Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work

Interventions to improve the sleep of nurses: A systematic review

Nurses are at a high risk for short sleep duration and poor sleep quality due to irregular work schedules and high occupational stress. Considering the effect of nurses' sleep on the safety and health of themselves and their patients, it is important to promote healthy sleep for nurses. We sought to synthesize the published experimental and quasi-experimental studies that address interventions to improve sleep in nurses. A systematic search was conducted for studies published in English up until May 15, 2023, using the databases PubMed, CINAHL, Academic Search Ultimate, and PsycINFO. In total, 38 articles were included, covering 22 experimental and 16 quasi-experimental studies with sample sizes ranging from 9 to 207. Studies were assessed using the Cochrane Risk of Bias tool and considered as low to medium quality. Thirty-six of the 38 studies reported positive findings for at least one sleep outcome. Intervention types included aroma therapy, dietary supplements, cognitive behavioral therapy, light therapy, mind-body therapy, sleep education, exercise, napping, shift schedule modification, and multicomponent intervention, all of which showed moderate effectiveness in promoting sleep outcomes of nurses. Comparing and contrasting studies on specific interventions for improving sleep in nurses is sparse and often equivocal. With the variations of research methodology and outcome measures, it is difficult to make a conclusion about each intervention's effectiveness on specific sleep outcomes. Additional high-quality research, including randomized controlled trials, is needed to evaluate strategies for improving sleep in this unique, safety-sensitive occupational group.

Bright light therapy for mental and behavioral illness: A systematic umbrella review

Bright light therapy (BLT) is a promising non-pharmacological treatment for a range of psychiatric conditions. The goal of this review was to provide a comprehensive overview of the efficacy of BLT across mental and behavioral illnesses. Using systematic umbrella review methodology, we searched Ovid MEDLINE, Embase, PsycInfo, Web of Science, and Google Scholar for systematic reviews of randomized controlled trials (RCTs) evaluating BLT for any mental or behavioral illness from the date of inception until March 2021. Review quality was assessed using the AMSTAR 2 tool and summary efficacy data were extracted from recent reviews. Of 792 unique records, 67 systematic reviews were included which targeted a range of disorders related to mood, neurocognition, sleep, and eating. Recent meta-analyses targeting seasonal or non-seasonal depression found that BLT outperformed light-related control conditions. Reviews of other disorders identified few RCTs and generally did not support the efficacy of BLT for various outcomes. Overall, the extant literature supports the efficacy of BLT for seasonal and non-seasonal depression, although higher quality systematic reviews are needed to increase confidence in these findings. There was no specific funding for this review, and it was preregistered on Prospero (ID: CRD42021240751).

A scoping review of the evidence for the impact of pharmacological and non-pharmacological interventions on shift work related sleep disturbance in an occupational setting

Background: Shift work is essential in society but can be detrimental to health and quality of life and is associated with decreased productivity and increased risk of accidents. Interventions to reduce these consequences are needed, but the extent and range of trial evidence for interventions for those most affected by their shift-work schedules is unclear. We therefore carried out a scoping review to assess the availability of evidence to inform the development and evaluation of future interventions. Methods: We aimed to identify clinical trials of any intervention for shift work-related sleep disturbance that included a comparator group, where the intervention was delivered in an occupational setting. We searched Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, EMBASE, Medline and Science Citation Index from inception to 30 th March 2020 for relevant citations. Citations were screened by two independent reviewers, a third reviewer resolved disagreements. Data were extracted by two independent reviewers. Results: From 1250 unique citations, 14 studies met inclusion criteria for comparative trials of treatment in an occupational setting. There were five trials of hypnotics, five trials of stimulants, and four trials of non-pharmacological therapies (cognitive behavioural therapy, light therapy, aromatherapy and herbal medicine). Outcomes included sleep parameters, day-time sleepiness, and quality of life. There were no consistently reported outcomes across trials. Conclusions: Interventions fell into three distinct groups investigated in distinct time periods without progression from efficacy trials to wider-scale interventions. The lack of consistent patient-reported outcome measures limits synthesising findings. Some trials focussed on optimising sleep, others on reducing wake-time sleepiness. Adequately powered trials of existing interventions are needed, with the development and testing of novel combination treatments in patients with well-defined shift work sleep disorder. A core set of clinically relevant outcomes will develop and standardise the evidence-base for shift work sleep disorder.

