Working Hours, Sleep, & Fatigue Forum

Abstract for Healthcare & Social Assistance Sector

Work Hours and Fatigue in the Healthcare and Social Assistance Sector (Extended version)

Claire C. Caruso, PhD, RN, FAAN*, National Institute for Occupational Safety and Health
Megan W. Arbour, PhD, CNM, FACNM, Frontier Nursing University
Laura Barger, PhD, Brigham and Women’s Hospital, Harvard Medical School
Ann M. Berger, PhD, APRN, AOCNS, FAAN, University of Nebraska Medical Center College of Nursing
Eileen R. Chasens, PhD, RN, FAAN, University of Pittsburgh
Jaime Dawson, American Nurses Association
J. Cole Edmonson, DNP, RN, FACHE, NEA-BC, FAAN, AMN Healthcare
Beverly Hittle, MSN, RN, University of Cincinnati
Christopher Landrigan, MD, MPH, Harvard University
Patricia A. Patrician, PhD, RN, FAAN, University of Alabama at Birmingham
Nancy S. Redeker, PhD, RN, FAAN, Yale University
Ann E. Rogers, PhD, RN, FAAN, FAASM, Emery University
Alison Trinkoff, ScD, MPH, RN, FAAN, University of Maryland
Sharon Tucker, PhD, RN, FAAN, Ohio State University

Corresponding Author: Claire C. Caruso, PhD, RN, FAAN, National Institute for Occupational Safety and Health, 1090 Tusculum Avenue, MS C-24, Cincinnati, Ohio 45226, ccaruso@cdc.gov.

Key Messages

  1. Of all HCSA workers, 28% have shift work schedules and 17% work 48 or more hours a week to provide their vital services around the clock.
  2. Compared to other sectors, HCSA has a significantly higher prevalence of fatigue, job stress, depression/anxiety, burnout, substance abuse, and non-fatal injuries and illnesses.
  3. Sleep deficiency is common; 52% of healthcare workers on night shift report sleeping 6 hours or less per day. Sleeping less than 7 hours on a regular basis is associated with numerous adverse health and safety outcomes.
  4. The highest research priorities are developing better designs for the work schedules and improving the culture, which historically has not given attention to the impact of shift work, long work hours, and fatigue on workers’ safety and health. Additional research priorities are identified to improve work hours, sleep, and fatigue issues in the HCSA sector.

Introduction

The Healthcare and Social Assistance (HCSA) Sector is one of the fastest growing industrial sectors in the United States, with over 20 million workers.1,2 About 80% of these workers are women, and African American and Asian workers account for a higher percentage of this sector in comparison with other sectors.3 To provide their critical services around the clock, workers in HCSA often have to work during the evening, at night, and sometimes irregular or long hours. Nearly 28% work evening shift, night shift, rotating shifts, or other non-day shift schedules.4 Almost 17% work 48 or more hours a week, and almost 6% work over 60 or more hours.4 Twelve-hour shifts are common, and some regularly work longer shifts. A portion of the sector, more than 100,000 resident physicians, work more than 60 hours per week.5

Burden

In addition to shift work and long work hours, HCSA workers are exposed to many other hazards in the work environment, such as high physical, social, emotional, and cognitive demands (which they often have little control over); fast-paced work; hazardous chemicals and drugs; infectious agents; and workplace violence.6 HCSA workers often deal with very sick and dying clients in difficult circumstances or with high needs. Although the work is highly meaningful and often emotionally rewarding, the job tasks are sometimes very difficult. Long shifts prolong workers’ daily exposure to these workplace hazards and reduce their time to recover. For musculoskeletal disorders, studies found that long work hours increase the risk for musculoskeletal disorders.7 Longer exposure to other hazards may also increase risk for adverse outcomes.

Compared to other sectors, HCSA has significantly higher prevalence of job stress, depression/anxiety, burnout, and substance abuse.8 Suicide rates among physicians and veterinarians are higher than in the general population.9,10 Workers in HCSA experience the highest numbers and rates of work-related non-fatal injuries and illnesses that require 3 days or more off from work.11,12 Shift work, long work hours, and inadequate sleep are likely critical contributors to the many health problems seen in HCSA workers. Sleep deficiency is common; 52% of healthcare workers on night shift report sleeping 6 hours or less per day, which is too short.13 Disturbances to sleep and circadian rhythms are known to increase risk for injuries, negative mood and body defenses against infections, cancer, cardiovascular disease, and metabolic disorders.14-16

Unlike transportation modes, for which the hours of service are regulated for public safety, few regulations target the work hours of HCSA workers. Fatigue in healthcare workers negatively impacts patient safety and the safety of the public while tired workers commute.17-20 A study reported that medical errors were the third leading cause of death in the United States.21 Worker fatigue from shift work, long work hours, and other factors likely contributes to these patient care errors.22,23

