Dr Libby Artingstall & Dr Sile McDaid, Co-Founders & Directors Team Mental Health.
Sleep: A non-negotiable necessity (Part 4)
For the final blog in our series on sleep, we will explore the impact of shift-work and consider what individuals working shifts can do to protect themselves, and what organisations can do to support their shift-working employees.
Shift-work has been defined by the national Sleep Foundation as ‘work that takes place on a schedule outside the traditional 9 am – 5 pm day. It can involve evening or night shifts, early morning shifts, and rotating shifts.’1
Across the UK, millions of employees carry out jobs that require shift-work. Around one in four (28%) of the UK population are shift-workers2 and a study published by the Trade Union Congress (TUC) in 2018 estimated than more than 3 million people in Britain work night shifts, accounting for one in nine of all employees.3
People who work shifts, especially during the night, tend to work against the body’s natural rhythm (detailed in our first blog on sleep) which can presents challenges to a person’s health and wellbeing. The evidence indicates that people who work shifts have poorer health than the general population.2 There is a 42% increased risk of depression in people working night shifts.4 Further consequences of shift work include fatigue, sleep disturbance, problems with appetite and digestion, disruption to family and social life, and potential reliance on stimulants and sedatives.5
As well as the physical and mental health related consequences, shift workers experiencing sleep deprivation and fatigue are at increased risk of making errors, having accidents, and being injured. These risks have been seen to increase further when a shift length is greater than 8 hours, when shifts are worked successively, when there are not enough breaks, and when working nights.6-7
Shift-work sleep disorder (circadian rhythm sleep disorder), is characterised by insomnia, excessive sleepiness, insufficient or unrefreshing sleep, poor concentration, lack of energy, irritability and even depression.8 Shift-work disorder is relatively common but is under recognised and under treated, resulting in potential medical, social, economic and quality of life consequences for individuals who experience it.9
As highlighted in our previous blogs on sleep, employers have legal duties to protect the health and safety of their employees at work and this includes managing risks from fatigue and sleep deprivation. They also have a duty of care to make sure employees are not suffering as a result of shift work sleep disorder.10 The Health and Safety Executive provides detailed guidance for employers in their ‘Managing Shift-Work Health and Safety Guidance’5 to ensure they protect and support their employees and meet their legal obligations. Some examples from their guidance include:
- Plan an appropriate workload that is relevant to the length and time of the shift. Where possible, demanding work should be scheduled for when workers are most alert and less likely to be fatigued.
- Schedule a variety of tasks into shift-work activity, including alternating sedentary mental tasks with physical tasks, as this can promote alertness or help to relieve fatigue.
- Avoid permanent nights because night shift workers are at increased risk of sleep loss, poor quality sleep, fatigue, disruption to family / social life, and ill health (mental and physical).
- Provide training and information to ensure that staff, especially those working permanent night shifts or early morning shifts, are aware of the risks and of sources of support.
- Adopt forward-rotating schedules (progressing from morning to afternoon to night shifts) rather than backward-rotating schedules because this may reduce sleep loss and fatigue.
- Avoid shifts longer than 12 hours in length, avoid overrun and discourage overtime. Over the course of long shifts, alertness and performance can significantly deteriorate and the risk of errors and accidents can increase.
- Rotate shifts every two to three days because this minimises disruption to the internal body clock and reduces the risk of fatigue and ill health. If this is not possible, the next best option is to slowly rotate shifts over at least a 3-week period because this maximises the adaptation of the internal body clock.
- Ensure, encourage and promote adequate rest time in work (frequent and regular breaks) and between shifts to reduce the risk of fatigue.
(Adapted from HSE, 2006)
Alongside an employer’s responsibility, ‘employees also have a duty to take reasonable care of their own health and safety and that of others at work who may be affected by their activities’.11 Below are some ‘top tips’ to support employees do this:
Tips for shift workers
- Sleep hygiene:
Although shift-work can make it difficult, ensuring a good sleep routine is important. Sleep during the day is usually lighter and shorter in duration, and therefore it can be less restorative than night-time sleep.12 To promote good sleep in the day, it may be helpful to use extra support. For example, things like black out blinds or eye masks to block out light, or using ear plugs or white noise to control external noise, can be beneficial. Try and plan a sleep schedule to compliment your shift pattern, aiming for 7 – 9 hours good quality sleep in a 24-hour period
- Family and friends:
Shift work can lead to people feeling isolated from family and friends. Therefore, it is important to think about how to connect with people and to plan social interactions that align with shift patterns. Another potential issue to consider is commitments to domestic duties. It can be helpful to plan time for ‘life admin’ to ensure that this does not compromise sleep.
- Getting to and from work:
People who work shifts often experience high levels of fatigue and sleepiness. It is thought that sleepiness causes up to one in five accidents on major roads in the UK.13 It is therefore essential to consider the potential hazards associated with driving when completing shift work and explore a safe alternative if required. If you are driving, consider some exercise or caffeine before the drive to make sure you feel awake, alert and safe to drive. When driving, especially if you are tired, the temptation is to rush to complete the journey. It is essential to take your time and drive carefully. If you do begin a journey but begin to feel tired, pull over and have a nap until you feel alert and safe to drive again.
People working shifts can experience problems with their appetite and digestion, therefore thinking about diet is especially important. The Office of Disease Prevention and Health Promotion recommend a daily calorie intake of 1600-2000 for women and 2000-3000 for men. Too few calories can leave us feeling tired, and too many can leave us feeling sluggish. Alongside the right quantity, it’s important to ensure the right quality of food. Some foods, particularly those containing highly processed sugar, can provide an initial energy kick through raising blood sugar levels quickly. However, these foods tend to have little nutritional value and can leave us feeling tired when blood sugar levels drop. Research from Harvard Medical School suggests that the sugars from foods with a ‘low glycaemic index’ (GI) are absorbed slowly and help avoid lags in energy.14 Eating smaller meals or snacks regularly can also help to reduce fatigue by providing a steadier supply of energy.
