Work, Sleep and Shift Work

TIME FOR A WAKE-UP CALL

By Carolyn Schur

The problems of fatigue and lack of sleep make headlines in the transportation industry, but the effects cut across all sectors wherever people work shifts.

In October of 1999, an RCMP constable was standing next to a vehicle he had pulled over while on routine patrol 10 Km south of Saskatoon, Saskatchewan. Seconds later, a transport truck, traveling at highway speed, drove straight into him without swerving or braking. The officer died. Driver fatigue was suspected as the cause.

That same month, an OPP constable of the Niagara detachment was killed in almost identical accident on the Queen Elizabeth Way when a van drove onto the shoulder of the highway and slammed into his parked cruiser -- which had its lights flashing and a blinking arrow sign on its roof to warn drivers of construction ahead. Driver fatigue was again suspected as the cause.

Coincidentally, a report from the Transportation Safety Board on an accident in which a bulk carrier ran aground in British Columbia was released a few days later. Among the findings? The pilot, who had been awake 19.5 hours already, had lost "situational awareness" and made an inexplicably bad decision. Pilots’ grueling 20-day-on, 10-day-off work schedule and the long hours were cited as a cause.

Shortly after these incidents made the news, a reporter asked me if they would serve as a "wake-up call" -- her words, not mine. I said, "No. The transportation industry is already well aware of the problems of fatigue and long hours of work and they need no further, tragic reminders of the serious consequences that can result."

But what about workers in other, less visible industries, whose fatigue-caused accidents do not make the front page or trigger Transportation Safety Board investigations?

When I think about where we are with our efforts to deal with fatigue, sleepiness, and long or rotating work schedules, I think about where we were with the drinking-and-driving issue 30 years ago, when nearly half of all fatalities on the road involved drinking and driving. We knew it was a problem and it was against the law, but we just didn’t take the issue as seriously as we do today. Driving home "a bit tipsy" after a party was considered normal. Prosecutions were few, and the penalty for those caught drunk behind the wheel was often no more than a small fine.

Since the 1970s, as more research and data on drinking and driving emerged, we have gradually changed our attitudes. There are now legal limits for blood alcohol content. Prosecution is virtually automatic for anyone caught drunk behind the wheel, as are fines and, for repeat offenses, imprisonment and lengthy licence suspensions. We’ve even gone so far as to hold bar owners liable for allowing intoxicated people to drive away. And, perhaps most important, drinking and driving is now widely considered to be what it is: a grossly foolish, dangerous and negligent act.

Our current level of awareness and concern over the hazards of shift work and fatigue is at about the level that our awareness of drunk driving was 30 years ago. But years of research and study have now given us a body of knowledge that confirms that shift work schedules are not merely arrangements of hours of work. By their design, they pose serious hazards to workers, and the consequences of being exposed to those hazards are significant for both workers and employers.

Some organizations, fortunately or unfortunately, have already had their "wake-up call." CN is the best known of these and it has undertaken extensive efforts to deal with the effects of fatigue and long hours of work on their employees. The trucking industry has also conducted studies and is attempting to develop appropriate regulations.

And to their credit, proactive managers in organizations like Nova in Alberta have implemented measures to help workers adapt, and lessen the effects of the primary hazards associated with shift work -- stress, fatigue and sleep loss.

The challenge, though, is to bring this same level of awareness, conviction and implementation to all round-the-clock and extended-hours workplaces.

Tools and protocols

In addition to a general lack of awareness and concern, another barrier is that we do not currently have available the tools and protocols for managing the shift work hazard that we have, for example, for dealing with hazardous materials. But, every day, scientists around the world are widening our knowledge base. In June, 2000, for example, I attended a symposium of the International Sleep Research Society (Shift work committee) which reviewed the most current research about hours of work and made recommendations to be forwarded to the European parliament.

This initiative prompted one of the academics attending to suggest that perhaps they should start to consider more practical applications of their research. So the work has started, and perhaps it won't be too long before we have well-researched tools and protocols.

In the meantime, I would like to tell you about the emerging trends and best practices that may be useful to you in your efforts to manage a shift work workplace.

Any efforts to mitigate the shift work hazard usually start with education for workers. Speakers, seminars, books, videos and newsletters are available regarding sleep, stress, diet and lifestyle. (See "Asleep at the Switch" OHS Canada, December 1997, p. 20; and "Sleeping on the Job", June/July 1998, p. 32. These articles are also available at www.ohscanada.com under "Virtual Issue.) These are valuable resources, but as with most education, workers need to understand why as well as how, because it is critical that they believe in and accept this behaviour as being important.