Efficacy of Dietary Supplements on Sleep Quality and Daytime Function of Shift Workers: A Systematic Review and Meta-Analysis

Background

Dietary supplements (DSs) may be useful for managing shift work disorder. But the efficiency of outcomes in clinical trials using simulated shift work populations as subjects is controversial. This review explores the potential role of DSs for improving sleep quality, daily functioning, and mood among shift workers in the real world.

Methods

A related literature search was conducted in PubMed, Web of Science, Embase, and Cochrane Library databases from their inception to July 2021. Information was collected on “shift work,” “irregular working hours,” “night shift,” “dietary supplements,” and “nutraceutical research data.” Sleep quality-related scales were the primary outcome measures. The meta-analysis was conducted using RevMan 5.4 (Cochrane Collaboration, London, England) and Stata 15.0 (StataCorp, LLC, College Station, TX, USA). Heterogeneity was examined by using I2 statistics, and publication bias was assessed via Egger's regression test.

Results

Twelve studies, which involved 917 participants, met the inclusion criteria. The DS groups had significant improvement in sleep quality scores (8 randomized controlled trials [RCTs]: p = 0.04; standard mean difference (SMD), −0.45 [−0.88 to −0.03]) and daytime function (7 RCTs: p = 0.02; SMD, −0.50 [−0.92 to −0.08]). The DS groups did not have a significant improvement in psychomotor vigilance (4 RCTs: p = 0.25; SMD, 0.52 [−0.36 to 1.41]), depression (5 RCTs: p = 0.14; SMD, −0.19 [−0.45 to 0.06]), or anxiety (4 RCTs: p = 0.27; SMD, −0.23 [−0.65 to 0.18]). All RCTs suggested a positive safety profile for DSs.

Conclusions

The findings of this meta-analysis indicated DSs may be beneficial for improving sleep quality and daytime function in shift workers. Although there is a wide range of DSs, the small amount of literature included for each type does not allow for subgroup analysis to be used to eliminate high heterogeneity. We have not yet included literatures on other languages either. Given these limitations of the study, there is still a need for more well-designed randomized controlled trials so that our review can be updated in the future to make the results more conclusive.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=273558, PROSPERO: CRD42021273558.

Science Forum: Sex differences and sex bias in human circadian and sleep physiology research

Growing evidence shows that sex differences impact many facets of human biology. Here we review and discuss the impact of sex on human circadian and sleep physiology, and we uncover a data gap in the field investigating the non-visual effects of light in humans. A virtual workshop on the biomedical implications of sex differences in sleep and circadian physiology then led to the following imperatives for future research: (1) design research to be inclusive and accessible, (2) implement recruitment strategies that lead to a sex-balanced sample, (3) use data visualization to grasp the effect of sex, (4) implement statistical analyses that include sex as a factor and/or perform group analyses by sex, where possible, (5) make participant-level data open and available to facilitate future meta-analytic efforts.

A scoping review of the evidence for the impact of pharmacological and non-pharmacological interventions on shift work related sleep disturbance in an occupational setting

