Sleep deprivation impacts every level of society, and personal responsibility must be assumed in order to avoid the effect it has on behavior
The invention of the lightbulb by Thomas Edison has revolutionized civilization as we know it today. His contribution to mankind was the extension of working hours beyond daylight in order to maximize production of labor. We sleep 25% less than our predecessors did a century ago. Americans are considered to be the most sleep-deprived people in the world, thus, Edison was possibly the most successful inventor in history.
The following questionnaire is slanted toward night-shift workers; however, it is applicable to workers on all shifts. One third of all Americans get 6 hours sleep or less per night.1 Please take a couple of minutes to respond to these questions before continuing. An explanation of each question may show how you might be an unknowing participant in the drone effect.
- Are you a nocturnal (nighttime) or diurnal (daytime) sleeper?
- How many hours sleep do you get on the day, or night, beginning your workweek?
- How many hours of sleep do you get in the day or night you come off your rotation?
- Have you called in sick in the past 6 months?
- Do you sense a need to stay active at work in order to stay awake?
- Have you ever fallen asleep at work?
- Do you have difficulty monitoring tasks or performing repetitious requirements?
- Do you notice mood swings or irritability during your workweek?
- Have you ever fallen asleep while driving home from work? At a red light?
- Do you take or drink any stimulants to stay awake during your shift?
- Do you take anything to help you sleep between shifts?
- Do you follow an exercise or workout program?
- Do you currently take antidepressants?
- Have you noticed any short-term memory loss?
The Drone Effect, a term coined by US Army researchers, describes an individual still involved in performance-on-task, but has become momentarily and functionally incapacitated, by either paralysis or blurred vision, or succumbed to microsleeps. Pilots, radar operators, and doctors have found themselves in this condition. Routine and monotonous tasks show a rapid decrement after 18 hours without sleep.2 Dawson and Reid3 evaluated performance after 17 hours awake and found performance degraded to a level equal to that caused by a blood alcohol level of 0.05%. At 24 hours, performance decrements were equivalent to that of a blood alcohol level of 0.10%. The economic results of this problem have been estimated at $150 billion a year in lost productivity, lawsuits, and fatalities. It has become common knowledge that the Exxon Valdez, Chernobyl, Three Mile Island, and the Challenger space shuttle accidents were caused at least in part by fatigued workers. The cleanup efforts of the first two still remain in progress and without a final cost. The ecological cost will be inestimable.
Sleepiness is a basic human need, just as hunger or thirst. If one eats, the hunger dissipates and just as drinking quenches thirst, sleepiness is satiated by sleep. Sleep deprivation is cumulative and yet sleep is not.4 Sleep cannot be placed in a depository and withdrawn later when the need arises. People cannot sleep for 14 hours thinking they have exceeded their sleep needs by 6 hours and then remain fully functional for the next 24 hours without an ensuing detriment to thought and performance.
Walter Reed Army Institute of Research sleep laboratory provides studies that reveal that the creative and critical thinking processes are performed in the prefrontal cortex. During sleep, this highly developed area of the brain essentially shuts down. With a reduction in sleep comes a reduction in the overall function of the prefrontal cortex. This translates to a reduction in attention span, critical thinking, and the ability to change directions with subsequent changes in information. Researchers have discovered that military personnel retain their abilities to perform with deadly accuracy when ordered to fire their weapons; however, they lose their ability to know exactly who and where is the enemy and their motivation to really care. Inadvertent friendly fire has been evidenced.4 With severe sleep deprivation, soldiers have been reported to attempt to put coins into trees, thinking they were soda machines.
The military has gone to great efforts to recognize the need for sleep and to perfect the art of sleep for servicemen. Walter Reed has invented the wrist actigraph to track how much sleep a soldier has had. It is computed to his schedule and sleep needs and then can show when and for how long he should grab a nap in order to keep performance levels high. Walter Reed is performing studies on hypnotics and stimulants as well as the development of sleep logs to determine which troops are rested enough for a risky mission or for sentinel duty.
Colonel Gregory Belenky, a neuropsychiatrist and director of the Walter Reed sleep laboratory, stated that in terms of survival, 3 hours sleep is fine if none of your decisions are critical…. To be able to think and plan, most people need 8 hours to be 100%. Belenky further stated that anything more than 5 minutes of sleep and you begin to accumulate benefit. If you get 30 minutes of sleep, youre better off than not getting any.4
The United States Naval Flight Surgeons Manual refers to the symptoms of fatigue and sleep loss as follows5:
- increased negativity and irritability;
- inability to concentrate;
- lack of energy;
- inability to maintain attentiveness to task;
- inability to recall what you just saw, read, or heard (short-term memory loss of recent events)
- apathy; and
- decreased interpersonal skills.
Interestingly, these are some of the same symptoms that are treated by antidepressants and SSRIs (selective serotonin re-uptake inhibitors) under a depression disorder protocol.