When we provide shift workers with strategies for sleep, stress and lifestyle, we are teaching them the "how". They will not make these practices a part of their behaviour if they haven't accepted the "why", that is, that sleep is not indispensable. Sleep is critical to our well-being and must be protected.

Further, workers need to learn that sleep quality is as important to their well-being as is sleep quantity. Most shift workers will have had the experience of being in bed during the day for six or seven hours and still wake up feeling both mentally and physically fatigued. This is a direct result of poor sleep quality.

Though we know many strategies that help workers to cope with shift work, we still are working from the premise that one shoe fits all. This is not the case. Every individual is unique in his or her response to shift work stress and fatigue, and at the very least they must consider their "circadian type" (Are you a night owl, an early bird or in between?), their age and family situation before deciding on strategies appropriate for them.

An example of this is when workers ask for help because they cannot fall asleep after a night shift. They beat themselves up because conventional wisdom tells them to go home and go to bed immediately to take advantage of the fact that their body is better able to get to sleep at that time. This is good advice if you're a night owl, but if you’re an early bird and you're coming home at 8 or 8:30 in the morning, your body temperature is rising very quickly and this might be a highly inappropriate time for you to try and sleep. A better understanding of how the body works and that each individual has a unique physiology will help workers better manage their sleep needs.

A job and a lifestyle

Helen is the spouse of a permanent night-shift worker. Her complaint is that "I no longer have a relationship with my husband. He just wants to sleep. He doesn't care about me and doesn't want to spend time with me."

Helen understands nothing of why her husband needs to sleep and they have made no efforts to have a relationship that is consistent with a shift work lifestyle.

Shift work is not just a job, but a lifestyle, and as such it is a lifestyle that involves the entire family and not just the worker. And if the worker is to be successful in coping with shift work, spousal support is critical.

Though we have recognized the importance of education for workers, only rarely does information get through to the spouse and family. Families that understand why sleep is vital to everyone's well-being and what strategies are effective for maintaining family relationships will be much happier and better able to deal with the inevitable stresses that shift work imposes.

Some organizations plan an "open house" or a "family day" at work. These events include a short seminar and time for families to interact with one another. A family support group that meets regularly is also an effective way for spouses and children to share ideas with others who know what they are going through.

We are also now recognizing the value of education for managers, support staff and contract negotiators. Managers who understand something about how the body works and why workers become fatigued are better able to manage safety and performance.

Education for both employer and employee contract negotiators is also vital. Most current contracts were negotiated with the best of intentions, but they often enshrine schedules that result in high levels of stress and fatigue or they restrict accommodation of employees who are unable to cope with the stresses of shift work. Education would ensure that contracts truly meet the needs of shift workers.

Sleep and lifestyle education is most effective when it is targeted to all new employees. Many new hires will not have worked a shift work schedule before and the start of a new job is an opportune time for them to recognize the lifestyle to which they are committing and to choose the strategies that will best help them to cope with the challenges.

All new employees should be required to develop a personal self-care plan and this should be reviewed with them at the end of the probationary period and annually thereafter.

The pre-employment period is also the best time to assess how predisposed candidates are to successfully cope with the challenges of shift work. Having this information as the employee begins the job will allow managers and occupational health professionals to better support those more prone to experiencing difficulties with sleep and frequently changing schedules.

Disability and accommodation

Though we are well aware of the impact of age and aging on shift workers, I frequently see workers aged 35 to 40 who have been shift workers for 10 to 15 years and who can no longer tolerate the fatigue and accumulated sleep debt. This is not a situation we anticipated and many employers do not yet have policies and procedures that would accommodate these employees.

Some shift workers go to their physicians, complain of stress, fatigue or difficulty sleeping and return to work with a recommendation that they be taken of shift work. This tells you the employee is having difficulty, but it tells you nothing about the source of the problem and whether or not it can be remedied.

We can, however, do much more thorough assessments and determine if the employee's difficulty is the result of physiologically factors, inappropriate self-care or any number of other factors known to affect shift work adjustment. Armed with this information, managers, human resources staff and occupational health professionals can then make appropriate decisions with the employee.

In Canada, we are starting to accept the premise that an inability to cope successfully with shift work is a disability and must be accommodated, but the experiences of employees vary from company to company. And most disability insurers continue to make claims decisions on the presenting physical or mental symptoms and diagnosis. This need no longer be the case since we can assess shift workers and their capacity to return to or continue with shift work.