Background: Shift work is essential in society but can be detrimental to health and quality of life and is associated with decreased productivity and increased risk of accidents. Interventions to reduce these consequences are needed, but the extent and range of trial evidence for interventions for those most affected by their shift-work schedules is unclear. We therefore carried out a scoping review to assess the availability of evidence to inform the development and evaluation of future interventions. Methods: We aimed to identify clinical trials of any intervention for shift work-related sleep disturbance that included a comparator group, where the intervention was delivered in an occupational setting. We searched Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, EMBASE, Medline and Science Citation Index from inception to 30th March 2020 for relevant citations. Citations were screened by two independent reviewers, a third reviewer resolved disagreements. Data were extracted by two independent reviewers. Results: From 1250 unique citations, 14 studies met inclusion criteria for comparative trials of treatment in an occupational setting. There were five trials of hypnotics, five trials of stimulants, and four trials of non-pharmacological therapies (cognitive behavioural therapy, light therapy, aromatherapy and herbal medicine). Outcomes included sleep parameters, day-time sleepiness, and quality of life. There were no consistently reported outcomes across trials. Conclusions: Interventions fell into three distinct groups investigated in distinct time periods without progression from efficacy trials to wider-scale interventions. The lack of consistent patient-reported outcome measures limits synthesising findings. Some trials focussed on optimising sleep, others on reducing wake-time sleepiness. Adequately powered trials of existing interventions are needed, with the development and testing of novel combination treatments in patients with well-defined shift work sleep disorder. A core set of clinically relevant outcomes will develop and standardise the evidence-base for shift work sleep disorder.

Dose-response effects of light therapy on sleepiness and circadian phase shift in shift workers: a meta-analysis and moderator analysis

Light therapy has been considered to be effective in mitigating sleepiness and regulating circadian phase shift in shift workers. However, the effective treatment dose of light therapy remains undetermined. We performed a meta-analysis of randomized experimental studies to determine the effect of light therapy doses on sleepiness and circadian phase shift in shift workers. An article search was performed in 10 electronic databases from inception to June 2020. Two raters independently screened and extracted data and reached consensus. Twenty-one eligible studies were included. Analyses were performed using random-effects models. Light therapy exerted significantly small to medium effects on sleepiness and large treatment effects on circadian phase shift. Moderator analyses performed with subgroup and metaregression analyses revealed that medium-intensity light therapy for a shorter duration more effectively reduced sleepiness at night, whereas higher-intensity light therapy more effectively induced phase shifting, but the required treatment duration remained inconclusive. This study provides evidence regarding the effect of light therapy in reducing sleepiness and shifting circadian phase in shift workers. Exposure to medium-intensity light for a short duration at night reduced sleepiness, whereas exposure to high-intensity light improved sleep by shifting their circadian phase.

Sleep Health Promotion Interventions and Their Effectiveness: An Umbrella Review

Sleep is receiving increasing attention in public health. The aim of this umbrella review is to determine what non-pharmacological sleep health interventions have been evaluated among healthy populations, by examining target groups, settings, and effectiveness in improving sleep quality and duration. Comprehensive searches were conducted in five electronic databases (January 1975–February 2019), yielding 6505 records. Thirty-five articles were selected meeting the following eligibility criteria: (1) systematic reviews or meta-analyses of (2) sleep health interventions in (3) primarily healthy populations. Two reviewers independently screened for inclusion, extracted the data, and assessed the review quality. This umbrella review was registered with PROSPERO (CRD42019126291). Eleven intervention types were defined, and their effectiveness discussed. Substantial evidence demonstrated the effectiveness of later school start times, behavior change methods, and mind–body exercise. Other intervention types, including sleep education or relaxation techniques, demonstrated some promising impacts on sleep, but with less consistent evidence. Results were limited by high heterogeneity between studies, mixed results, and variable review quality. Nevertheless, this umbrella review is a first step towards understanding the current state of sleep health promotion and gives an overview of interventions across the lifespan.

Relationship between the night shift work and thyroid disorders: A systematic review and meta-analysis

OBJECTIVES

The night shift workers were reported to have health consequences, ranging from mild, as cluster headache, to severe, as heart attacks and hormonal irregularities. This study is aimed to perform a systematic review and meta-analyze of the association between the night shift work and the thyroid disorders.

METHODS

We comprehensively searched eight databases, including PubMed and Google Scholar for the relevant articles. This systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.