Internal audits within hospitals have also shown deadly errors in medication administration and decision-making degradations during critical assessments in changing patient circumstances. Night nurses make twice the medication errors as day nurses3 and experience nearly three time the auto accidents commuting to and from work. In comparison to all shift workers, night-shift workers have the highest incidence of fatigue due to sleep deprivation.3 Night-shift workers have a sleep debt built into their workweek that does not exist for day-shift personnel. Studies have indicated that night-shift workers average 8 hours less sleep per week than day-shift workers. Medical personnel working 12-hour shifts, including day-shift workers, having only 11.5 hours off between shifts, average 6.9 hours sleep.3 Lack of sleep increases susceptibility to infectious diseases. Night personnel run a much greater risk of loss of employment due to sleeping on the job because of sleep deprivation, fatigue, and the circadian trough, which must be tackled between 2 am and 6 am. During this period, workers experience considerable sleepiness, slower response times, increased errors, and accidents.3 Sleeping on the job is reported to be as high as 20% among night workers.3
The argument may be offered that night workers have the same amount of time off between shifts as day workers, so why do they not use their time to obtain the appropriate amount of sleep? The obvious difference is daylight and dark. Because of the suprachiasmatic nuclei (the pacemaker of the circadian rhythm) and its processing of the zeitgebers (environmental cues) that it receives, there is a natural preference to sleep when it is dark and be active when it is light.3 Night workers are constantly trying to reverse their circadian rhythms by reversing the sleep-when-its dark to sleep-when-its-light. They are also constantly fighting hormonal, secretory, and temperature rhythms that dictate diurnal action and nocturnal rest.3 Night workers are working against their own systems in order to accommodate scheduling requirements, whether they are hospital workers, police officers, military personnel performing night missions, or airline pilots and crew flying the red-eye.
Night personnel go to great lengths to provide an environment that attempts to shut out light and sound by having dark-colored bedrooms and blinds and sleeping with white noise boxes. After all these efforts to produce an environment that is conducive to sleep, they still cannot sleep. They average 1.5 hours less sleep per day than do day workers.3
Is There Hope?
What can be done to help dissuade the onset of sleepiness, sleep deprivation, increased sleep debt, and the staggering consequences to health, home, work, and fellow man?
There is a correlation between the hours between shifts and sleep duration. It is concluded that at least 16 hours off-duty time is needed between shifts in order to insure 7-8 hours sleep.3
Another study has shown that prophylactic naps have been effective in the improvement of performance and the reduction of sleepiness. Naps, in place of stimulants, have proven to be more efficient. The timing of when to take a nap in relation to the circadian cycle may also be as important as the nap itself. Naps have a maintenance and a restorative effect.5
An argument for shorter shifts has been made in regard to increased performance levels and decreased accidents. Eight-hour shifts have the best results in job performance.3
Individuals who are physically fit and exercise regularly have higher circadian rhythm amplitudes, which enables them to be more tolerant of shift work.3
A Tautological Perspective
Anyone getting 8 hours of sleep per night may think he or she is immune to this problem of sleep deprivation, but this is not the case. Motor vehicle accidents are greatest at 2:00 in the afternoon and it only takes one of the drivers to be sleepy. A truck driver over-extends his abilities while trying to arrive as soon as possible, omitting his last break from driving; he awakens as the accident is already in progress and cannot alter the course of his vehicle to prevent the impact with the oncoming car.
Barges tend to collide with bridges in the predawn hours, just before the early shift workers have to cross those bridges in order to get to work. A night nurse has reached the junction of her circadian trough and her sleep deprivation at 3 am; she gives the wrong medication and the patient becomes a statistic. This could happen to anyone, anytime.
The Drone Effect impacts every level of society. Personal responsibility must be assumed regarding the need for sleep in the same way responsibility is required by the consumption of alcohol. Bureaucracy and legislation will inevitably play a role in this, as is already evidenced in some states. Night-shift workers unequivocably have a difficult time overcoming their circadian rhythms, but they are also notorious for borrowing against their own sleep needs by limiting the hours of sleep prior to the first and last shifts of their rotation. Employers must recognize the need for creative scheduling in a reduction of time on shift versus the need for increased hours off duty. Mandatory overtime is a phrase that predicates increased sleep deprivation, but the policy for sleeping on the job still requires termination. Workers are permitted to take breaks for cigarettes, snacks, and coffee, but there is no option to use the same break in a more productive manner that would provide some restoration and improved performance, such as a nap. Sleep laboratories, above all others, should set the standard of practice for employers by applying the knowledge that exists within the field of sleep medicine today. Perhaps a day will come when a piece of exercise equipment is standard practice in the control room of Americas sleep laboratories.
Paula G. Williams, MA, CRTT, RPSGT, is a night technologist at Parkridge Sleep Disorders Center in Chattanooga, Tenn.
Special thanks are extended to Ann Ayala, REEGT, RPSGT, and Kim Kennedy, RRT.
1. Segelken R. National (sleep) debt is killing Americans and hurting economy, Cornell psychologist says: New James Maas book, Power Sleep, aimed at nation of walking zombies. Cornell News [serial online]. January 19, 1998. Available at: http://www.news.cornell.edu/releases/Jan98/sleep_dep.hrs.html. Accessed September 12, 2001.
2. Schulte B. Army tests underscore the importance of sleep. Knight Ridder Newspapers. November 26, 1998. Page 2. Available at: http://www.bergen.com/
healthw/sleep199811246.htm. Accessed September 16, 2001.
3. Battelle Memorial Institute, JIL Information Systems. The Battelle Report: An Overview of the Scientific Literature Concerning Fatigue, Sleep and the Circadian Cycle. Allied Pilots Association Web Site. January 1998. Pages 2-23. Available at: http: //www. alliedpilots. org/pub/presskit/safety/battlereport.html. Accessed September 16, 2001.
4. Sleep to Survive. Soldiers Online Web site. August 1996. Available at: http://www.dtic.mil/soldiers/august96/sleep1.html. Accessed September 16, 2001.
5. United States Naval Flight Surgeons Manual. Third Edition. 1991. Chapter 19: Fatigue. Virtual Naval Hospital Web site. Available at: http://www.vnh.org/ FSManual/19/05Identifying.html. Accessed September 16, 2001.