David X. Swenson Ph.D., Licensed Psychologist, Duluth, MN

1
Working With One Eye Closed The effects of
shiftwork and coping with its consequences
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
2
Program Objectives

• To explain how circadian rhythm and shift
  adjustment are related to performance health
• To Recognize the signs and symptoms of shiftwork
  adjustment
• To describe personal, family, and organizational
  techniques for coping with shiftwork overtime
  concerns

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
3
True or False?

• People can lose up to one hour of sleep per day
  with no
  adverse effects
• People can learn to completely adjust to night
  work
• Older experienced people can adjust faster to
  shifts than younger
• Women show more shift adjustment signs than do
  men
• Exercise, cold water, and fresh air can remove
  fatigue effects
• Most people are good judges of their alertness
• The average amount of sleep people really need is
  between 6-7 hours
• Overtime has no effect on health or performance
  so long as a person wants to do it
• Caffeine is not effective and should not be used
  to maintain alertness
• Napping is an ineffective way to cope with shift
  fatigue

4
Hazards of Shiftwork
Shiftwork-Related Disasters

• Three-Mile Island (1979)
• Bhopal chemical spill (1984)
• Chernobyl Nuclear Plant (1986)
• Challenger Space Shuttle (1986)
• Exxon Valdez tanker (1989)
• Star Princess ship grounding (1995)
• American Airline 1420 (1999)
• Canadian National train wreck (2001)
• 100,000 traffic accidents 1500 deaths annually
  (sleep 2nd only to alcohol)

all had fatigue-related contributing factors
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
5
When every day is Labor Day Work, Work, Work

• About 25 of the workforce now works
  nonstandard schedules
• annual work hours are 4 higher than
  in 1980
• The average person works 150 more hours/year than
  in 1910
• 1/3 of workforce regularly works more than
  40-hour week 20 work 50
• Even after four eight hour sleep sessions
  following sleep debt, people continue to make
  judgment, attention, and other cognitive errors
• The Japanese even have a medical diagnosis
  Karoshi death from overwork!

6
Overtime costs
Overtime cost

• Extended hours lead to 15-fold increase in worker
  compensation claims
• Higher rates of absenteeism (5.8)
• Higher rates of turnover (healthcare12.4,
  services processing 11.6, )
• 60 moderate to severe fatigue (processing 68,
  healthcare 60, transportation 54
• Number of facilities disciplining napping rose
  from 38 in 2002 to 57 in 2003
• Increase in accident rates (after 9 hours 2x as
  high at 12 hours)
• Costs 150 billion per year in fatigue related
  accidents
• Exacerbated health problems cost 28.1 billion in
  higher insurance costs

7
Personal Impact of Shiftwork
Personal Impact of Shiftwork

• 79 of casino workers complain of sleep
  disturbance fatigue
  (GMB Union, Scotland)
• 83 of night shift feel tired (4 of dayshift)
• Work capacity declines 5-10 during nights
• Higher incidence of drug alcohol abuse
• Higher relationship problems divorce rate (2x
  day shift)
• Higher medical emotional problems
• Feel career capped during 3rd-10th year
• 20-30 leave SW within the first 2-3 years
• Reduced job alertness costs 70 billion/year
• Overtime workers 2x as likely to report jobs as
  stressful
• Retired persons report SW as more negative
• Low control of work increases adverse effects
• Increase in customer complaints
• 17-19 hours w/o sleep is equivalent to DUI (BAC
  .05) 24 hours sustained wakefulness (BAC .10)

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
8
More effects on workers

• 66 fatigue makes stress harder to deal with
• 68 sleepiness interferes with concentration
• 68 of shiftworkers had sleep problems
• 58 decision making problem solving harder
• 57 listening to others was a chore
• 51 say sleepiness interferes with amount of work
  done
• 30 decline in quality and quantity of work when
  fatigued
• 27 sleepy at work two or more days a week
• 19 frequent work errors due to fatigue (sales
  35, retail 33, finance real estate 29
• 14 late to work due to sleepiness
• 7 have changed jobs to get more sleep

Sleep Foundation study, 2000, 1154 adults
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Casino-Specific Fatigue Problems

• Cognitive skills
• Inattention, distractibility, poor concentration
• Impaired memory, recall (forgetting key steps
  procedures)
• Slower decision making (shortcuts)
• slower counting and calculation errors
  microsleep (miscounting errors, miss details,
  surveillance errors)
• Less fluent communication skills (conflict
  management)
• Physical
• slower reaction time, slower finger dexterity,
  poor coordination
• Emotional
• Irritability (over-reaction, impatience,
  hypersensitivity, lower frustration tolerance),
  depression (apathetic)