Need

The authors discussed the research topics needed to improve work hours and related sleep issues in HCSA. The Delphi method was used to anonymously rank-order research priorities by importance to improving HCSA worker health and safety and public safety. Authors gave the highest priority to the design of work schedules. Many HCSA workers have to work during the evening and at night to provide their vital services. During environmental emergencies and other disasters, long work hours cannot be avoided. Research is needed to determine better ways to schedule workers in this sector to provide their services around the clock and to improve their ability to maintain their own health, safety, and sense of well-being. Given the growing evidence that night shift work with persistent circadian disruption is a carcinogen and is linked to the development of type 2 diabetes and cardiovascular disease,24-27 research is needed to design work schedules that allow workers to align their circadian rhythms with their work times.

The second highest priority is improving the culture of safety in HCSA that influences its approach to work hours and fatigue. Historically, little attention has been given to the impact of shift work, long work hours, and fatigue on workers’ safety and health. Research is needed to move this sector toward improvements on this topic including studies of the cost of worker fatigue to the organization and patient safety.

The next three topics ranked closely: HCSA leadership issues, education/training, and countermeasures for fatigue. Leaders often do not realize or appreciate the demands and financial costs connected with shift work and long work hours or the strategies for reducing the risks. As a result, they are not applying evidence-based practices in their operations. Workers and managers often lack education about this topic because it is not usually included in entry-level education programs for these professions. Research is needed to develop and test education interventions and methods for dissemination. Because fatigue cannot be entirely eliminated, further development of countermeasures for fatigue are needed as well as implementation strategies that are acceptable to workers and leaders and smoothly fit the healthcare operations (for example, use of naps during work shifts).

The authors identified four additional priority areas. Workers in this sector are at risk for drowsy driving due to night work and long work shifts. Some workers commute long distances, a circumstance which in combination with long work hours can further increase their risk for drowsy driving. Strategies to reduce these risks are needed. In addition, easily applied tests to determine a worker’s fitness for duty would help managers as well as workers assess their ability to perform their jobs. Technologies are needed to reduce workload and fatigue. For example, dictating devices could save time with documentation, and lighting devices could promote adjustment of circadian rhythms to work hours. Research is needed on individual differences that protect or make workers more vulnerable to shift work and long hours. The prevalence of short sleep (<7 hours per 24-hour period) is higher in U.S.-born and non-U.S.-born blacks working in healthcare than in all other races.28 The prevalence of insomnia is significantly higher among women than men,29 and women continue to carry out more domestic household chores than men.30 These factors, combined with shift work and long hours, may lead to further problems with sleep and fatigue among women and workers of various races/ethnicities.

Impact

Research to improve risks related to work hours, sleep, and fatigue among HCSA workers will benefit workers, their patients, their employers, and society. Research on the topics discussed above will help HCSA workers provide their services around the clock and maintain their own health, safety, and sense of well-being. Improved sleep and alignment of circadian rhythms with work times will reduce workers’ negative moods, adverse reproductive outcomes, and development of several types of chronic disease. Job satisfaction and job tenure will increase. Employers will benefit from better job performance, higher quality of services, less absenteeism, less job turnover, lower worker compensation costs, and adequate staffing to carry out the work. HCSA workers’ improved job performance will benefit their patients. Society will benefit from fewer HCSA workers driving drowsy, which endangers them and other people on the roads. Society will also benefit from having enough highly skilled HCSA workers to meet the growing needs of the aging population and of the 60% of the U.S. population with chronic illnesses in need of these services.31

