Healthy People 2020 Sleep Health
Roxana Boucaud
Daphne Elien
Mahadeo Ramsamuj
New York City College of Technology
Nursing Department.
Sleep health is one of the new topics identified on the growing list of health initiatives within the Healthy People 2020 nationwide health improvement priorities sponsored by The Department of Health and Human Services.. According to this organization, poor sleep health is a common problem with 25% of adults in the United States. This problem is defined as “insufficient sleep or rest at least 15 out of every 30 days.” They further assert that awareness of this “public health burden” among the general population, health care professionals, and policy makers is low and as such, “a well-coordinated strategy to improve sleep health is needed’ (Healthy People.gov, 2010)
To further amplify the problem, the Center for Disease Control (CDC), characterized the problem of poor sleep health as a “public health epidemic.” In depicting the scope of the problem, they noted that “sleep insufficiency is linked to motor vehicle crashes, industrial disasters, and medical and other occupational errors”. And that “unintentionally falling asleep, nodding off while driving, and having difficulty performing daily tasks because of sleepiness may all contribute to these hazardous outcomes.” Like the Healthy People 2020 campaign, the CDC (2011) observed that people who experience prolonged sleep deprivation are putting themselves at risk for chronic medical problems which are already widespread across the United States. The most prevalent chronic medical problems include hypertension, diabetes, depression, obesity, and cancer. Additionally, these same individuals increase their mortality risk due to a multitude of compounded effects due to sleep deprivation that jeopardizes their personal safety. And as such, their overall quality of life and productivity suffers. The CDC (2011) estimated that 50 – 70 million adults in the United States have sleep or wakefulness disorder. To break it down further, a survey on Self- reported Sleep-related difficulties among adults 20 years of age and older notes that 23.2% experienced difficulty concentrating on things, 18.2% experienced difficulty remembering things, 11.3% experienced difficulty while driving or taking public transportation, and 8.6% experienced difficulty with job performance (CDC, 2011). The National Sleep Foundation (2011) suggests that adults need 7-9 hours daily. But according to data from a National Health Interview Survey sponsored by the National Center for Health Statistics, nearly 30% of adults reported an average of ≤6 hours of sleep per day in 2005-2007 (Schoenborn CA, Adams PF, 2010).
One population in which poor sleep health have far reaching consequences for is that of health care professionals. And as such, this discussion will narrowly focus on how sleep deprivation affects health care professionals and how the community health nurse (CHN) can have a positive influence towards reducing the adverse effects of this public health problem. As Judith A. Owens (2007) asserts, sleep deprivation results in compromised cognitive function and fatigue. Particular to health care professionals, long continuous work hours with limited time for sleep in between shifts does not allow for adequate recuperation of the body and mind. This reduces their physical, cognitive, and emotional tolerance which in turn deleteriously affects their personal health, well- being, and job performance. These compounded effects then results in negative patient outcomes as it pertains to patient safety and mortality. Furthermore, in addition to them being a danger to themselves because of sleep deprivation, they are also a danger to the public (Owens, J.A., 2007).
Another reason that this problem of sleep deprivation in health care professionals needs to be addressed is that like, the general population, awareness of its prevalence among health care professionals is low. As a CHN, the need to explore other underlying causes that entail this “public health epidemic” and address solutions geared towards the objectives stipulated by Healthy People 2020 is overdue.
As mentioned earlier, common precursors for the lack of sleep among healthcare professionals are long shift hours. Other precursors include rotating shifts and overnight call duty. According to the National Association for Neonatal Nurses (NANN) “2-5% of nurses work more than 60 hours a week, 28% work shifts that are 12 hours or longer, and in intensive care units, 36% work more than 12 hours a day” (NANN, 2007). In comparison with the nurses, Olsen, E.J., Drage, L.A., & Auger, R.R. (2009) pointed out that, the medial interns and residents work an average of 71 hours per week and four extended shifts per month for an average of 32 hours. A breakdown of theses hours show that time allotment falls within the limits put forth by the Accreditation Council for Graduate Medical Education – 80 hours per week. Yet 46% of interns surveyed agreed that sleep loss and fatigue have a major impact on their work. The enormity of the impact is such that, 41% of 254 medical residents noted fatigue as a cause of their most significant medical mistake, with one third of those mistakes resulting in a patient fatality. Surgical residents made up twice as many errors post – overnight call. Anesthesia residents demonstrated sleepiness similar to that of narcoleptics.
A major attribute of being a healthcare professional is the ability to focus and think critically in all situations. Sleep deprivation adversely affects problem solving, memory, job performance, the ability to learn, and motivation. All these factors can mean the difference between life and death of a patient. Olsen, E.J., Drage, L.A., & Auger, R.R. (2009) stated that, “hourly declines in cognitive psychomotor performance are similar to those observed with a progressive rise in blood alcohol concentration”.
Sleep deprivation is a consequence of the American 24/7 society. Since the business of healthcare is a 24 hours, 7 days a week enterprise , it mandates that healthcare professionals also be cognitively functional within this continuing time frame, while adhering to their ethical principal of beneficence. Also it is important to note that the escalating cost of the preparatory educational curriculum which culminates in their respective field of practice requires the establishment of financial leveraging in terms of educational loans. To add to that, the rising cost of living exceeds current compensation rendered for these respective occupations (i.e., physicians, nurses). As a result the need for extended work hours by way of “moonlighting”, second jobs and discretionary over time compounds the problem of sleep deprivation in this population.
False perception regarding professional ethics adds to the problem of sleep deprivation. For example, doctors and nurses alike believe that staying on task with a particular patient/case is a measure of dedication towards quality patient care. Although this seems to be an admirable quality, both patient and staff safety is compromised due to mental and physical fatigue (Olsen, E.J., Drage, L.A., & Auger, R.R. (2009).