RESULTS

We finally included six papers involving 4074 participants. Four papers were eligible for meta-analysis involving 1864 night shift workers and 2017 day shift workers. We against found that thyroid stimulating hormone (TSH) is significantly higher in the night shift group compared to the day shift group.

CONCLUSIONS

The higher TSH among the night shift workers is attributed to disruption of the circadian rhythm and sleep/wake cycle, with subsequent eating disorders. We proposed that more attention should be paid to the working pattern and the related health consequences.

Sleep-Related Problems in Night Shift Nurses: Towards an Individualized Interventional Practice

Rotating shifts (mostly 8- or 12-h) are common among nurses to ensure continuity of care. This scheduling system encompasses several adverse health and performance consequences. One of the most injurious effects of night-time shift work is the deterioration of sleep patterns due to both circadian rhythm disruption and increased sleep homeostatic pressure. Sleep problems lead to secondary effects on other aspects of wellbeing and cognitive functioning, increasing the risk of errors and workplace accidents. A wide range of interventions has been proposed to improve the sleep quality of nurses and promote an increase in attention levels. In recent years, particular attention has been paid to individual and environmental factors mediating the subjective ability to cope with sleep deprivation during the night shift. Given the predictive role of these factors on the negative impact of a night shift, an individualized intervention could represent an effective countermeasure by ensuring suitable management of shift schedules. Therefore, the aims of this mini-review are to: (a) provide an updated overview of the literature on sleep problems in night shift nurses and their adverse consequences; and (b) critically analyze the psychosocial factors that mediate the negative impact of shift work with the ultimate goal of defining an effective countermeasure based on an individualized approach.

Alerting and Circadian Effects of Short-Wavelength vs. Long-Wavelength Narrow-Bandwidth Light during a Simulated Night Shift

Light can be used to facilitate alertness, task performance and circadian adaptation during night work. Novel strategies for illumination of workplaces, using ceiling mounted LED-luminaires, allow the use of a range of different light conditions, altering intensity and spectral composition. This study (ClinicalTrials.gov Identifier NCT03203538) investigated the effects of short-wavelength narrow-bandwidth light (λ_max = 455 nm) compared to long-wavelength narrow-bandwidth light (λ_max = 625 nm), with similar photon density (~2.8 × 10¹⁴ photons/cm²/s) across light conditions, during a simulated night shift (23:00–06:45 h) when conducting cognitive performance tasks. Light conditions were administered by ceiling mounted LED-luminaires. Using a within-subjects repeated measurements study design, a total of 34 healthy young adults (27 females and 7 males; mean age = 21.6 years, SD = 2.0 years) participated. The results revealed significantly reduced sleepiness and improved task performance during the night shift with short-wavelength light compared to long-wavelength light. There was also a larger shift of the melatonin rhythm (phase delay) after working a night shift in short-wavelength light compared to long-wavelength light. Participants’ visual comfort was rated as better in the short-wavelength light than the long-wavelength light. Ceiling mounted LED-luminaires may be feasible to use in real workplaces, as these have the potential to provide light conditions that are favorable for alertness and performance among night workers.

Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review

BACKGROUND

Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. The World Health Organization (WHO) has warned about the potential negative impact of the COVID-19 crisis on the mental well-being of health and social care professionals. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.

OBJECTIVES

Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.

SEARCH METHODS

On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions.

SELECTION CRITERIA

We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together.

MAIN RESULTS

We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies). Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout. Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings. We are moderately confident that the following two factors were barriers to intervention implementation: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention. We are moderately confident that the following three factors were facilitators of intervention implementation: interventions that could be adapted for local needs; having effective communication, both formally and socially; and having positive, safe and supportive learning environments for frontline workers. We are moderately confident that the knowledge or beliefs, or both, that people have about an intervention can act as either barriers or facilitators to implementation of the intervention.

