Coping with Shift Work-
Strategies for workers who sleep at unusual times.
There is evidence that shift work can result in significant social and family problems. More than 22
million Americans work a shift other than a regular day shift and must face the problems of sleeping
during the day and being alert on the job at night. Working a schedule different from most of the world
can be challenging, but following the guidelines in this booklet may help make shift work easier to live
with--and safer, too.
Two particular sleep-related problems are associated with shift work: difficulty sleeping during the day,
and difficulty staying alert at night. There is evidence that shift work can result in significant social and
family problems, and in an increased incidence of illness. Shift workers most affected are those who
work nights (generally between 11:00 p.m. and 7:00 a.m.), and those who rotate shifts.
The body's circadian rhythm is its alternating cycle of sleeping and waking. In healthy adults, sleep
tends to occur during a particular phase of the circadian rhythm. Those who work the night shift must
attempt to sleep when their bodies want to be awake, resulting in a contradictory relationship between
sleep time and circadian rhythm.
Some researchers believe that complete adjustment to permanent irregular shifts may take as long as
three years, and others believe the body never fully adjusts to an abnormal sleep/wake schedule.
Whichever is true, night workers tend to be continually sleep-deprived. The average sleep cycle for a
night shift worker sleeping during the day is two to four hours shorter than that of a day worker
sleeping at night. Day sleep is light, fragmented, and more likely to be disrupted. Sleep deprivation
and insomnia can be severe in shift workers.
Also, the sleep problems of shift workers are sometimes complicated by a sleep disorder (such as
narcolepsy or sleep apnea) and/or a schedule that does not allow for sufficient sleep. A visit to a health
care provider is in order if you suspect you may have a sleep disorder.
Consequences of circadian rhythm disorder
The circadian rhythm affects job performance, since people are generally sleepiest between 2:00 and
5:00 a.m., even after years of working nights. Numerous laboratory studies, as well as field studies,
demonstrate that sleepiness affects an individual's performance, memory, intellectual capacity, motor
coordination, and mood.
Those who work the night shift must attempt to sleep when their bodies want to be awake. Examples
abound of serious accidents that appear to be secondary to insufficient sleep and consequent
sleepiness among night workers: the Three Mile Island nuclear power plant incident and the Exxon
Valdez grounding are among these. The cost of sleep-related accidents to society is enormous. The
consequences of shift work are clearly not trivial.
Shift workers must also cope with the social problems that result from working while the rest of the
world is in bed, and sleeping while the rest of the world is at work or engaged in leisure activities.
Many night workers complain that they don't have enough time to spend with family and friends, to
relax, make appointments, run errands, and so on. Since most activities are planned according to the
schedule of a typical day worker, a shift worker may feel alienated and frustrated by the differences
between his or her personal schedule and that of the rest of the world.
Treatment strategies
A variety of treatment strategies is necessary because work settings vary considerably, and the ideal
strategy for workers in a hospital, for example, may not be desirable for workers on an assembly line.
Also, some people are better suited to shift work than others. "Night people" adjust to the night shift
better than "morning people." Older workers on the whole find it increasingly difficult to work nights and
rotating shifts. Several strategies appear to benefit the problems of shift work; the approach likely to be
most helpful depends upon the individual worker and the circumstances.
Work schedules
A work schedule that allows employees to sleep when they are off duty and be alert when on duty is
ideal. The best distribution of schedules for shift work operations vary by industry and by job within an
industry. Work scheduling changes that accommodate the circadian rhythm by rotating clockwise--
from day to evening to night--are helpful. Studies have shown that changes in the work schedule that
consider circadian factors are likely to lead workers to be more productive and feel more satisfied, and
to reduce accidents. An ideal schedule in a particular situation must be individually determined.
Breaks
Breaks scheduled during work hours may enhance alertness. There is some evidence that brief rest
periods in certain types of jobs may reduce fatigue without reducing output; in fact, breaks may actually
increase productivity and worker satisfaction. Employers are encouraged to investigate scheduling
changes that may benefit employees and productivity.
Sleep schedules
Permanent night workers should maintain a regular (day) sleep schedule seven days a week, even on
days off work. Reverting to a typical day schedule during time off will simply make it harder to sleep
during the day after returning to work.
Those who rotate shifts can adjust sleep schedules so that they will be able to adapt more easily to
the new shift. On the last few days of the evening shift, for example, betimes and arise times should be
delayed on to two hours. Workers can then begin their stint on the night shift already well on the way to
being adapted to the new schedule.
Family and social considerations, of course, may make it difficult or impossible to follow these
suggestions to delay sleep. Any advantage gained by using this technique can be lost by returning to a
normal day/night schedule on days off.
Workers who are subject to on-call shifts will recognize that their sleep problems are somewhat
different from those of night and rotating shift workers. Because on-call workers usually can't predict
work schedules far enough in advance to plan an appropriate sleep/wake schedule, they should try to
be well-rested at all times. They may find naps helpful.
Although there is some evidence that sleep obtained in a single stretch is preferable to the same
amount of sleep obtained in several segments, shift workers who can't maintain their sleep during the
day may increase the overall number of hours they sleep by napping. Napping can benefit shift
workers in terms of both the sleep problems and the performance difficulties associated with their
schedules. Brief naps taken during a work shift may only temporarily enhance alertness, since
performance can be hindered briefly as a result of sleep inertia. Sleep inertia is the body's tendency to
want to remain at rest for 15 minutes to an hour after awakening. The effects of sleep inertia on the
employee's responsibilities must be considered, especially if there is a need to wake up quickly and
react immediately to a job situation.
