Raising awareness for yourself and your patients As shiftworkers, nurses are at risk for shiftwork sleep disorder (SWSD), which cancause physiologic and psychological distress and lead to various errors. Nursesalso are well positioned to identify SWSD in patients. American Nurse Today, the American Nurses Association, and the American Nurses Foundation, incollaboration with CORE Medical Education, LLC, developed a web-basedcontinuing nursing education (CNE) program on SWSD for nurses, with anunrestricted educational grant from Teva Pharmaceuticals. As part of this initiative,nurses were asked to complete a survey before and after participating in the CNEprogram to determine what they had learned. This report discusses SWSD andsurvey results and includes the article “Tips for achieving healthy sleep.”

The CNE program is available at http://ananursece.healthstream.com. The program and thisreport are supported by an unrestricted educational grant from Teva Pharmaceuticals to theAmerican Nurses Foundation. The CNE provider is the American Nurses Association’s Centerfor Continuing Education and Professional Development.

ore than 22 million Americansmeet the criteria for shiftworker.Among them are nurses, whosework schedules revolve aroundthe 24/7 needs of patient care.Nurses may be required to workseveral consecutive shifts of 10,12, or 16 hours, followed by just1 to 2 days off. (See Definingshiftworkers.) According to the Centers for

Disease Control and Prevention(CDC), lack of sleep due to longshifts and shiftwork sleep disor-ders (SWSD) in particular posesa serious health burden. (Seewww.cdc.gov/niosh/topics/workschedules.) SWSD affectswork performance, impairs safe-ty, and alters quality of life.

What’s more, research shows itcontributes to development or ex-acerbation of various comorbidconditions, including cardiovas-cular disease, diabetes, GI disor-ders, and depression. Personswith SWSD suffer not just ex-treme sleepiness but significantand often detrimental health ef-fects of those comorbid condi-tions. Nurses need to be awareof SWSD and be able to detectsigns and symptoms both inthemselves and patients.In October 2012, the Ameri-

can Nurses Associationlaunched a continuing nursingeducation (CNE) activity titled“Shiftwork Sleep Disorder: TheRole of the Nurse, Understand-ing SWSD for You and Your Pa-tients.” This activity featured anaudioguided clinical web courseand an educational patient tool -kit (available at http://eo2.commpartners.com/users/swsd/). Michael Decker, PhD, RN,

RRT, Diplomate of the AmericanBoard of Sleep Medicine andByrdine F. Lewis Program Chairin Nursing at Georgia State Uni-versity, served as program chair.Together with faculty composedof leaders in the research andclinical management of SWSD,Dr. Decker developed this CNEactivity to provide nurses with ed-

ucation on signs and symptomsof SWSD, negative health andperformance consequences ofSWSD, screening tools, the latestmanagement guidelines and rec-ommendations, and strategiesnurses can use to help patients,colleagues, and themselves.Eight weeks after nurses par-

ticipated in the CNE activity,they were contacted to take partin a voluntary outcomes surveyto measure their progress inmeeting the program’s stated ed-ucational objectives, as well asto measure changes in theirknowledge and competency.American Nurse Today (AMNT)spoke with Dr. Decker about theoutcomes of this CNE activity.

20 American Nurse Today Volume 8, Number 5 www.AmericanNurseToday.com

Shiftwork sleep disorder: Raising awareness for yourselfand your patients As a shiftworker, you may have this disorder yourself. As acaregiver, you may detect it in patients.

M Definingshiftworkers Shiftworkers are employeeswho work “rotating” or extend-ed shifts (shifts of more than 8 hours). For example, a shift- worker may work 2 weeks of 7 AM-to-3:30 PM shifts, followedby 2 weeks of 11 PM-to 7:30-AMshifts. An extended shiftworker may

work 7:00 AM to 7:00 PM forseveral consecutive days, fol-lowed by 1 to 2 days off.