Shift work hazards cannot be alleviated simply by providing education for workers. Workers' efforts must be supported by appropriate management and operational policies and conditions in the workplace.

Think, for example, about the managers and support services in your workplace. Do they truly serve and reflect a 24-hour workplace, or do they operate on a 9 to 5 schedule? I frequently hear workers complain, "The people on day shift get hot meals in the cafeteria. On night shift all we get is a vending machine with drinks and chips and chocolate bars," or "I wanted to go home and sleep, but I had to stay for a meeting."

In all of these situations, workers are exposed to additional loads of stress and fatigue. We need to move to managing 24-hour workplaces as 24-hour workplaces and not as 9-to-5 workplaces which also happen to have a night shift.

Recipe for sleepiness

Once this philosophy becomes operational, you can follow through by asking, "What work processes or conditions in this workplace promote sleepiness or mental or physical fatigue?"

Think, for example, of a long-distance truck driver. He sits for long periods of time, looks continuously in one direction, is surrounded by "white" noise, in a warm environment, for long hours at a time, often in the dark or dimly lit surroundings and has little or no interaction with others. This is a recipe for sleepiness.

Your workplace may not be the cab of a transport truck, but what are the conditions in your workplace that would have the same effect? Consider lighting, design of work stations and equipment, design of work processes, repetitive action, inaction, continuous physical or mental exertion, quiet, dark, excessive heat, noise, lack of interaction and other factors.

What adjustments or changes could you make to facilitate employee alertness and reduce fatigue? Consider having an ergonomist assess your workplace processes and conditions and recommend strategies appropriate for your workplace.

In addition, evaluate all processes to determine if they are appropriate for the day shift and the night shift. Cognitive efficiency, which is required of those who process information or work in control rooms, is impaired when one is fatigued. Therefore, night workers may not respond correctly or efficiently to information received at the same rate or in the same amount as it is in the daytime.

"Fatigue-busting" strategies need not involve wholesale changes in your workplace. If you are not able to make physical or process changes, allow frequent breaks -- at least every 90 minutes, and more frequently during the night. The breaks need only be five or 10 minutes. Another effective strategy is to ensure frequent interaction between employees, even if this is simply a phone call or a brief comment.

Napping

"I pay people to work, not sleep!" "Yes, we have a napping policy -- I catch you sleeping, you're out the door." I'm sure you've heard the comments, or perhaps even been known to utter them yourself. But research has shown that napping does enhance short-term alertness and performance. (See "Sleeping on the Job", June/July 1998, p. 32.) And you know that employees who are overwhelmed by sleepiness will nap even if it is prohibited.

"Do you want it to happen in an unplanned and unanticipated way, maybe at a critical moment?" asks Dr. Martin Moore-Ede. "Or is it better to allow a safety valve and allow people to nap at certain discrete times in the workplace when it's safe?" (Dr. Martin Moore-Ede, CEO, Circadian Technologies Inc., Cambridge, quoted in transcript of "Sleep Famine", broadcast on the Nature of Things, CBC TV, Jan. 24/00.)

Provide designated napping facilities. A small exercise mat or a recliner chair can suit these needs just as well.

Work schedules are major determinants of the stress and fatigue to which workers are exposed. Yet there is no one best schedule and the best schedule for any particular workplace will depend on a set of variables and complexities unique to that workplace.

Some companies have implemented shorter rotations with no more than two night shifts at a time, and have found these to be effective in reducing fatigue. As well, the European Foundation for the Improvement of Living and Working Conditions recommends that shift workers work fewer hours per week on average and have a greater number of days for rest and recovery.

A more recent innovation is to train workers to perform more than one set of skills or operations. This facilitates multi-shifting and provides more flexibility for operational needs, as well as providing workers with more opportunities for training and advancement in the company.

Having control of one's work and schedule is one of the factors known to reduce worker stress. For shift workers this would include an opportunity to decide on shifts worked or the option to trade shifts. One hospital ward has moved entirely to self-scheduling and found that the levels of stress and fatigue were measurably reduced, while performance and morale were improved.

Very high intensity lights replicate the sun and can impact our circadian rhythms, thus resulting in changes to our sleeping and waking schedules. This has led researchers to experiment with light in workplaces where alertness at various hours is critical. Initially this was done at NASA in the United States, but now the technology has been made available for commercial purposes and some workplaces have had ceiling systems installed.