Naps taken off-shift at an appropriate point in a worker's circadian rhythm can help offset the sleep
loss associated with poor daytime sleep. While naps are not a substitute for a regular schedule of
adequate sleep, they can help people who are sleep-deprived reduce their sleep debt and improve
alertness, at least temporarily.
Prescription medication
Hypnotic medications (sleeping pills), such as benzodiazepines, are often used by shift workers to
override the circadian rhythm in order to induce sleep. There are disadvantages to using these
medications, including side-effects in some individuals. The long-term use of medication should be
avoided because its effectiveness wears off over time and dependency on the drug may develop. Most
important, however, is the evidence that improving daytime sleep with the use of hypnotics only
marginally improves alertness and performance on the subsequent night shift. Although sleeping pills
may provide relief, and may be appropriate in conjunction with other measures, they do not address
the actual cause of the shift worker's sleep difficulties, since sleeping pills cannot reset the internal
clock.
If you think you may benefit from taking a sleeping pill occasionally, talk with a health care provider.
Over-the-counter sleep aids are not desirable for inducing sleep, since many of these cause
prolonged drowsiness for several hours after awakening and are therefore not safe.
Stimulants
Studies have shown that the occasional use of stimulants, such as caffeine, can significantly reduce
sleepiness and improve your ability to be alert on the night shift. However, caffeine should be avoided
as much as possible and, if used, taken early in the day, since it can cause insomnia.
Melatonin
Our brain's natural production of melatonin also has a circadian rhythm that appears to affect our
sleep/wake cycle. Melatonin is a chemical produced by the pineal gland in the brain at night during
sleep. Research has recently begun to investigate the possibility that giving a synthetic form of
melatonin to night workers in the morning may help shift their circadian rhythms so they can sleep
during the day and be alert at night.
Bright light therapy
Some recent studies have produced preliminary evidence that timed exposure to bright light can help
adjust the sleep cycle quickly.
Just as the sun helps set the body's clock, exposure to bright light may actually have the effect of
shifting the circadian phase, reversing the sleep/wake schedule of night shift workers so that they are
able to sleep during the day and be alert on the job at night. Bright-light boxes are available from
several manufacturers. A healthcare provider can determine the proper timing of exposure. Along the
same lines, workers should wear sunglasses on the trip home from the night shift in order to avoid
excess light stimulation. This will help minimize the effect of sunlight on their body clocks.
Sleep hygiene
All shift workers can benefit by following the guidelines of good sleep hygiene, especially the need to
sleep in a dark, quiet room. Proper sleep hygiene requires using the bedroom only for sleep and
sexual activity (not for watching TV or balancing the checkbook, keeping the room temperature cool
and comfortable, relaxing before falling asleep, and having a regular routing for bed preparations,
such as brushing teeth, putting on pajamas, and so on. It may also be helpful to buy dark curtains for
the bedroom windows, or to wear eyeshades for sleep. Shift workers may also be helped by using
"white noise" (produced by tuning a radio to the far end of the dial, or by running a fan) to block out
external noise. Turning off the phone (an answering machine can be used if necessary) and
disconnecting the doorbell or putting up a "Do Not Disturb" sign can also help.
Workplace conditions
Lighting levels, temperature, and job responsibilities in the workplace are among the factors likely to
play a role in the alertness levels of shift workers. The workplace should be cool rather than warm, and
should be bright to promote worker alertness. Employers should be sure that night workers have
plenty of caffeinated beverages available, and that they can choose foods other than those typically
available from vending machines. The setup of the workplace will determine how best to control these
factors to promote alertness on the job. In general, employers and employees should educate
themselves about the effects of shift work in their workplace, and should encourage safety and
efficiency.
Other measures
Diet may also play a role in a good sleep: shift workers should eat meals that are high in protein and
carbohydrates, and should avoid fried or hard-to-digest foods. It is not advisable for a shift worker (or
anyone else) to go to bed when hungry or immediately after eating a large meal.
Good sleep habits
These guidelines can be applied to all types of sleep disorders. They will help most people, including
shift workers, get sound and sufficient sleep:
- Get up about the same time every day.
- Go to bed only when sleepy.
- Establish a relaxing pre-sleep ritual, such as a warm bath, light bedtime snack, or 10 minutes
of reading.
- Exercise regularly. Confine vigorous exercise to the early part of the day (at least six hours prior
to bedtime).
- Mild exercise, such as simple stretching or walking, should be carried out no later than four
hours before bedtime. Shift workers should eat meals high in protein and carbohydrates.
- Maintain a regular schedule.
- Regular times for eating meals, taking medications, doing chores, and other activities keep our
inner clocks running smoothly.
- Avoid caffeine within six hours of bedtime.
- Don't drink alcohol, especially when you are sleepy; even a small dose of alcohol when you are
tired can have a potent effect.
- Avoid smoking close to bedtime.
- If you find napping helpful on a regular basis, try to nap at the same time every day. Mid-
afternoon is best for most people.
- Use sleeping pills only conservatively. Doctors generally prescribe sleeping pills for periods no
longer than three weeks. Never combine sleeping pills with alcohol.
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