Nurses need to beaware of SWSD and beable to detect signsand symptoms both inthemselves andpatients.

www.AmericanNurseToday.com May 2013 American Nurse Today 21

AMNT: Why do you thinkSWSD is an important topic fornurses?Dr. Decker: In most healthcarefacilities, many clinical staffmembers work rotating or ex-tended shifts. Sleep loss may fol-low these shifts—for example,from being awakened duringdaytime “sleep time” by phonecalls and the need to deal withfamily obligations, ongoing aca-demic pursuits, or just life ingeneral. Such sleep loss cancontribute to development ofSWSD. Besides sleep disruption

caused by activities of daily liv-ing, some people may have asleep-related disorder, such assleep apnea, restless legs, or in-somnia. During my time at theCDC, our research suggested upto one-third of the U.S. popula-tion may have insomnia, morethan 20% have some degree ofsleep apnea, and a large num-ber have restless legs. Thosefindings suggest many shiftwork-ers may have a comorbid sleepdisorder and may be unawareof it. Considering the combina-tion of sleep loss due to shift-work and additional sleep lossfrom an undiagnosed sleep dis-order, cumulative sleep loss maybe significant.Sleep is an active brain

process needed to maintain nor-mal neural function. If sleep timefalls below the “normal” amountof approximately 8 hours or ifsleep continuity is disrupted, ex-ecutive brain processes (includ-ing working memory, critical-thinking skills, and reactiontimes) may be disturbed duringsubsequent waking hours. Stud-ies by leading sleep-researchprograms and the CDC show a

link between short sleep durationand reduced daytime vigilance,depression, and several chronicconditions (including diabetes,cardiovascular disease, obesity,and cancer).Research on shiftwork impact

shows negative outcomes in thephysical, psychological, and so-cial domains. Morbidity associ-ated with SWSD is significantlyhigher than that experienced bydaytime workers with identicalsymptoms, such as sleep-relatedaccidents, depression, absen-teeism, and missed family andsocial activities.Growing concern centers on

whether workers can maintainadequate performance levelsover long shifts, particularlywhen those shifts span nighttimehours. One study reported shift-work was the main factor linkedto medical errors. Another foundthat professional mistakes, suchas drug administration errors, in-correct operation of medicalequipment by nurses, andneedlestick injuries were associ-ated specifically with excessivesleepiness.

AMNT: What were some ofyour main findings from thesurvey that participants tookafter completing the CNEprogram? Dr. Decker: Before taking ourCNE activity, the overwhelmingmajority of nurse participantsdidn’t recognize many adverseoutcomes attributable to SWSD.Only 16% were aware thatSWSD is a risk factor for trafficaccidents, diabetes, cancer, andillness necessitating sick leave.But after completing the activity,nearly two-thirds (63%) recog-nized SWSD can contribute to

any of these conditions. (SeeRecognizing SWSD in patients:Before and after.)

AMNT: Are you surprised thatnearly half the participantsdidn’t routinely consider SWSDas a possible cause of excessivesleepiness in patients andcoworkers?Dr. Decker: Yes. Much like po-lice officers, firefighters, para-medics, and pilots, nurses andother healthcare workers are atrisk for SWSD. One potentialreason for this underrecognitionmay be reduced awareness ofthe many factors contributing toSWSD, including the number ofconsecutive hours and days aperson routinely works and du-ration of uninterrupted sleep be-fore working hours begin. Withmore jobs now requiring shift-work, nurses and other health-care workers need to be vigi-lant. And they must keep inmind that the number of peoplereporting SWSD symptoms hasbeen rising. They need to beproactive and advocate both fortheir own health and their pa-tients’. (See Tools for assessingexcessive sleepiness.)

Sleep quality is asimportant as quantity;uninterrupted sleep,particularly duringdaytime, is a must.

AMNT: What are the standardmanagement strategies forSWSD? Dr. Decker: Treatment takes amultifaceted approach, with twoultimate goals: the patient sus-tains wakefulness when wakeful-ness is required and achievessleep when sleep is required.The first step in achieving thesegoals may focus on sleep hy-giene and planned napping toimprove both the quantity andquality of sleep. Extending sleeptimes by going to bed earlier ona regular basis can increasesleep time and start compensat-ing for lost sleep. Sleep qualityis as important as quantity; unin-terrupted sleep, particularly dur-ing daytime, is a must. All shiftworkers and their em-

ployers should learn strategiesfor improving sleep hygiene andcreating an environment forrestorative sleep. These strate-gies include: • using bright light therapy be-fore or during a night shift

• reducing daylight exposureon the commute home fromwork, if possible

• establishing a dark, quietsleep environment at home(for example, by using black-out curtains or melatonin med-ication before a requiredsleep period)

• napping to increase sleepquantity (napping timed judi-ciously before and/or duringwork to counteract shiftworksleepiness can increase on-the-job alertness)

