Posted April 25, 2023
In this episode, Nathan talks about sleep again: part three of his mini-series about sleep difficulties, problems, and insomnia and how to improve those for nurses and midwives.
In the previous episodes, Nathan provided an overview of effective evidence-based ways to optimise sleep and recovery in shift workers. Today’s episode focused on shift work sleep disorder and the issues it creates for nurses and midwives.
People might put a lot of pressure on themselves to sleep and fall asleep during the day. This psychological pressure we put on ourselves can create a lot of stress and lead to that arousal, making sleep very difficult. So remind yourself that getting rest is essential, and if you are struggling with sleeping, seeking help is really important. These can help optimise sleep and recovery in shift workers.
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Nathan Illman 00:05
Welcome to another episode of nurse wellbeing mission Podcast. I’m Nathan. I am a clinical psychologist devoted to helping nurses and midwives prepare for emotionally challenging work. I like to focus on mental health prevention, not just reactive approaches. And in this episode, I’m going to be talking about sleep. Again, this is part three of a little mini-series that I’ve been doing on sleep. We started off several weeks back talking about effective evidence-based ways to optimize sleep. That’s for people who aren’t necessarily struggling with their sleep, who just want to get better sleep. Last episode, we focused on sleep problems, trouble sleeping, and insomnia. And I provided an overview of effective ways to overcome those sleep problems. And some of you may have listened to that and thought, Okay, well, some of these are good, but I work night shifts, I’m a shift worker. So have you got any assistance or help for me, because it’s quite a specific scenario, where the times that you’re going to bed and awake are rotating, or maybe on a night shift. So things are a little bit different for you. And that’s what we’re here today to talk about. So this episode is all about shift work, the specific problems that it creates for nurses and midwives. And we’re going to be going into much more detail about something called shift work sleep disorder, which is a sleep disorder associated with shift work. So if you don’t already follow nurse wellbeing mission, then you can find me on social media on Instagram, it’s at underscore nurse while being mission, you can come join my free Facebook group where I provide lots of resources, including the podcast. So just search for nurse and midwife wellbeing mission on Facebook, and you can find me on Twitter, at nurse wellbeing, let’s dive into this episode. And so should we start talking about shift work in general, what is shift work? shift work is where someone works outside of traditional working hours. In Western society, we have developed this shift pattern that is approximately something like nine to five. And this all started, of course, in the industrial revolution, where there was lots of factory work, and this shift pattern became the norm. So shift work is defined as someone who works outside of that it might be that you work into the evening, or into the night, or completely through the night. And as we know, many nurses and some midwives as well, are required to do this as part of their roles. So it might be doing night shifts, starting at eight and finishing eight in the morning, something like that, and potentially rotating night shifts every few days doing that. And then going back on to doing day shifts is a core part of certain jobs. People who work night shifts are a massive contributor to important services in society. In my opinion, they’re not valued enough. We often don’t really give thanks to those people. So if you’re listening as someone who does night shifts, then I personally thank you for being on call it unsocial hours of the night and quite frankly putting your own health and well-being at risk in service of helping other people.