10
Mammal Sleep No Playing possum for Shiftworkers
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
11
ZeitgebersCircadian Cues for sleep alertness
ZeitgebersCircadian Cues
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
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The Circadian Cycle Physiological Basis of Shift
Adjustment
Day
SCN
x
Pineal Body
Blood Chemistry Glandular Activity Digestion Brain
Waves Arousal
Night
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
13
Effects of the Circadian CycleA Balancing Act
Typical Rest Time
Typical Activity Time

• Raise heart rate
• Raise blood pressure
• Raise body temp
• Increase muscle Tone
• Increase breathing
• Stimulate alertness

• Lower heart rate
• Lower blood pressure
• Lower body temp
• Decrease muscle tone
• Decrease breathing
• Induce sleep

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
14
Alertness Temperature
Peak Alertness
Lowest Alertness
40 35 30 25 20 15 10
Wide Awake
Warmer
Temperature
37.2 37.0 36.9 36.8 36.7 36.6
Alertness
Body Temp Deg. C
Alertness
Cooler
Sleepy
10pm 7am 4pm 1am 10am 7pm 4am 1pm
Time of Day
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
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Abilities by hours
Around the Clock Performance Peak times for
abilities
Noon Eyesight
Early Afternoon math, long term memory, physical
flexibility, manual dexterity, grip strength
Late Mid-Morning alertness, thinking
Late Afternoon Gross physical coordination,
athletic ability
Early Mid-Morning short term memory
Early Evening sense of smell and taste
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
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Lights are on, but no ones home

• Under high fatigue, people experience bouts of
  microsleep for 3-10 seconds
• Sleep progresses from front of brain to back
  judgment to motor to vision areas fail
• People are not aware when they microsleep
• People are not good judges of their level of
  alertness
• Driving and actions can continue when judgment is
  disabled

ZZZZZZZZ
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Fatigue and the brain
Brain activity in the brain on a counting problem
after a normal night of sleep (top) and following
sleep deprivation (bottom). Yellow and red show
areas of activation
in some cases, the lights arent even on!
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Stages and Levels of Sleep
Most REM sleep missed
Insufficient REM sleep ? emotional
fatigue Insufficient deep sleep ? physical fatigue
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
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Sleep debt assessment
Sleep Debt Assessment
How likely are you to doze off or fall asleep in
the following situations? Score yourself using
this scale

• Sitting and reading
• Watching TV
• Sitting, inactive in a public place, e.g., a
  theater or meeting
• As a passenger in a car for an hour without a
  break
• Lying down to rest in the afternoon when
  circumstances permit
• Sitting and talking to someone
• Sitting quietly after a lunch without alcohol
• In a car while stopped for a few minutes in
  traffic

0-5 Slight or no sleep debt 6-10 Moderate sleep
debt 11-20 Heavy sleep debt 21-25 Extreme sleep
debt
0 would never doze 1 slight chance of dozing
2 moderate chance of dozing 3 high chance
of dozing
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Age Gender Effects

• Shift intolerance increases after age 40
• After 40, womens health improves, mens declines
• Women have higher injury rate than men
• Women report more shift adjustment problems
• Men quit shift work more often than women
• Older experienced staff have much shift
  adjustment knowledge to share
• Flattening of circadian rhythms and shift toward
  fragile sleep and morningness
• Sleep durations declines during aging
• Aging accentuates digestive, musculo-skeletal,
  and respiratory problems

Often due to dual demands of homemaker and
worker
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
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The Vicious Cycle of Shiftwork
Poor Sleep
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
22
Shiftwork Variations No one size fits all

• Forward vs. Backward
• 8, 10, or 12- hour shifts
• Rotating vs. Permanent
• Time on, off, between shifts
• Overtime, overlap, extended duty

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
23
Shift Scheduling DesignWhat we Know

• Rapid shift minimizes readjustment
• Long rotations require off-duty consistency
• Permanent shifts do not produce fixed sleep
• Hourly Weekly rotations are worst
• 8 to 10 or 12 hour shift not a problem
• Shift should move forward or clockwise
• Shifts work better in metropolitan areas
• 60 prefer days, 30 nights, 10 rotation

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
24
Family Social Adjustments
Perceptions of Shiftworkers Family