• improving shiftwork conditions(for instance, bright-light expo-sure during a night shift andappropriately timed naps)

• improving shift schedules, including use of clockwise-

22 American Nurse Today Volume 8, Number 5 www.AmericanNurseToday.com

Tools for assessing excessive sleepinessMultiple diagnostic tools are available to measure sleepiness, ranging from questionnairesto laboratory-based multiple sleep-latency testing. A widely accepted, easily implementedquestionnaire is the Epworth Sleepiness Scale (ESS). This brief eight-item questionnaireasks about a person’s chances of “dozing” in sedentary situations, such as when reading abook or sitting in a meeting. Besides screening for sleepiness, ESS can be used todetermine sleepiness reduction after an intervention.

Clinicians can use the ESS in both office and inpatient settings. The maximum score is24. The average score for a healthy, alert person ranges from about 4 to 7. A score of 10or higher suggests clinically significant sleepiness.

In the survey sent to nurses who took the CNE activity “Shiftwork Sleep Disorder: TheRole of the Nurse, Understanding SWSD for You and Your Patients,” 89% said they’dnever used the ESS before participating in the CNE activity. After participating in it, nearly 46% reported they sometimes or always used the ESS to help determine patients’sleepiness level.

BEFORE you participated in this CNE activity, did you use the EpworthSleepiness Scale (ESS) to measure excessive sleepiness in the office setting?

AFTER participating in this CNE activity, have you used the EpworthSleepiness Scale (ESS) to measure excessive sleepiness in the office setting?

Sometimes43.5%

Never23.5%

Neutral16.5%

Almost never14.1%

Always 2.4%

Never89.3%

Almost never6%

Neutral3.6%

Sometimes1.2%

www.AmericanNurseToday.com May 2013 American Nurse Today 23

rotating shifts and avoidingconsecutive shifts longer than12 hours.If behavioral changes don’t

bring the expected improvement,prescription medications may beconsidered. The wakefulness-promoting drugs modafinil andarmodafinil are the only drugsapproved for treating SWSD.Evaluated specifically in patientswith excessive sleepiness attribut-able to SWSD, they have beenshown to reduce sleepiness dur-ing the work period, with associ-ated benefits of decreased acci-dents and near-misses during thecommute home. Before participating in our

CNE program, 60% of nursessaid they’d considered using on-ly caffeine to improve SWSDsymptoms. Two months aftercompleting it, twice as many re-ported using multiple strategies,including sleep hygiene, phar-macologic management, bright-light exposure, and caffeine.

AMNT: Do you have anytakeaway thoughts? Dr. Decker: Because sleep disor-ders aren’t “top of mind” formany healthcare providers,they’re significantly underdiag-nosed and undermanaged. Clini-cians have an increased respon-sibility to recognize theimportant role that sleep plays inour overall well-being. It’s crucialthat we recognize presentingsigns and symptoms of excessivesleepiness and SWSD. In thehospital, patients with these dis-orders commonly present afterbeing involved in motor-vehicleor work-related accidents. In of-fice-based practices, they mayseek help for a specific disorderthat may be a comorbid illness

associated with shiftwork orSWSD. In these patients, weneed to recognize the possibilityof excessive sleepiness or SWSDand ask about the patient’s sleepand work habits. Nurses are ina unique position: Many of us

are shiftworkers ourselves, andwe can play an important role inidentifying and implementingbest practices to improve thelives of those with sleep disor-ders—patients, colleagues, andourselves. P

To learn more about SWSD, accessthe online multimedia education program “Shiftwork Sleep Dis -order: The Role of the Nurse” at http://ananursece.healthstream.com.

Faculty for this program:

Michael Decker, PhD, RN, RRT, is anassociate professor, Diplomate of theAmerican Board of Sleep medicine,and Byrdine F. Lewis Program Chairat Georgia State University School ofNursing and Health Professionals inAtlanta, Georgia.

Jeanne Geiger-Brown, PhD, RN, isan associate professor at the Univer-sity of Maryland in Baltimore. A fed-erally funded researcher in the areaof sleep and fatigue, she has pub-lished more than 30 works related tonursing work demands and adverseoutcomes.

Kathryn Lee, PhD, FAAN, CBSM, is a professor and associate dean for research at the University ofCalifornia, San Francisco, School of Nursing.

James Wyatt, PhD, DABSM, CBSM,is the director of Sleep DisorderServices and Research Center andan associate professor at the RushUniversity Medical Center inChicago, Illinois.