Nathan Illman 03:43
So what is the problem with working night shifts? And how why would it impact our well-being if you’re listening to this, and you’re someone who does night shift, so you’ve done night shift in the past, you will be all too familiar with the difficulties it can create for you both physically and mentally. If we’re looking at this from a scientific perspective, and what affects sleep and how we sleep, then we know that our sleep patterns are very much determined by light and dark cycles. So I went into this in more detail in that first episode on how to optimize sleep. So essentially our circadian rhythm that biological clock that our bodies follow. And all of the cells in our in our bodies, in fact, kind of follow this circadian rhythm that is triggered by the rising of the sun and exposure to light through our eyes. And then of course darkness as well. So what’s happening when you’re working a night shift is essentially you are fighting against the body’s natural desire to sleep at night. All of the metabolic systems going on in your body would normally be slowing down for example when you’re going to sleep at
Nathan Illman 05:00
and you are not only you, you having to be awake and alert, there might be quite stressful things that you’re having to do overnight shift as well. So this is really jarring for the body. And then of course, the next day you’re going back and you might actually be exposed to sunlight on the way home, which is not really a normal thing before we go to sleep. Normally, our body, our brain, and our body want it to be dark to help trigger that unnatural sleep process. So you’re going home, you might be bright outside, and then you are trying to sleep through the day, which is when your body would normally want to be awake. Now, of course, if you do permanent night shifts, for a long period of time, it is easier to adapt to this, especially if you do good little environmental modifications like you make sure you have a pitch-black room when you get home. And it’s very quiet. And it’s kind of perfect. But for many people, this isn’t the case, many people do rotating shifts, which is more problematic because you’re having to get your body used to a natural thing of a day shift, then an unnatural thing of a night shift, and then keep switching back and forth. And just in the same way, we feel jetlag when we travel across time zones, a similar kind of thing is happening here. So it’s called circadian Miss alignment. One of the other big problems, of course, with working the night shift is when you’re on those night shifts, it disrupts your social life, there’s this kind of social aspect that impacts your well-being. So for example, you might be a bit more isolated and not get as much social time with your friends and family when you’re working night shifts. And of course, these are the things that bring us lots of joy and contribute to positive emotion and happiness in our life. So if you are having to sleep during the day, and you’re not able to see people, then of course that can negatively impact you. Working rotating night and day shifts as well can be problematic for establishing and maintaining healthy habits. So what we know about the science of making habits and maintaining these positive health behaviors like exercise, and good nutrition, is that really, we want to be doing them at the same kind of dead time each day. And maintaining a habit throughout the week, in order to ensure that we actually follow through with these things. And of course, if you are switching between having to sleep at night and then having to sleep at day, it’s quite difficult for you to maintain doing exercise at the same time each day, for example. So it’s understandable then that people working rotating night shifts and day shifts, and probably less likely to be keeping up those positive health behaviors. So it’s because of these things, then the fact that the night shift is working against your natural biology, there are hundreds of 1000s of years of evolution, and this kind of social aspect of working night shifts that leads to mental and physical health problems. So in terms of physical health, what we know is that people who work night shifts are at increased risk for some types of cancer. So breast cancer and colon cancer, for example, people who work night shifts are more risks of cardiovascular disease. So increased blood pressure, for example, and also stroke as well. We also know that metabolic disorders are more common in people who work night shifts. So for example, obesity, and also type two diabetes are more common in those who work night shifts in terms of mental ill health rates of depression, and anxiety and sleep disorders are more common in people who work night shifts.
Nathan Illman 09:08
So the research is very clear that working night shift is unfortunately bad for mental and physical health. And if you’re listening to this, you probably already would have gotten a sense of that for yourself in your own life, the effect it can have. Now of course, this is not hard, and faster doesn’t mean that everybody is going to experience things in the same way. But there is enough data here to make it a worthwhile thing for us to care about and to try and improve people’s sleep to help them adapt between rotating shifts and to try and optimize sleep. And as I’ll be covering in this episode, to help resolve shift work sleep disorder, which is essentially a form of insomnia that people experience when working on night shifts. So what is shift work SLEEP DISORDER today estimated about 30% of nurses working night shift experience this, and is characterized by problems with insomnia. So that is difficulty falling asleep or staying asleep. It is difficulties with impaired concentration and sleepiness on times where the person is awake because that might be on the night shift or on the days where they’re off. And it is associated with reduced productivity, making errors, and really what we call functional impairment. So basically, you’re struggling, you’re feeling maybe stressed out, maybe you’re feeling anxiety, you’re not