Fighting fatigue requires more than caffeine

Scheduling, sleep breaks lessen fatigue risk

Medical residents aren't the only hospital employees suffering from fatigue. Night shifts, rotating shifts, long work hours, and sleep disorders can lead to fatigue — and risks for both health care workers and their patients. Hospitals must be proactive and take steps to address the problem of fatigue, says Todd Dawson, Vice President, Circadian Technologies of Stoneham, MA, a consulting firm that specializes in fatigue management.

Too often, nurses, physicians, and other health care professionals believe their sense of dedication can supersede their bodily fatigue, Dawson says. If the tasks are very important, "'then I'm not going to fall asleep.' The problem is we do fall asleep. Even people driving fall asleep," he notes.

"How much incentive do you need with 40 or 50 passengers on your bus? People's lives are in your hands. But we know people do fall asleep behind the wheel," he says.

Health care workers who are fatigued may lose their focus, especially when performing routine tasks. With more extreme fatigue, they may experience "microsleep," episodes of involuntary sleep. In fact, studies show that working while fatigued can be equivalent to working under the influence of alcohol.

"If there does happen to be a case where fatigue is cited as a problem [related to medical error], organizations can't say 'Oh, we didn't know,'" says Dawson.

Dawson recommends that hospitals provide training to raise awareness about fatigue. Employers also should consider the systemic issues that influence fatigue.

Schedules: "The schedule has the strongest influence on an individual's ability to get good sleep," he says. "What we like to see is a schedule that provides the right opportunity to get good rest so people have the best opportunity to be alert and be well-rested at work."

Shift-workers should minimize the number of transitions — day to night or night to day, Dawson says. Extremely fast rotations lead to fatigue. The minimum should be 24 hours between shifts, and ideally employees should have 48 hours from the end of one shift to the beginning of the next, he says.

Murderer's row

How many days in a row you work also has an impact on fatigue, he says. Four 12-hour shifts in a row should be the maximum, he says. Even more than six or seven 8-hour shifts can lead to increased fatigue, he says.

Overtime is another common factor in fatigue, as employees take on hours beyond their scheduled shifts and lose the time they needed to recuperate.

Circadian rhythm: Alertness is governed, in part, by our biology. Adrenaline kicks in when there's an emergency. "Your body will start to change to give you that boost of energy and awareness that you need," Dawson says. But as soon as the tasks return to the routine — reading charts, reading orders — fatigue can set in, depending on your natural body clock.

If you have gotten a good night's sleep, your alertness will naturally be high in the morning — at around 8 a.m. to 10 a.m. Alertness steadily drops until it reaches a low between noon and 2 p.m. Then the cycle repeats, rising until mid-evening — around 6 or 7 p.m., Dawson says.

Alertness will fall at night, with a steep drop after midnight or 1 a.m., to a low-point at about 5 a.m. (Of course, there are some individual differences — among "night owls" and "larks.") The night-time drop-off in alertness is good for people who are sleeping — but not so good if you're trying to work.

Employees and supervisors should be aware of the body's natural rhythms of alertness and fatigue, Dawson says.

Caffeine: Caffeine can be useful to combat the circadian low-point in a worker's shift — as long as they don't drink excessive amounts (four cups of coffee or more), he says. Caffeine will provide alertness for about four to six hours, he says.

"Used properly and timed when you need it, caffeine is a pretty powerful tool that people can use," he says.

Sleep: "The antidote for lack of sleep is sleep," says Dawson. That sounds rather obvious — but how do you add more sleep to your day? For some night-shift workers, that may involve a short nap during a mid-shift break. People driving home after a night-shift — during that low-point of diminished alertness — may benefit from a brief nap before getting on the road, he says.

"If you can take a 15 or 20 minute nap, that's going to give you a boost for the next three hours without impacting your ability to sleep later in the day," he says.

Exercise and diet: Regular exercise — at least three times a week for 30 minutes at a time — has an overall benefit on sleep patterns.

"There are several studies showing that people who do exercise on a regular basis sleep longer on average," Dawson says. "The quality of their sleep is improved. The sleep latency, the time it takes to fall asleep, is improved. Shift workers tend to recover from their shifts quicker. They also adapt to their shifts better."

Exercise also has some immediate benefits to boost alertness. Night shift workers might want to do some moderate exercise at around midnight or 1 a.m., such as walking, biking on a stationary bike, or stretching, he says.

Food: A sugary snack, such as a candy bar or soda, can give a burst of energy. But the energy spurt is short-lived and, unlike caffeine, it is followed by a crash. The best strategy is to "graze" during the night shift, eating small amounts of healthy foods, Dawson says.

The digestive system follows a circadian rhythm of its own, he says. "For most of us, our nighttime stomach rhythm is to basically be shut down. Your ability to eat and digest efficiently is much reduced at night," he says.

"You will get hungry because you're using energy," he says. "You'll want some energy [from food], but you don't want it in big blocks of food. Stay away from fatty or greasy foods. They're more difficult to digest, which is even more of a problem at night."

Age: As the health care workforce ages, how do they cope with shift work? In general, it takes more time to recover from changes in sleep patterns and alterations to the circadian rhythm, Dawson says. But those workers who have been on rotating shifts or the night shift for many years still tend to cope well, he says.

"They're naturally predisposed to handle shift work, or they biologically need less sleep," he says. "They've figured out what works and what doesn't."

For those who are chronically sleep-deprived, napping can help fill in gaps, he advises. It doesn't necessarily benefit workers to have regular night shifts as opposed to rotating shifts that have enough time in between for adequate sleep, he says. After all, on days off, most people revert to a day schedule.

"When we look at rotating shifts versus fixed [night] shifts, we find for the most part it comes down to personal preference," he says. "A review of the literature is fairly inconclusive about which is better."