An early symptom of dehydration can be fatigue, therefore remember to drink water and stay hydrated during your shifts.
Specific tips for nights shift workers
- Before your shift: Ensure you have a good sleep routine in place and aim to establish a similar bedtime and wake up time. To help increase your levels of alertness try doing exercise before your shift. Avoid a large, heavy meal and prepare regular, good quality snacks to have throughout your shift. Consider safe transport and think about how best to get to and from work.
- During your shift: Keep yourself exposed to bright lights, use caffeine sensibly and bear in mind what might happen when the effects of caffeine wear off (see sleep blog part 2). Eat good quality snacks during your shift and ensure you get adequate breaks. On a short break it can be helpful to move around and get fresh air to help you stay alert. A 20-minute nap may also help to improve alertness, performance, and mood.15 Be aware that between 2.00 – 4.00am you will likely experience the biggest dip in your energy levels.16 Where possible, work with your colleagues to support each other because this can help you stay alert and limit errors.
- After your shift: First, think about how to get home safely. Don’t drive if you don’t feel safe! Wearing dark glasses when you leave work, to limit exposure to bright light, can help to prepare you for sleep during the day.17 It’s important to know that at around 6.00am, cortisol levels will start to increase and melatonin levels will start to fall. This results in increasing levels of alertness, with a peak at around 10am.18 If it is difficult to get to sleep, try and do something to relax and wind down. Implementing the usual sleep hygiene techniques is extremely important. In particular, avoid doing vigorous exercise as this will increase alertness, and don’t go to bed hungry but try to avoid a large meal before sleeping. (For more information on sleep hygiene see sleep blog part 2).
Throughout this series of blogs, we have set out why we consider sleep to be a non-negotiable necessity. In our opinion, for the sake of our physical health, mental health, and the safety of others, it is now more important than ever for us to prioritise it. We must be proactive and take steps to ensure good sleep hygiene, we must address any difficulties we experience, and we must seek support from health care professionals if required.
(Part 1 – 3 of our series of blogs on sleep can be accessed through our COVID-19 resource page)
- National Sleep Foundation (NSF). Shift Work Disorder, sleep tools and tips. Four things you need to know about shift work. Available online at: https://www.sleepfoundation.org/articles/four-things-you-need-know-about-shift-work
- NHS Choices. 2014. Shift workers more likely to report poor health. http://www.nhs.uk/news/2014/12December/Pages/Shiftworkers-more-likely-to-report-poor-health.aspx (accessed March 2016).
- Trade Union Congress (TUC). 2018. Number of people working night shifts up by more than 150,000 in 5 years. Available online at: https://www.tuc.org.uk/news/number-people-working-night-shifts-more-150000-5-years
- Angerere, P., Schmook, R., Elfamtel, I. and Li, J. 2017. Night Work and the Risk of Depression: A Systematic Review. Deutsches Arzteblatt International, 2017; 114(24): 404-411. Available online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5499504/
- Health and Safety Executive (HSE). (2006). Managing shiftwork Health and safety guidance. Available online at: https://www.hse.gov.uk/pUbns/priced/hsg256.pdf
- Folkard, S. and Tucker, P. (2003). Shift work, safety and productivity. Occupational Medicine, 2003; 53(2): 95-101
- Folkard, S., Lombardi, D.A. and Tucker, P. (2005). Shiftwork: Safety, sleepiness and sleep. Industrial Health, 2005; 43: 20-23
- Sleep Foundation. (2016). Shift work disorder – symptoms. https://sleepfoundation.org/sleep-disorders-problems/shift-work-sleepdisorder-symptoms
- Schwartz, J.R. Roth, T. (2006). Shift work sleep disorder: burden of illness and approaches to management. http://www.ncbi.nlm.nih. gov/pubmed/17181377
- Royal Society for Public Health. (2016). Waking up to the health benefits of sleep. Available online at: https://www.rsph.org.uk/uploads/assets/uploaded/50220c8f-febb-416e-8f3f7a4d2f973897.pdf
- Business in the Community (BITC). (2018). Sleep and recovery: a toolkit for employers. Available online at: https://www.bitc.org.uk/wp-content/uploads/2019/10/bitc-wellbeing-toolkit-sleeprecovery-jan2018.pdf
- Monk, T.H. and Folkard, S. (1992). Making shiftwork tolerable. Taylor and Francis, 1992
- Horne, J.A and Reyner, L.A. (1999). Vehicle accidents related to sleep: A review. Occupational and Environmental Medicine, 1999; 56(5): 289-294
- Harvard Health Publishing Harvard Medical School. (2019). 9 tips to boost your energy naturally. Available online at: https://www.health.harvard.edu/energy-and-fatigue/9-tips-to-boost-your-energy-naturally
- National Sleep Foundation. (2020). How Long Is an Ideal Nap? Available online at: https://www.sleep.org/articles/how-long-to-nap/
- National Sleep Foundation (NSF). (2020). How Sleep Works, Sleep Routine, Sleep Study, The Science of Sleep: What is Circadian Rhythm? Available online at: https://www.sleepfoundation.org/articles/what-circadian-rhythm
- McIntosh, M. (2016). The impact of shift work. Medical News Today. Available online at: https://www.medicalnewstoday.com/articles/288310
- Royal Society for Public health / The Sleep Geek. (2019). Understanding sleep: don’t hit snooze on your health. Available online at : https://rsph.gomocentral.com/content/3c63e51c-ef8e-4bfa-b432-ee1a42e2b31c/web