getting enough sleep, you’re feeling tired. And that’s impacting your mental health, and then that is impacting what you’re doing at work as well. So it’s slightly different to just sleep problems that we were discussing last time, or insomnia that anyone could experience because it’s a little bit more specific to this situation where you’re working night shifts. Therefore, the approach that we’re going to use to help try and improve this is slightly different. Because rather than just trying to optimize sleep for someone who’s trying to go to sleep at night, we’re going to factor in the fact that if you’re in rotating shifts, which is very common, you’re trying to optimize sleep during the day, and then a night potentially, so we’ll get into that shortly. So in terms of what causes shift work, Sleep Disorder. Of course, that circadian misalignment I mentioned before, is an obvious one. So the battling against what your brain and body are trying to do, over time can just create issues with sleeping, it can just make it hard, because of the biology of it. But often there is a psychological component as well. And as we know, from research on insomnia, is that stress is a big contributing factor to people not sleeping well to people feeling like they can’t get off to sleep because of things going through their head, or potentially waking in the middle of the night as well. So we’ve got stress as a cause of insomnia and shift work SLEEP DISORDER combined with this unnatural trying to go to sleep when your body wants to be awake and vice versa. An extra little point I would like to make in terms of the types of people who are more at risk of developing sleep disorders, and potentially shift work sleep disorder is that women make up the greatest proportion of Nursing and Midwifery. And women tend to experience higher levels of stress. That’s from societal pressure on women, women tend to have additional caregiving responsibilities, and therefore role conflict outside of the home. And it’s known that that creates high levels of stress for women. So this is one reason why rates of shift work sleep disorder, maybe higher, and just insomnia in general in nursing and midwifery. Okay, so we’ve talked about shift work sleep disorder, and what it is, let’s get into some strategies and techniques for overcoming these difficulties and helping to optimize sleep for people who are rotating shifts, a useful place to start, in fact, is talking about the differences between those who work rotating shifts and people who are on permanent shifts, and what we know from the research about the differences between those. So researchers found that unfortunately, both of those are still associated with physical and mental health difficulties. However, what we know is that the rate of difficulties is higher with those people who are working, rotating shifts. So again, this links back to what we’ve already spoken about this whole idea of circadian misalignment, it’s not really that much of a surprise, that rotating shifts are more damaging for health than being on permanent shifts. Now, of course, being on permanent night shift is extremely unattractive life choice for many people, because how are you going to socialize with the other 90% or whatever it
Nathan Illman 14:25
is of the population who aren’t working? shift work is very difficult. So unfortunately for most people, and in most organizations, really, the only option is to be working on rotating shifts. But having said that, there is some research which points to ways in which we can help optimize the transition between those people who are rotating from a night shift to a day shift. So one of those relates to whether that transition is being made in a forward fashion or a backward fashion. So what we know is that it’s better when someone transitions forward in their shift pattern. So for example, the beginning of the week, if you’re working a day shift or a quote-unquote normal shift that many other people would be working, and then that is gradually moved forward so that later in the week, you are then working, starting later in the afternoon, and working somewhat into the evening. And then eventually you transition on to a full night shift. And then eventually, that might transition into another day shift. The reason for this is, is that it just helps with the natural circadian alignment, our body prefers to go forward in that fashion to adjust to a different sleep schedule. Rather than going backwards, it will probably come as no surprise to many people as well, the actual number of consecutive nights that someone is doing is also linked to the negative effect as well. And less, as we said, that person is on permanent night shifts, the more someone is working a night shift, the more that sleep debt is probably building up because most people aren’t getting the required seven to nine hours sleep the following day. So organizations are really advised to limit the number of consecutive nights, really to three at the most, maybe two. And giving people adequate rest in between those shifts in between the actual night shifts themselves, but then also in between the transition between a night and a day shift. So what I’ll be doing next is summarizing some techniques and little tools you can use to optimize sleep when you’re working, rotating night shifts, and de shift. And hopefully, this will help with some of the difficulties you might be experiencing. If you have got that insomnia, or indeed shift work sleep disorder. And these can be combined with all of the tools that I discussed in the last episode. So I’d really recommend checking that out. In particular, I talk about some of the factors that maintain sleep difficulties, some of the psychological difficulties, and behavioral things people do that maintain those problems with sleep. So if we start off by considering the day of your first night shift, then it’s really important to sleep in as long as possible. So the idea here is that you’re wanting to maximize the sleep you have before that first night shift. Because you know, basically you’re going to be working against what