SHIFT WORK DISORDER

Shift Work Disorder: Are Clinicians Recognizing the Symptoms?

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Problem

The healthcare industry represents one of the largest groups of workers that work alternative shifts or shift work. According to data collected by the United States Department of Labor, Bureau of Labor Statistics more than 36 million Americans work rotating or irregular shifts. [1] Additionally, the United States has exceeded its daily working hours compared to countries such as Japan and Europe. [2] Shift work has become a way to increase productivity and service without increasing demands on infrastructure. [3] This as a common trend, especially in the United States among both men and women, especially in service occupations. Doctors and nurses represent the millions of professionals that work varied shifts providing patient care, but also have inherent risks associated with shift work.

Shift work is defined as any work schedule that is outside the routine “9 to 5” business work day. It is associated with circadian rhythm sleep disorder when an individual’s work schedule interferes with their normal sleep-wake cycle. [4] Hospitalists, doctors, nurses, and midlevels, who primarily work a varied combination of days and nights providing care to inpatients, are a group of service professionals affected by shift work. While being flexible by working various shifts in a 24 hour period can help patient satisfaction and access to healthcare, the health and quality care risks associated with shift work can be mounting.

Symptoms

The National Sleep Foundation published a poll entitled 2005 Sleep in America[5] The results revealed that compared to those that work day shift, shift workers suffered more from insomnia, falling asleep while driving, or driving while fatigued which could lead to fatal accidents. This raises a question for providers in primary care when to assess individuals who complain of insomnia. The primary symptoms and consequences that individuals with shift work disorder (SWD) present with include:

  • Insomnia
  • Reduced work performance
  • Problems with personal relationships
  • Mood or behavioral changes (i.e. irritability, depression)
  • Trouble focusing/decreased mental clarity
  • Development of gastrointestinal and cardiovascular disorders

Among healthcare providers, especially residents, consequences of various work shifts and long hours resulted in the following:

  • 36% more medical and diagnostic errors
  • 61% greater risks of needle stick injuries after more than 20 hours on duty

Healthcare providers in primary care need to be able to recognize these symptoms. Questions should be asked regarding an individual’s work and personal relationships to see if it is the result of shift work disorder before immediately assuming one has insomnia due to other causes. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) 6 if an individual with sleep issues presents with any of the following, consider SWD:

  • Persistent or recurring pattern of disruption in sleep primarily the result of an alteration in one’s circadian rhythm
  • Disruption in sleep that leads to excessive sleepiness, insomnia, or both
  • The disruption in sleep causes clinically significant distress or impairment in one’s occupational, social, or other areas of physical and mental functioning

Additionally, clinicians need to be able to ask the following screening questions to help confirm the diagnosis of SWD:

  • Is your home, work, or social life negatively affected by your lack of sleep?
  • Do you struggle to stay awake when you should be awake?
  • Do you work non-traditional shifts or work hours?

If a patient answers ‘yes’, then consider SWD.

Treatment

Though there is no formal treatment guidelines for SWD, a clinician can provide suggestions. Both pharmacological and behavioral methods can be beneficial. Offering a patient a Food and Drug Administration (FDA) approved, non-habit forming medication (i.e. trazodone) for sleep may also help with issues of depression or irritability. Behavioral modifications may include providing advice on the individual establishing a routine of normal sleep hours. Suggestions can also be made to individuals to avoid caffeine intake close to bedtime and allowing the bedroom to be a place for sleeping only, which means removing televisions, radios, etc. that can subconsciously be heard when one should be engaging in deep, restful sleep. In healthcare, errors surrounding care of patients from interns and residents has led to laws governing the maximum amount of time residents can be up providing care to patients. Other tips for handling SWD include taking brief short naps during break periods and going for a quick, brisk walk.

Summary

SWD affects a huge proportion of the working population. It is often a diagnosis that can be overlooked and linked to medical errors by clinicians, depression and other illnesses. Clinicians in primary care need to be able to recognize and consider SWD when presented with complaints from patients who report insomnia and other psychological difficulties. Recognizing and addressing these issues early on can prevent future health and psychological risks that improve one’s health and behavior. Choosing to ignore the risks of this condition has already proved deadly…just remember the Space Shuttle Columbia and Exxon Valdez, historical disasters linked to human fatigue.


Tonya Sawyer-McGee, DNP, MSN, RN, ACNP-BC
Doctor of Nursing Practice, Chatham University
MSN, University of Texas at Arlington
BSN, Prairie View A&M University


Published May 6, 2014


Biosketch:

Dr. Sawyer-McGee is an acute care nurse practitioner, who currently works at Parkland Health and Hospital System in Dallas, Texas, in internal medicine at one of Parkland’s Community-Oriented Primary Care Clinics. She has been practicing as a nurse and practitioner since 1997 and specializes in medical and acute care of patients. Prior to Parkland, Dr. Sawyer-McGee was a gastrointestinal oncology nurse practitioner at the University of Texas Southwestern Medical Center. During her time at UT Southwestern, she was also a consultant for Amgen, a pharmaceutical company, a role in which she traveled across Texas educating practitioners, pharmacists, nurses and other medical and allied professionals on the latest treatments for colon cancer.

A native of Kentucky, Dr. Sawyer-McGee precepts nurses and nurse practitioner students, is an adjunct faculty for American Sentinel University, is a member of Sigma Theta Tau International Nursing Honor Society, Sigma Gamma Rho Sorority, Iota Phi Lambda Sorority, Inc., the North Texas Nurse Practitioners, and an E-advisory member for the Practicing Clinician’s Exchange.


References:

  1. McMenamin TM.  A time to work: recent trends in shift work and flexible schedules. Monthly Labor Review. 2007;130(12): 3-15.
  2. Gornick JC, Heron A, Eisenbrey R. The work-family balance. An analysis of European, Japanese and U.S. work-time policies. EPI Briefing Paper #18, May 24, 2007. http://www.gpn.org/bp189/bp189.pdf. Accessed March 20, 2014.
  3. Haynes BP. (2008) “Impact of workplace connectivity on office productivity”. J Corp Real Estate. 2008; Vol. 10 (4):286-302.
  4. Morgenthaler TI, Lee-Chiong T, Alessi C, et al; Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep. 2007 Nov;30(11):1445-1459.
  5. National Sleep Foundation. 2005 Sleep in American Poll: Summary of findings. Washington, DC: National Sleep Foundation.