AUTHORS' CONCLUSIONS

There is a lack of both quantitative and qualitative evidence from studies carried out during or after disease epidemics and pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers. Alternative sources of evidence (e.g. from other healthcare crises, and general evidence about interventions that support mental well-being) could therefore be used to inform decision making. When selecting interventions aimed at supporting frontline workers' mental health, organisational, social, personal, and psychological factors may all be important. Research to determine the effectiveness of interventions is a high priority. The COVID-19 pandemic provides unique opportunities for robust evaluation of interventions. Future studies must be developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice, and with appropriate length of follow-up. Factors that may act as barriers and facilitators to implementation of interventions should be considered during the planning of future research and when selecting interventions to deliver within local settings.

A quasi-experimental study into the effects of naps and therapy glasses on fatigue and well-being

Aim

To investigate the effects of a napping facility and therapy glasses on fatigue and well‐being at the end of the night shift.

Background

Night shift work has adverse effects on fatigue and well‐being.

Methods

A quasi‐experimental study was conducted, and data were collected on 243 night shifts of 95 nurses who had either access to a napping facility, therapy glasses, both facilities or no facilities. Multilevel analyses were conducted to predict fatigue and well‐being.

Results

Night shifts of nurses having access to both facilities were associated with less fatigue and more well‐being. The use of therapy glasses related negatively to fatigue and positively to well‐being. The use of the napping facility was not associated with fatigue and well‐being. However, having slept while napping and sleeping time during napping were negatively associated with fatigue and positively associated with well‐being.

Conclusion

Therapy glasses and sleeping in a napping facility can be effective interventions in reducing the adverse effects of night shift work.

Implications for Nursing Management

Therapy glasses seem an effective investment to facilitate the well‐being of nurses. To enhance sleeping during napping, it is worthwhile to let nurses get accustomed to the napping facility and customize settings to personal preferences.

Can Special Light Glasses Reduce Sleepiness and Improve Sleep of Nightshift Workers? A Placebo-Controlled Explorative Field Study

Nightshift workers go against the natural sleep-wake rhythm. Light can shift the circadian clock but can also induce acute alertness. This placebo-controlled exploratory field study examined the effectiveness of light glasses to improve alertness while reducing the sleep complaints of hospital nurses working nightshifts. In a crossover within-subjects design, 23 nurses participated, using treatment glasses and placebo glasses. Sleepiness and sleep parameters were measured. A linear mixed model analysis on sleepiness revealed no significant main effect of the light intervention. An interaction effect was found indicating that under the placebo condition, sleepiness was significantly higher on the first nightshift than on the last night, while under the treatment condition, sleepiness remained stable across nightshift sessions. Sleepiness during the commute home also showed a significant interaction effect, demonstrating that after the first nightshift, driver sleepiness was higher for placebo than for treatment. Subjective sleep quality showed a negative main effect of treatment vs. placebo, particularly after the first nightshift. In retrospect, both types of light glasses were self-rated as effective. The use of light glasses during the nightshift may help to reduce driver sleepiness during the commute home, which is relevant, as all participants drove home by car or (motor) bike.

Workplace-based interventions to promote healthy lifestyles in the NHS workforce: a rapid scoping and evidence map

Background

The health and well-being of staff working in the NHS is a significant issue for UK health care. We sought to identify research relevant to the promotion of healthy lifestyles among NHS staff on behalf of NHS England.

Objectives

To map existing reviews on workplace-based interventions to promote health and well-being, and to assess the scope for further evidence synthesis work.

Design

Rapid and responsive scoping search and evidence map.

Participants

Adult employees in any occupational setting and in any role.

Interventions

Any intervention aimed at promoting or maintaining physical or mental health and well-being. Early intervention initiatives and those addressing violence against staff, workplace bullying or harassment were also included.

Main outcome measures

Any outcome related to the effectiveness, cost-effectiveness or implementation of interventions.

Data sources

A scoping search of nine databases was conducted to identify systematic reviews on health and well-being at work. Searches were limited by publication date (2000 to January/February 2019).