your body is going to be wanting to do that night, which is going to sleep so sleep in as long as you can the morning of that day, then in the afternoon, if you can try and take a nap as well, that is excellent. Because what you’re doing there is essentially giving yourself more energy to get through that first night shift. A couple of weeks ago, I had a wonderful guest on this podcast. Despina are teeny, who was talking about a randomized control trial she did that looked at Bright light exposure in nurses before night shifts, so highly recommend giving that a listen. But just to summarize, that can also be a helpful intervention that you can use at home to prepare you before night shifts, that has now some evidence to suggest that it can reduce fatigue and improve your alertness and stuff whilst on shift. So having a bright light box that you can buy online, exposing yourself to 40 or so minutes of light before you go on shift. drinking caffeine before you go on shift can be helpful. So the goal here is to help you stay awake on my shift. Now as you get into that night shift in terms of maintaining your alertness, then napping is really a recommendation from some of the research literature. So organizations really have responsibility here to provide safe, quiet, and really just hospitable spaces, where nurses and midwives and other health care workers are able to take a nap. And ideally when nap is taken in the first part of your shift. So this might not be relevant if you’d had a nap earlier on that day and you’re really actually not tired. But of course, for many people, that wouldn’t necessarily have been the case. So having the opportunity to take a nap whilst on the shift is helpful. And then not drinking caffeine later into your shift. Certainly not napping later into your shift. Because then at this stage, what you’re trying to do is allowing your body to prepare for sleep when you get home on that day. Now when you leave work, what you want to do here is avoid light exposure. So it’s the light exposure, which is going to trigger all of those mechanisms in your brain and body that are going to want to keep you awake When you’re wanting to go to sleep, so wearing sunglasses on the way home is going to be helpful. As soon as you get home. The goal here is to get to sleep as soon as possible. So trying to create some kind of routine, where you’re prioritizing your sleep and recovery. Having a dark and quiet and cool room in your home is super important. So a lot of this really also involves having discussions with people that you might be cohabitating with. So helping them understand the importance of creating a quiet environment for you to people with families, this might be quite a tricky thing to do. But helping your kids, for example, understand why it’s important that mommy or daddy has quiet time to sleep during the day, and you’ve been boundaries about getting that sleep as well and giving yourself enough sleep opportunity. Something else that was really worth mentioning here is alcohol. So drinking alcohol, when you get home, for example, after a night shift, some people may do this be wanting to wind down, we just know that alcohol is not helpful for sleep, alcohol may help you get off to sleep if it’s been a difficult shift. But it is going to impact the quality of that sleep. So really avoiding alcohol, whether you’re working just normal nine-to-five shifts, or whatever it is 12 hour shifts during the day or night shifts. Alcohol is something to avoid right before you go to sleep as his caffeine and other kinds of stimulants, they in those days in between the night shifts. As I said, we’re trying to maximize the amount of sleep that you get. But just linking back to what I mentioned to the insomnia episode last time, is that people might put a lot of pressure on themselves to get to sleep and to fall asleep during the day. And this psychological pressure that we’re putting on ourselves can create a lot of stress and lead to that arousal, which makes sleep very difficult. So just reminding yourself that getting rest is important. And that it’s okay. For example, if you have a bad day, where you don’t sleep that well and trying not to focus too much on what the negative effect of that might be. Because as soon as we start worrying and go down that route, it creates more anxiety. And that higher arousal makes it very, very difficult to fall asleep. Okay, so you’ve done your night shift, and now you have to try and reset, you’re going to be going back to working day shifts. So what do you do? What is the strategy to use after the final night shift? Well, something
Nathan Illman 22:50
that can be really helpful is when you get home. So you’ve been doing the same thing as before you have worn sunglasses and try to avoid light exposure, you’ve tried to avoid caffeine and stuff, you still want to be able to sleep when you get home on that first morning, but not sleeping as long. So your goal here is to try and re-establish your usual routine, the routine that you would have if you were someone who was working during the day and sleeping at night. So of course, you want to sleep a little bit to begin with, because otherwise, the rest of the day is going to be a write-off. And it’s just extremely unlikely that you will be able to stay awake all the way until your usual bedtime at night. So go home and have a nap have a nap of between 90 minutes and a couple of hours and set yourself an alarm to wake up. So you’re going to do this just to go through a sleep cycle or to it’s going to help you feel more refreshed and to give you the energy to continue with the rest of the day. And then really, you know in the afternoon avoiding caffeine and anything that’s going to affect your sleep later on that night and trying to stay awake as close as possible into what your normal bedtime would be. So say, for example, your bedtime is around 10:30 pm. You want to try and stay awake as long as you can until then because the idea is that you are trying to recreate a routine. This idea of routine is something I always come back to when I’m talking to people about