But there is no need to make major capital and financial commitments to gain the same effect, particularly since you may only be trying to impact one or two workers. Small desktop appliances and visors are readily available, but if you are planning on using such appliances you must have the advice of a physician and a professional who can recommend an appropriate exposure schedule.

Researchers have long used electronic wristbands and headbands to monitor for physical signs of sleepiness, and like other technology, these devices are now commercially available. Though there are concerns about worker privacy, in safety-sensitive workplaces (transportation, nuclear facilities) these concerns are taking a back seat to safety. Many train locomotives are now equipped with a devise that requires frequent responses from the engineer to ensure that alertness is maintained and operators at some nuclear stations are wearing visor devices to monitor physical symptoms of sleepiness. As the costs and consequences of major accidents soar, one can expect that fatigue monitoring devices will become more common in more workplaces.

Driving and dozing

Though we are well aware of the risks of sleepiness and fatigue in the transportation industry, there is a transportation danger which we are only now starting to consider. That is the danger of sleepiness and potential for accidents while driving home after the night shift.

One client we have worked with is an operations manager at a large processing facility which is located 30 miles from the urban centre that supplies most of the work force. He says, "Anyone who has driven in the morning after a night shift can tell you stories about falling asleep and going off the road or not remembering how they got home."

"But in the last month," he adds, "we had several employees roll vehicles and get injured, and that's when I knew we had to do something."

In an attempt to alleviate the danger to employees, some companies are providing transportation for employees, while others are providing sleeping rooms where employees can rest before going out on the road.

If employees insist on driving, teach them techniques to maintain alertness in the vehicle. These include providing fresh air, drinking water, making frequent head movements and varying the route home. Munching on carrot sticks or pretzels can also serve to keep you more alert.

There is a move in Europe to control various aspects of shift work through legislation, but the uniqueness of each workplace makes this a difficult goal to achieve. In Canada, Saskatchewan has broken ground by enacting Section 82 of the Occupational Health and Safety Act. This section speaks specifically of shift work and requires employers to make shift workers aware of the hazards of shift work and how to protect themselves against these hazards.

We are only beginning to realize that there is an obligation associated with shift work hazard as with any other workplace hazard, and when we fail to minimize the hazard, we may be liable.

With new legislation and greater awareness of the hazards of shift work, this becomes much more critical. We now have very few legal precedents and most human resources, occupational health and legal professionals don't quite yet know how to address some of the concerns. However, in the few cases that have been brought forward, the employer has been found liable and the general trend seems to be to find against the employer.

A Saskatoon employment lawyer concludes, "This issue is going to explode. It will just take something to happen and then everybody will be scrambling."

So, let this serve as your wake up call. Undertake due-diligence as you would for any other hazard in your workplace. Provide education for your employees and implement operational policies, procedures and conditions to alleviate worker stress, fatigue and sleepiness.

This kind of proactive response to shift work issues will mean that when something does happen and everyone else is scrambling, you'll be well ahead of the game and better able to protect against liability.

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Controlled Napping

Employees who are extremely fatigued or who cannot overcome the strong physiological need to sleep, often fall asleep at their station or find a quiet spot where they can get a nap without anyone knowing. This presents several problems, not the least of which is that they may injure themselves and others. Certainly productivity suffers.

If you recognize the value of napping and want to avoid the dangers of "random" napping, consider these criteria in the development of a napping policy appropriate for your workplace:

• the nap should be no longer than 20 minutes;
• the nap be taken at a designated nap area away from the work station;
• only one nap per shift should be taken;
• the employee should inform a designated person of his or her need for a nap;
• the employee must ensure that someone is covering his or her work station.

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Casual and on-call staffing

Another trend, prompted by employers' needs to have greater financial and management flexibility, is the use of casual and "on-call" staff. This is a phenomena we know and have studied with physicians in hospitals, but the practice is now widespread. Much of the nursing staff in hospitals is now deemed to be "casual", correctional officers work long periods as casuals before they ever get assigned to a permanent position, and locomotive engineers wait hours by the phone for the next train to be ready.

In all of these instances, there is an expectation that the employee be available for work at a moment's notice at any time of the day or night.

Others in long-term care homes and emergency medical services simply work or are "on-call" for three or four days in a row, and if their services are required that entire time, they are required to work that entire time.

By any standard, these are onerous conditions and expectations. Employees experience severe sleep debt, physical and mental breakdown, burn-out and stresses in personal and family life. Yet, aside from declining to work, employees have few options for maintaining their health and well-being.

Only major changes in attitudes about work, expectations of workers and employer's responsibilities will alleviate this situation.

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