Review methods

The titles and abstracts of over 8241 records were screened and a total of 408 potentially relevant publications were identified. Information on key characteristics were extracted from the titles and abstracts of all potentially relevant publications. Descriptive statistics (counts and percentages) for key characteristics were generated and data from reviews and ‘reviews of reviews’ were used to produce the evidence map.

Results

Evidence related to a broad range of physical and mental health issues was identified across 12 ‘reviews of reviews’ and 312 other reviews, including 16 Cochrane reviews. There also exists National Institute for Health and Care Excellence guidance addressing multiple issues of potential relevance. A large number of reviews focused on mental health, changing lifestyle behaviour, such as physical activity, or on general workplace health/health promotion. Most of the reviews that focused only on health-care staff addressed mental health issues, and stress/burnout in particular.

Limitations

The scoping search process was extensive and clearly effective at identifying relevant publications, but the strategy used may not have identified every potentially relevant review. Owing to the large number of potentially relevant reviews identified from the scoping search, it was necessary to produce the evidence map using information from the titles and abstracts of reviews only.

Conclusions

It is doubtful that further evidence synthesis work at this stage would generate substantial new knowledge, particularly within the context of the NHS Health and Wellbeing Framework[NHS England. Workforce Health and Wellbeing Framework. 2018. URL: www.nhsemployers.org/-/media/Employers/Publications/Health-and-wellbeing/NHS-Workforce-HWB-Framework_updated-July-18.pdf (accessed 10 January 2019)] published in 2018. Additional synthesis work may be useful if it addressed an identifiable need and it was possible to identify one of the following: (1) a specific and focused research question arising from the current evidence map; it may then be appropriate to focus on a smaller number of reviews only, and provide a more thorough and critical assessment of the available evidence; and (2) a specific gap in the literature (i.e. an issue not already addressed by existing reviews or guidance); it may then be possible to undertake further literature searching and conduct a new evidence review.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 18. See the NIHR Journals Library website for further project information.

Excessive sleepiness in shift work disorder: a narrative review of the last 5 years

INTRODUCTION

Shift work sleep disorder (SWSD), also known as shift work disorder (SWD), is a circadian rhythm sleep disorder characterized by insomnia and/or excessive sleepiness, associated with a recurring work schedule that overlaps the usual time designated for sleeping.

PURPOSE

This article aims to provide a narrative review of the pharmacological trials conducted on SWD in the last 5 years, to better address safety and health issues inherent to this disorder.

METHODS

An electronic literature search was conducted using PubMed. All eligible randomized controlled trials (RCTs) and cross-over RCTs with employees undertaking shift work (including night shifts) were considered, yielding three articles.

RESULTS

All three studies showed the efficacy of armodafinil in improving subjective and objective sleepiness, clinical conditions, and global functioning regardless of shift duration. Both performance and driving simulator performance tests administered during the night shift bore better results following armodafinil administration than after placebo. However, armodafinil only reduced subjective disability in individuals working more than 9 h; furthermore, even after armodafinil, alertness was reduced but not normalized.

CONCLUSION

These studies underscore the importance of preventing and/or minimizing disturbances due to shift work. This may be achieved through various strategies, such as the employer's commitment to adopt ergonomic criteria in shift design and to implement work-environment interventions like controlled bright light. Health personnel is of pivotal importance to detect potential factors of intolerance to shift work or early symptoms of SWD. Additional and improved studies are needed to further evaluate the effectiveness and safety of both pharmacological and non-pharmacological interventions.