improving their sleep because the brain and body love the routine. So you go to sleep that night, the next morning trying to wake up at a set time and then keeping that routine for the next couple of days or the next few days, however long. You are then on day shifts. Again, as we talked about in the insomnia episode last time. One of the problems that is associated with insomnia is that people’s routines get messed up and they start putting in long naps because they’re tired because they haven’t slept the night before and then their bedtime changes and their wake time changes and this maintains the issues With sleep disorders, so after you finished your run of night shifts, take a nap, going to bed at a normal time and trying to stick to a routine as best you can. Now, you might be listening to this, wondering what role medications can have for you if you have shift work sleep disorder, and for example, you have trouble sleeping during the day. Now, of course, there are a class of medications called hypnotics that can help with sleep and also herbal medicines, for example, I guess the thing with these is that there is not a huge amount of research data to support their use and what effect they have in the long term. And there are lots of individual differences with different people which are going to affect the efficacy of using those. And also their use can be problematic in terms of maintaining people’s insomnia. As I mentioned last time, what can often happen when people start using drugs to help them fall asleep, or even stay awake is that people come become dependent on that to get to sleep. And unfortunately, that dependence is what can maintain a, an anxiety, or focus on trying to control sleep, which may indeed create these long-term difficulties because sleep is a natural process. As I spoke about in that last episode, a recent review that was published this year by Rebecca Conway Jones and colleagues actually looked at the evidence for both pharmacological and non-pharmacological interventions specifically see work shift disorder, shift work sleep disorder, in fact, and what they found was that the quality of evidence is not particularly good. Now, the recommendations I provided you in his episode are solid, and David referenced those in their paper. But what they suggest is that we need a lot more research, to look at the efficacy, for example of these hypnotic drugs in treating shift work, Sleep Disorder, and even some of these other behavioral interventions. It’s a complex topic, I think it’s something that needs to be teased apart a lot more. There are a lot of things that can contribute to someone’s difficulties with sleeping. And I think this really comes to an important point that I would like to stress is that, if you are struggling with your sleeping seeking help is really important. So I’ve produced this hopefully helpful podcast series that people will listen to, and maybe you’ll pick up some things in here and try them out. And it will really help you. But if you’re still struggling, there are professionals out there that can help you, I’d recommend approaching your occupational health department at work, you may have some kind of employee assistance program that can provide help with this potentially a psychologist that can help you or going to your GP and having a discussion with them being referred on to a service related to this point, I think is coming back to this idea that stress is a big cause of sleep difficulties for people. When people are chronically stressed, it becomes very difficult to sleep because the conditions that are needed for sleep are being relaxed and not having a high state of arousal in our brain and our body. So engaging in regular activities, which are designed to help relieve stress is so important. So doing things like exercise and eating a balanced meal, spending time socializing with people having access to social support people who are able to have a conversation and empathize with the people that you feel you’re able to share your troubles with, for example, or accessing professional help. At times, seeing a psychologist or having a coach, or speaking to a spiritual leader could be another way that it is going to be helpful for you to help relieve stress in your life. So having some kind of strategy on a day-to-day or week-to-week basis is going to help reduce some of the stress experienced as part of your role as a nurse or midwife should help with some of these sleep difficulties. This actually leads on to something exciting that I’m doing at the moment. I’m currently in the process of getting an online course together, which is around helping nurses and midwives improve their relationship to stress and to deal with stress better and actually learning some skills to optimize this stress response. And that’s going to help people feel a lot better and to sleep better. So watch this space for that. I’ll be talking about it more in future episodes when I formally launch the online course. So I guess in tying things together summarizing what we’ve talked about in this episode, shiftwork is common in nurses and midwives. shiftwork sleep disorder is a specific type of sleep disorder encountered by people who work night shifts and day shifts, it’s around 30% of those people. And it creates negative health and mental health difficulties. We’ve talked about some strategies that can be used to help optimize sleep when rotating between shifts. And I’ve made reference again to some of the tools that one can use, covered in our last episode from insomnia, that one can integrate with those tools that we’ve talked about today for optimizing sleep and helping the transition between night shifts and day shifts. So if you’re somebody who works, shift work, and you’re struggling with sleep, try and put into play some of those things if you’re not doing them already. And let me know how it goes. You can reach out to me on social media. I’d love to hear from you. I love people’s feedback. I’m gonna leave things there for today and I will see you here in the next episode of NASA being mission podcast. Bye for now.