Mark your calendar for the plannedAmerican Nurses Association SWSDwebinar on December 18, 2013,from 1 to 2 PM EST.

Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.

Recognizing SWSD in patients: Before and afterThe chart below compares nurses’ ability to recognize shiftwork sleep disorder(SWSD) in specific types of patients (traffic accidents, sick leave, diabetes, cancer, allof these patients, or none of these patients) before and after participating in theSWSD continuing nursing education activity.

0

10

20

30

40

50

60

70

44.2% 3.5% 26.7% 11.6% 8.1% 5.8% 10.5% 3.5% 16.3% 62.8% 32.6% 12.8%

Traffic Sick Diabetes Cancer All of None ofaccidents leave these patients these patients

Before After

24 American Nurse Today Volume 8, Number 5 www.AmericanNurseToday.com

ealthy sleep improves our person-al health and ability to work pro-ductively and safely. To maintainhealthy sleep habits (also calledsleep hygiene), we must controlthe factors that can interfere withsleep. Sleep interference can re-sult from both behavioral and en-vironmental factors. Behavioralfactors are choices a personmakes that affect sleep, such ascaffeine use, diet, and exercise.Environmental factors are exter-nal and include noise, tempera-

ture, light, stress, work schedules,length of commute, and familyand social obligations. Most nurses who work shifts or

long hours are familiar with sleepinterference. Working the nightshift is especially disruptive be-cause it goes against our naturalsleep-wake cycle. Despite thesechallenges, though, you can fol-low the tips below to improveboth the quality and length ofsleep.An estimated 50 to 70 million

people in the United States sufferfrom sleep disorders. For them,even the best coping strategiesmay not help. If you have ongoing trouble falling or stayingasleep and it’s affecting youralertness at work or while driv-ing, consult your healthcare pro-fessional. PVisit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.

Jaime Murphy Dawson is senior policy analyst in theANA Department for Health, Safety, and Wellness.

Tips for achieving healthy sleepLearn about the behavioral and environmental factors that can interfere with your sleep. By Jaime Murphy Dawson, MPH

H

Make sleep a priority. Sleep is a necessity, not a luxury.Ask your partner or spouse and other family members tohelp by encouraging you to sleep and not disturbing youwhen you’re sleeping. If necessary, remind them that sleepwill keep you healthy, reduce stress, and help you do yourjob safely.

Establish a routine. Having a consistent, peaceful bedtimeroutine prepares your mind and body for sleep. Your rou-tine may involve taking a warm bath, reading, journaling,or listening to soothing music. Reducing stress and unwind-ing from the day will help you fall asleep faster andachieve a better quality of sleep.

Eat a healthy diet. Avoid heavy or spicy foods before bed-time. If you drink alcoholic beverages, do so in moderationand stop drinking a few hours before you go to bed. Whilealcohol causes drowsiness, it may disturb your sleep andcause you to awaken sooner.

Sleep in a dark, quiet, cool room. A good sleep environmentmakes a difference. If you sleep during the day, keep yourbedroom as dark as possible by using room-darkening cur-tains or shades or wearing an eye mask. Use a “white noise”machine or wear earplugs to create a quiet environment.Make sure your room is at an optimal sleeping temperature.

Reduce screen time. Light and noise from televisions, smart-phones, and tablets are stimulating and can make it harderfor you to fall asleep. To avoid temptation, recharge elec-tronic devices outside your bedroom so they’re not withinarm’s reach.

Use caffeine in moderation. The half-life of caffeine is 5 to6 hours—even longer for some people. So if you drink caf-feinated beverages at work, do so only at the beginning ofyour shift. That way, the caffeine will be out of your systemwhen you’re ready to sleep.

Time your exercise right. Body temperature starts to dipwhen it’s time for sleep and stays lower while we sleep.Generally, 20 to 30 minutes of vigorous exercise 5 to 6hours before bedtime raises body temperature for a fewhours, and then leads to a temperature dip that’s ideal forsleeping. Timing is important: exercising too close to bed-time can cause difficulty falling asleep as it stimulates theheart, muscles, and brain.

Turn down the lights. Light is the primary factor influencingcircadian rhythms (the body process that regulates periodsof alertness and fatigue throughout the day). Bright light in-creases alertness. Turning off or dimming lights 1 to 2hours before going to bed can promote sleepiness.