Developing a Tailored Website for Promoting Awareness about Obstructive Sleep Apnea (OSA) Among Blacks in Community-Based Settings

Blacks are at greater risk for lower sleep quality and higher risk for obstructive sleep apnea (OSA) than other racial groups. In this study, we summarize the development of a tailored website including visuals, key messages, and video narratives, to promote awareness about sleep apnea among community-dwelling blacks. We utilized mixed methods, including in-depth interviews, usability-testing procedures, and brief surveys (n = 9, 55% female, 100% black, average age 38.5 years). Themes from the qualitative analysis illuminated varied knowledge regarding OSA symptoms and prevalent self-reported experience with sleep disturbance and OSA symptoms (e.g., snoring). On a scale from 1 (not at all) to 5 (very high), participants provided favorable ratings of website usefulness (mean = 4.9), user friendliness (mean = 4.9) and attractiveness (mean = 4.3). Our findings suggest although tailored health communication has potential for serving as a tool for advancing health equity, usability-testing of health materials is critical to ensure that culturally and linguistically tailored messages are acceptable and actionable in the intended population.

Working Time Society consensus statements: Evidence based interventions using light to improve circadian adaptation to working hours

Interventions and strategies to improve health through the management of circadian (re) adaptation have been explored in the field, and in both human and animal laboratory manipulations of shiftwork. As part of an initiative by the Working Time Society (WTS) and International Committee on Occupational Health (ICOH), this review summarises the literature on the management of circadian (re) adaption using bright light treatment. Recommendations to maximise circadian adaptation are summarised for practitioners based on a variety of shiftwork schedules. In slowly rotating night shift schedules bright light appears most suitable when used in connection with the first three night shifts. These interventions are improved when combined with orange glasses (to block blue-green light exposure) for the commute home. Non-shifting strategies involve a lower dosage of light at night and promoting natural daylight exposure during the day (also recommended for day shifts) in acordance with the phase and amplitude response curves to light in humans.

Bright environmental light improves the sleepiness of nightshift ICU nurses

Background

Shift work can disturb circadian homeostasis and result in fatigue, excessive sleepiness, and reduced quality of life. Light therapy has been shown to impart positive effects in night shift workers. We sought to determine whether or not prolonged exposure to bright light during a night shift reduces sleepiness and enhances psychomotor performance among ICU nurses.

Methods

This is a single-center randomized, crossover clinical trial at a surgical trauma ICU. ICU nurses working a night shift were exposed to a 10-h period of high illuminance (1500–2000 lx) white light compared to standard ambient fluorescent lighting of the hospital. They then completed the Stanford Sleepiness Scale and the Psychomotor Vigilance Test. The primary and secondary endpoints were analyzed using the paired t test. A p value <0.05 was considered significant.

Results

A total of 43 matched pairs completed both lighting exposures and were analyzed. When exposed to high illuminance lighting subjects experienced reduced sleepiness scores on the Stanford Sleepiness Scale than when exposed to standard hospital lighting: mean (sem) 2.6 (0.2) vs. 3.0 (0.2), p = 0.03. However, they committed more psychomotor errors: 2.3 (0.2) vs. 1.7 (0.2), p = 0.03.

Conclusions

A bright lighting environment for ICU nurses working the night shift reduces sleepiness but increases the number of psychomotor errors.

Trial registration

ClinicalTrials.gov, NCT03331822. Retrospectively registered on 6 November 2017.

