleep deprivation also might lead to difficulties with prioritizing and recording procedures, and sleep-deprived technicians may have trouble properly titrating CPAP or even miss significant cardiac emergencies. “If the technician is not completely alert and rested, the brain’s ability to function quickly is impaired,” Hungs says. “The brain works harder to counteract sleep deprivation effects, but operates less effectively, and concentration levels drop. The brain’s ability to problem solve is greatly impaired, and decision-making abilities can be compromised.”

SOLUTIONS: PROPER MANAGEMENT

For the sleep professional who struggles with sleep deprivation, there are several practices that should be employed. When working a shift that increases the odds of sleep deprivation, eating properly will aid in maintaining health. Research by Warwick Medical School at the University of Warwick, in the United Kingdom, has found that sleep deprivation is associated with an almost twofold increased risk of being obese for both children and adults.² Researcher Professor Francesco Cappuccio points out that short sleep duration may lead to obesity through an increase of appetite via hormonal changes caused by the sleep deprivation. Seeing that sleep deprivation increases the odds of obesity, maintaining a healthy diet is an important part of shift workers’ health.

Family support also is key to managing shift work. “Night shifts cause disruption to personal and family lives and may result in higher levels of stress,” Hungs says. “Sleep technicians may lose up to 4 hours of sleep a day, even leading to shift work sleep disorder, which can leave sufferers anxious and depressed in addition to being exhausted. Friends and family need to understand that your day is like their night. You need quiet to sleep.” Children especially need to be understanding of the needs of the shift worker. It may be necessary to establish household rules so that proper sleep health can be maintained.

Often, caffeine may seem like a solution to tiredness, but according to research in the journal SLEEP, caffeine consumption should be done in moderation. The researchers who conducted the study suggest that shift workers, medical residents, truck drivers, and others who need to stay alert consider taking frequent low doses of caffeine. “While there is no perfect substitute for sleep, our results point the way toward a much better method for using caffeine in order to maintain optimal vigilance and attention, particularly when someone has to remain awake longer than the traditional 16-hour wake episode,” said James Wyatt, PhD, sleep researcher at Rush University Medical Center and lead author on the study, in a press release.³

In order to manage sleep, some shift workers use prescription sleep aids. Many sleep aids carry some risk of dependency. Laboratory tests and clinical studies show that even low-dose benzodiazepines, especially in long-term use, create the potential for dependence and abuse.⁴ Prescription sleep aids always should be used according to the doctor’s prescription and should not be shared.

According to the National Sleep Foundation (NSF), shift workers also should plan their most tedious work activities for when they are most alert and plan their more stimulating activities for when they are at their lowest period of alertness.

POLICY AND SCHEDULING

Handling shift work is not only the responsibility of the employee but also the duty of the employer. Lab managers always should schedule with the technician in mind. One healthy practice is to keep the technician’s shift under 12 hours. This time limit should include extra assignments like meetings and training sessions. Technicians’ shifts should be blocked together so they do not have to juggle their sleep schedule. A productive break schedule should be established, and employers should consider allowing napping on breaks. A brief nap combined with a low dose of caffeine is an effective way to combat sleepiness. According to information from the NSF, alertness at work also can be promoted by ensuring that more than one technician is scheduled for a shift. This way, technicians can keep each other alert and watch for signs of tiredness.

With a staffing environment where technicians look out for one another, employees also can ensure that coworkers can safely drive home at the end of a shift. Encouraging safe driving, establishing an employee alertness program, and creating a carpooling plan are all helpful in ensuring staff safety. Employers also should be sure to have an open door policy where staff can discuss issues concerning shifts, scheduling, and sleep deprivation.

For the sleep technician who is working nights, it can be a struggle to try to balance work, family life, and friendships. Janice Herrmann, RSPGT, coordinator, Mercy Sleep Center, Sacramento, Calif, says, “The best thing is to stay on the same sleep schedule all week,” but she adds, “It’s a very difficult thing to do.” Ultimately, she says, “The key is to actually change your lifestyle and sleep. If people maintain their sleep, they can do well.”

Jeffrey Bixby, RPSGT, is a sleep technician at the University of Minnesota/St Cloud Hospital Family Medicine Residency, St Cloud, Minn. He can be reached at [email protected].

REFERENCES

1. PROVIGIL. Sleep Disorders. Shift work sleep disorder. [removed]http://www.provigil.com/patient/disorders/shiftwork.aspx[/removed]. Accessed August 22, 2007.
2. EurekAlert! Public News List. http://www.eurekalert.org/pub_releases/2006-07/uow-sd071206.php. Accessed August 22, 2007.
3. EurekAlert! Public News List. http://www.eurekalert.org/pub_releases/2004-05/rpsl-sfd050604.php. Accessed August 22, 2007.
4. EurekAlert! Public News List. http://www.eurekalert.org/pub_releases/2006-06/apa-nsm053106.php. Accessed August 22, 2007.