References

  1. Bureau of Labor Statistics. 2019. Industries at a glance: Healthcare and Social Assistance. Retrieved from https://www.bls.gov/iag/tgs/iag62.htmexternal icon
  2. Bureau of Labor Statistics. 2017. Employment Projections—2016-26. Retrieved from https://www.bls.gov/news.release/pdf/ecopro.pdfpdf iconexternal icon
  3. Boiano J. 2009. Chapter 2 HCSA Sector Demographics. In NORA Healthcare and Social Assistance Sector Council, State of the Sector – Health Care and Social Assistance: Identification of Research Opportunities for the Next Decade of NORA. DHHD (NIOSH) No. 2009-139.
  4. Alterman, T., Luckhaupt, S. E., Dahlhamer, J. M., Ward, B. W., & Calvert, G. M. (2013). Prevalence rates of work organization characteristics among workers in the U.S.: data from the 2010 National Health Interview Survey. Am. J Ind. Med, 56(6), 647-659.
  5. Accreditation Council for Graduate Medical Education. (ND). Summary of Changes to ACGME Common Program Requirements Section VI. Retrieved from https://www.acgme.org/external iconWhat-We-Do/Accreditation/Common-Program-Requirements/Summary-of-Proposed-Changes-to-ACGME-Common-Program-Requirements-Section-VI.
  6. NORA Healthcare and Social Assistance Sector Council. 2008. State of the sector | healthcare and social assistance: identification of research opportunities for the next decade of NORA. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2009-139.
  7. Caruso CC, Waters TR [2008]. A review of work schedule issues and musculoskeletal disorders with an emphasis on the healthcare sector. Ind Health 46:523-534.
  8. Dyrbye LN, Shanafelt TD, Sinsky CA, Cipriano PF, Bhatt J, Ommaya A, West CP, & Meyers D. 2017. Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. doi: 10.31478/201707b. Retrieved from https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care/external icon
  9. Schernhammer, E. S., & Colditz, G. A. (2004). Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry, 161(12), 2295-2302. doi:10.1176/appi.ajp.161.12.2295
  10. Nett RJ, Witte TK, Holzbauer SM, et al. Risk factors for suicide, attitudes toward mental illness, and practice-related stressors among US veterinarians. Journal of the American Veterinary Medical Association 2015;247:945-55.
  11. Occupational Safety and Health Administration. (nd). Healthcare. Retrieved from https://www.osha.gov/SLTC/healthcarefacilities/index.htmlexternal icon
  12. Bureau of Labor Statistics. 2017. Injuries, Illnesses, and Fatalities. Retrieved from https://www.bls.gov/iif/soii-chart-data-2016.htmexternal icon
  13. Luckhaupt, S. E. (2012). Short Sleep Duration Among Workers – United States, 2010. MMWR, 61(16);281-285(16), 281-285.
  14. Watson, N. F., Badr, M. S., Belenky, G., Bliwise, D. L., Buxton, O. M., Buysse, D., … Tasali, E. (2015). Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Journal of Clinical Sleep Medicine, 11, 591-592. DOI: 10.5664/jcsm.4950
  15. Luyster, F. S., Strollo, P. J., Jr., Zee, P. C., & Walsh, J. K. (2012). Sleep: a health imperative. Sleep, 35(6), 727-734.
  16. Irwin, M. R., & Opp, M. R. (2017). Sleep Health: Reciprocal Regulation of Sleep and Innate Immunity. Neuropsychopharmacology, 42(1), 129-155. doi:10.1038/npp.2016.148
  17. Bae SH, Fabry D [2014]. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review. Nurs Outlook 62(2):138-156.
  18. Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nurs Res, 60, 1-8.
  19. Ftouni, S., Sletten, T. L., Howard, M., Anderson, C., Lenne, M. G., Lockley, S. W., & Rajaratnam, S. M. (2013). Objective and subjective measures of sleepiness, and their associations with on-road driving events in shift workers. J Sleep Res, 22, 58-69.
  20. Lee, M. L., Howard, M. E., Horrey, W. J., Liang, Y., Anderson, C., Shreeve, M. S., O’Brien, C. S., Czeisler, C. A. (2016). High risk of near-crash driving events following night-shift work. Proc Natl Acad Sci, 113, 176-181. doi:10.1073/pnas.1510383112.
  21. Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ, 353, i2139. doi:10.1136/bmj.i2139
  22. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. 2004. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. Oct 28;351(18):1838-48.
  23. Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, Speizer FE, Czeisler CA. 2006. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. Dec;3(12):e487.
  24. Monk TH, Buysse DJ [2013]. Exposure to shift work as a risk factor for diabetes. J Biol Rhythms 28 (5):356-359.
  25. Buxton OM, Cain SW, O’Connor SP, Porter JH, Duffy JF, Wang W, Czeisler CA, Shea SA [2012]. Adverse metabolic consequences in humans of prolonged sleep restriction combined with circadian disruption. Science Translational Medicine 4 (129):129ra43 1-19.
  26. Leproult R, Holmback U, Van Cauter E [2014]. Circadian misalignment augments markers of insulin resistance and inflammation, independently of sleep loss. Diabetes 63 (6):1860-1869.
  27. Smith MR, Eastman CI [2012]. Shift work: health, performance and safety problems, traditional countermeasures, and innovative management strategies to reduce circadian misalignment. Nature Sci Sleep 4: 111-132
  28. Jackson, C. L., Hu, F. B., Redline, S., Williams, D. R., Mattei, J., & Kawachi, I. (2014). Racial/ethnic disparities in short sleep duration by occupation: The contribution of immigrant status. Social Science & Medicine, 118, 71-79. Doi:10.1016/j.socscimed.2014.07.059
  29. Zhang, B., & Wing, Y. K. (2006). Sex differences in insomnia: a meta-analysis. Sleep, 29(1), 85-93.
  30. Bureau of Labor Statistics. (2016). American Time Use Survey Household Activities. Retrieved from https://www.bls.gov/tus/charts/household.htmexternal icon
  31. Centers for Disease Control and Prevention. 2019. Chronic diseases in America. Retrieved from https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
Page last reviewed: May 22, 2019