Lastly, the lack of insight among healthcare professionals regarding the untoward effects that result from interrupted sleep helps to prolong this public health problem. Misconceptions such as the use of nicotine, caffeine, bright lights, long naps, etc, are thought to be lasting effective counter measures against the circadian physiology. The temporary gains towards wakefulness from these countermeasures are not thoroughly acknowledged.
Some of the most significant solutions to this burgeoning problem of sleep deprivation in the realm of health care includes, health care professionals taking planned naps as opposed to unplanned naps. Planned naps of approximately 20 minutes in duration reduce the risk of sleep inertia, also known as grogginess upon waking. This practice is especially effective for both, rotating and permanent shift workers who have a difficult time staying alert and focused “during the body’s circadian nadir (2-4am)”( Brown&Trinkoff,p357).
The judicious use of caffeine or caffeinated beverages should be consumed up to11:00 am and no further to prevent sleep fragmentation during waking hours. Caffeine is a common stimulant that requires approximately 30 minutes to produce peak levels of wakefulness, and two cups can maintain wakefulness and cognitive alertness for several hours. Health care workers need to be especially cognizant of the need to preserve and maintain their own safety as well as others after driving home at the culmination of one’s shift.
Caruso et..al (2010) posits that if a person experiences drowsiness while driving, they should stop driving, drink a small amount of coffee, then take a short nap. Upon awakening, the person will gain the benefit of both measures by way of increased wakefulness and alertness. The combination of a 2.5 hr nap before a night shift and caffeine at the beginning of the shift had also been noted to have positive effects on these aforementioned outcomes.
Like many of us, driving while drowsy is a significant problem for extremely fatigued nurses as well. Motor vehicle collisions are all together common experiences on their commute, especially on the return trip home.
Another significant intervention to combat sleep deprivation is the implementation of work schedule adjustments. Nurses that work 12 hour shifts should be leaving their place of employment regularly at the end of their respective shifts. “Leaving on time must become a guarantee rather than an unlikely occurrence” (Brown&Trinkoff,p.358). Holding staff meetings after a long night’s work is never productive as most of the night shift is nodding off. Asking night shift nurses to extend their duty time- this is particularly unsafe, in addition to reducing handoff and end-of-shift tasks. Nurses should also be given respect for their day off and this has been shown to increase the risk of bodily injuries. Policies need to be implemented that prevent nurses from being called in to work on their scheduled days off in addition to vacation days.
The use of bright environmental lighting promotes alertness and is a significant signal for circadian rhythms. Common gradations of artificial light promote alertness. “For night workers, some researchers suggest intermittently going into well-lit areas during the first several hours of the shift and reducing light exposure a few hours before bedtime to help prepare the body for sleep.”(Caruso & Hitchcock, p.195). Some researchers have also found that utilizing light blocking sunglasses when leaving work can curtail the circadian effects of daylight.
With the increase risk of incidences occurring among not only to healthcare professionals but also to patients, the role of the CHN becomes beneficial in implementing the recommended solutions. The roles that the CHN can play to help the healthcare community are educator, advocator, and change agent.
As an educator the CHN can inform the healthcare community about sleep hygiene, effects of sleep deprivation, and implications for patient and personal safety. According to Owens, “education is necessary to affect any substantial and sustained behavioral change on the individual level (i.e. the individual needs to understand the rationale for the changes to buy into them, and also to accept personal responsibility for instituting for them” (pg. 92).
The role of an advocator allows for the collaboration with management for a functional work schedule. This allows for the reduction of long work hours and excessive over time. To extend this idea across the country, the CHN can work with the ANA to lobby for regulatory change.
The role of the CHN as a change agent would be to work the individual to increase personal insight. Meetings can be held to discuss unit dynamics that might contribute to the underlying problem. A staff work schedule can be developed with the help of management to enhance healthcare qualities.
In conclusion, sleep health is a public epidemic. Sleep deprivation affects the mental, physical, and emotional balance. As the healthcare profession becomes increasing demanding, healthcare workers are putting in more hours, thus getting an insufficient amount of sleep. As a result their ability to perform at their optimal level has decreased, leading to the endangerment of the patient. The goal is to increase the awareness through education, advocacy, and change initiative. Only through these measures can the community health nurse begin to facilitate desirable effects.
References
CDC. Centers For Disease and Control Prevention, (2011). Insufficient sleep is a public
health epidemic. Retrieved on December, 2nd 2011 from website: http://www.cdc.gov/features/dsSleep/
Healthy People.gov. Department of Health and Human Services, (2010). Sleep health. Retrieved on December 2nd 2011 from website: http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=38
National Sleep Foundation. (2011). How much sleep do we really need?. Retrieved on December 2nd, 2011 from website: http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need
Olsen, E.J., Drage, L.A., & Auger, R.R. (2009). Sleep deprivation, physician
performance and patient safety. Chest Journal, 135(5). 1389 – 1395.
doi: 10.1378/chest.08-1952.
Owens, J. A. (2007). Sleep loss and fatigue in healthcare professionals. Journal of
Perinatal and Neonatal Nursing, 21(April – June 2007), 92-100.
Schoenborn CA, Adams PF. Health behaviors of adults: United States, 2005–2007.
National Center for Health Statistics. Vital Health Stat 10(245). 2010.
Brown, J., & Trinkoff,A.(2010) Is it Time to Pull the Plug on 12- Hour Shifts? Jona 40(9), 367-359.
Caruso,C.,& Hitchcock,E.(2010) Strategies for Nurses to Prevent Sleep-Related Injuries and Errors. Rehabilitation Nursing 35(5),192-197.