• Shift recovery out of phase with diurnal
  society, necessities, family activities
• Insufficient companionship, intimacy, support,
  sharing, and protection
• Recovery time on rest days reduces quantity and
  quality of family time
• Less time for home maintenance chores
• Fatigue mood affects interaction
• Conflicts have cumulative effect
• Spouses feel resentment guilt

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
25
Spouse Survey
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
26
Shift-Proofing the Home

• Disturbance Reduction
• Relocate the bedroom, 68-72 temp
• Double glazed, sound resistant windows
• Wall insulation, rugs, curtains
• Doorbell and phone off
• White sound or ear plugs
• No domestic machinery
• Heavy curtains or sleep mask

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
27
Shift-Proofing the Home

• Behavioral Changes
• Discuss importance of quiet time
• No visitors (or quiet ones)
• Develop sleep preparation routine
• Develop sleep facilitative skills
• Use bed for sleep and intimacy only

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
28
Family Social Adjustments
Recommendations

• Training preparation for the employee
• Orientation education for the family
• Social networking
• Support groups
• Family meetings
• Quality family activities
• Post a calendar schedule
• Consultation counseling

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
29
Nutritional Considerations (?)
Begin Shift
End Shift

• Start with carbohydrates (sugars starches)
• No caffeine, tobacco, or alcohol five hours
  before sleep period
• Avoid heavy, spicy, hard to digest food

• Start with proteins
• Add legumes and low fat dairy products
• Broil/boil/raw rather than fry
• Eat light after midnight
• Minimize caffeine tobacco
• Available healthy snacks

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
30
Caffeine Mounts Up!

• One 7-oz cup has 65-175 mg. caffeine
• Coffee Drip (115-175mg), brew (80-135), instant
  (65-100), tea (30-70), decaf (2-4)
• Soda Jolt (100), Mr. Pibb (58), Mt. Dew (54),
  Mellow Yellow (53), 7-Up (0)
• Medications Vivarin 200, No Doz 100, cold relief
  tablets (30), Execedrin (65)
• Other Chocolate (30)

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
31
Just one more for the road Coffee caffeine
effects

• Benefits Increased alertness mental
  stimulation, reduced fatigue, increased
  metabolism, manual skills
• Caffeine reaction appetite loss but gastric
  secretion, irritability, anxiety, irregular heart
  rate, insomnia
• Recommendations Minimize monitor intake none 5
  hours before off shift
• Heavy caffeine use during sleep deprivation
  elevates stress hormones
• Dont take caffeine 4 hours (men) or 6 hours
  (women) before planning sleep

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
32
Medication EffectsMany change the quality of
sleep

• Antidepressants (MAO-Inhibitors) sleepless,
  
  habit forming, suppress REM sleep, REM rebound,
  
  fast pulse, dry mouth
• Amphetamines high risk of abuse withdrawal
• Antihistimines Bronchodilators sleep but side
  effects
• Caffeine containing meds (e.g., Excedrin) upset
  stomach sleep
• Sleep Aids (e.g., Sleep-Eze, Nytol) composition
  changes, risk of long term use
• Tranquilizers (e.g., Valuim, Librium) daytime
  sedation, possibly related to irritability
  temper
• Some thyroid preparations, high blood pressure
  meds, birth control pills (rare)

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
33
Melatonin Provigil Magic Bullets?

• Melatonin (1-10 mg) alleviates jet lag,
  facilitates shift adjustment, improves daytime
  sleep, decreases insomnia. Few side effects or
  dependency/withdrawal. Long term effects not
  studied.
• Provigil (200mg) alleviates fatigue, enhances
  alertness, improves mood and memory. Less likely
  to cause jitteriness/anxiety. Widely used
  off-label, but not well understood mechanism

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
34
Seasonal Affective Disorder (SAD) Winter Blues
SAD A seasonal disorder of mood and energy
related to decreased exposure to natural
light in northern
climates 6 clinical, 10-20 sub-clinical
OCCURRENCE Sept/Nov to March/April, mild
reaction on persistent cloudy days, nightshift
indoor work. Women more than men, after age 30,
SIGNS depression, low energy, fatigue, apathy,
irritability, anxiety, lower stress tolerance,
sleep disturbance, overeating, craving sweets,
poor concentration, slower reaction, lowered
immune function, decreased sex interest, mood
swings.
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
35
Another Bright Idea!
Light Regulates Circadian

• Bright light (min 2500 lux) suppresses melatonin
  to help reset circadian rhythm
• 1-4 hours of bright light is required on
  awakening or beginning of shift
• Better sleep sleep pattern, performance,
  physical and emotional well-being result
• Rated as highly effective in promoting adjustment
  to shift work

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
36
Enlightening the treatment of SAD

• may not be insurance covered
• 30 minutes to two hours exposure
• 2,500-10,000 lux lightbox or lightvisor
  (100-300)
• requires regular use (evening use may disturb
  sleep)
• fluorescent and full spectrum lights (not
  tanning bed Uv)
• 1-hour daily outside daylight walking/exercise
• SSRI antidepressants (e.g., Prozac)

37
Technological Developments

• Light arrays can increase shift entrainment
• Portable light goggles can be used to suppress
  melatonin during night shift
• FIT Workplace Safety Screener Measurement of
  pupillary response to flashing and moving light
  and eyelid fluttering can indicate shift fatigue
• Computerized assessment of visual perception,
  information processing, hand-eye coordination,
  reaction time, and decision making
• Video monitoring of the percentage of eyelid
  closings over time
• Alerting devices can sound off when dozing
• Computer scheduling programs can optimize shifts

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
38
The A-B-Zzzzzzzzs of Napping
What we know about napping

• 70-80 admit falling asleep anyway
• Shorter main sleep but same total sleep
• Naps rest periods are beneficial to mood
• First 20-30 of sleep is best quality
• Best time is noon to 6 pm, with peak from 1-3 pm
• Without naps, up to 30 performance decline
• Benefits not uniform, some sleep worse
• Sleep Inertia may occur

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
39
The A-B-Zzzzzzzzs of Napping
Recommendations for Napping

• Should be taken before sleep debt occurs
• Nap prior to night shift/continuous operation
• Schedule during expected quiet periods
• Nap 10- 30 minutes
• Limit naps to prevent partner isolation
• Provide appropriate nap areas
• Keep a notebook to monitor effects

David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
40
Management Considerations
1. Involve employees 2. Set shift rosters
early 3. Minimize overtime extra duty 4. Allow
6-12 months trial period 5. Orient educate all
stakeholders to understand shiftwork 6. Conduct
risk assessment of tasks and monitor accidents,
illness absentees, errors, complaints 7.
Managers might take a night shift during the
year 8. Conduct research to find out what works
and what doesnt
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
41
Recommendations for Shiftwork Supervisors

• Use sound shiftwork principles for designing
  schedules
  (e.g., forward rotation, days off, short
  shifts,
  etc.)
• Use overtime time sheet to be submitted with
  
  regular time sheet to identify potential overtime
  
  problems before they occur
• Ask and coach employees in their use of shift
  coping techniques
• Ensure classes and training opportunities for
  night shift
• Keep work areas brightly painted, clean, well lit
  ventilated
• Provide vending machines with healthy products
• Maintain high contact with night workers
• Videotape mandatory meetings to allow viewing
  during regular shift
• Negotiate better suited meeting schedules for
  night workers

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The Better Cycle of Shiftwork
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
43
For more information contact
David X. Swenson Ph.D. LP Management
Department College of St. Scholastica 1200
Kenwood Ave Duluth, MN 55811 Phone
[phone] Email dswenson_at_css.edu FAX
[phone] http//faculty.css.edu/dswenson/web/
sitemap.html
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
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Napping Potential

• Can you easily nap during the daytime when
  you are not
  particularly sleep-deprived?
• Can you easily nap during the daytime to "catch
  up" on lost sleep, such as after one or more late
  nights?
• On days off, do you take a daytime nap?
• Do you feel refreshed after a daytime nap?
• Do you use brief naps (less than 30 minutes) to
  sustain your alertness during an extended
  monotonous task (for example, driving a long
  distance) or when staying up all night?

The more you answer affirmative, the more napping
may work for you to deal with shift stress
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Keeping A Journal
A journal is the most effective way of
discovering what works! How are these related to
each other?
Food Exercise Stress Naps Alcohol Medication
Performance
Sleep time Level of Rest Times Awake
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN
48
Day Larks Night Owls (15-20)
1. Arise early easily or with difficulty? 2. Stay
up late with difficulty or easily? 3. Would
rather exercise in morning or evening? 4. Does
your efficiency/energy peak early in the day or
evening? 5. Things look better in the morning or
evening? 6. Favorite meal is breakfast or
dinner? 7. Prefer physical/outdoor activities or
night life or quiet? 8. Compensate for sleep loss
by going to bed earlier or sleeping later? 9. Nap
in afternoon (about 200) or nap in evening
(about 700?
David X. Swenson Ph.D., Licensed Psychologist,
Duluth, MN