A Review of Scales to Evaluate Sleep Disturbances in Movement Disorders

Patients with movement disorders have a high prevalence of sleep disturbances that can be classified as (1) nocturnal sleep symptoms, such as insomnia, nocturia, restless legs syndrome (RLS), periodic limb movements (PLM), obstructive sleep apnea (OSA), and REM sleep behavior disorder; and (2) diurnal problems that include excessive daytime sleepiness (EDS) and sleep attacks. The objective of this review is to provide a practical overview of the most relevant scales that assess these disturbances to guide the choice of the most useful instrument/s depending on the line of research or clinical focus. For each scale, the reader will find a brief description of practicalities and psychometric properties, use in movement disorder cohorts and analyzed strengths and limitations. To assess insomnia, the Pittsburgh Sleep Quality Index, a generic scale, and three disease-specific scales: the Parkinson Disease Sleep Scale (PDSS), the PDSS-2, and Scales for outcomes in Parkinson's disease (PD)-Sleep-Nocturnal Sleep subscale are discussed. To evaluate nocturia, there are no specific tools, but some extensively validated generic urinary symptom scales (the Overall Bladder Questionnaire and the Overactive Bladder Symptom Score) and some PD-specific scales that include a nocturia item are available. To measure RLS severity, there are currently four domain-specific generic scales: The International Restless Legs Scale, the Johns Hopkins Restless Legs Severity Scale, the Restless Legs Syndrome-6 measure, a Pediatric RLS Severity Scale, and the Augmentation Severity Rating Scale (a scale to evaluate augmentation under treatment) and several instruments that assess impact on quality of sleep and health-related quality of life. To evaluate the presence of PLM, no clinical scales have been developed to date. As far as OSA, commonly used instruments such as the Sleep Apnea Scale of the Sleep Disorders Questionnaire, the STOP-Bang questionnaire, and the Berlin Questionnaire are reviewed. Three scales have been extensively used to assess EDS: the generic Epworth Sleepiness Scale, the Stanford Sleepiness Scale, and the PD-specific Scales for outcomes in PD-Sleep-Daytime sleepiness subscale. To date, only the Inappropriate Sleep Composite Score specifically evaluates propensity to sleep attacks.

Night shift preparation, performance, and perception: are there differences between emergency medicine nurses, residents, and faculty?

Objective

Determine differences between faculty, residents, and nurses regarding night shift preparation, performance, recovery, and perception of emotional and physical health effects.

Methods

Survey study performed at an urban university medical center emergency department with an accredited residency program in emergency medicine.

Results

Forty-seven faculty, 37 residents, and 90 nurses completed the survey. There was no difference in use of physical sleep aids between groups, except nurses utilized blackout curtains more (69%) than residents (60%) and faculty (45%). Bedroom temperature preference was similar. The routine use of pharmacologic sleep aids differed: nurses and residents (both 38%) compared to faculty (13%). Residents routinely used melatonin more (79%) than did faculty (33%) and nurses (38%). Faculty preferred not to eat (45%), whereas residents (24%) preferred a full meal. The majority (>72%) in all groups drank coffee before their night shift and reported feeling tired despite their routine, with 4:00 a.m. as median nadir. Faculty reported a higher rate (41%) of falling asleep while driving compared to residents (14%) and nurses (32%), but the accident rate (3% to 6%) did not differ significantly. All had similar opinions regarding night shift-associated health effects. However, faculty reported lower level of satisfaction working night shifts, whereas nurses agreed less than the other groups regarding increased risk of drug and alcohol dependence.

Conclusion

Faculty, residents, and nurses shared many characteristics. Faculty tended to not use pharmacologic sleep aids, not eat before their shift, fall asleep at a higher rate while driving home, and enjoy night shift work less.

An International Study on the Determinants of Poor Sleep Amongst 15,000 Users of Connected Devices

BACKGROUND

Sleep is a modifiable lifestyle factor that can be a target for efficient intervention studies to improve the quality of life and decrease the risk or burden of some chronic conditions. Knowing the profiles of individuals with poor sleep patterns is therefore a prerequisite. Wearable devices have recently opened new areas in medical research as potential efficient tools to measure lifestyle factors such as sleep quantity and quality.

OBJECTIVES

The goal of our research is to identify the determinants of poor sleep based on data from a large population of users of connected devices.

METHODS

We analyzed data from 15,839 individuals (13,658 males and 2181 females) considered highly connected customers having purchased and used at least 3 connected devices from the consumer electronics company Withings (now Nokia). Total and deep sleep durations as well as the ratio of deep/total sleep as a proxy of sleep quality were analyzed in association with available data on age, sex, weight, heart rate, steps, and diastolic and systolic blood pressures.

RESULTS

With respect to the deep/total sleep duration ratio used as a proxy of sleep quality, we have observed that those at risk of having a poor ratio (≤0.40) were more frequently males (odds ratio [OR]_{female vs male}=0.45, 95% CI 0.38-0.54), younger individuals (OR_{>60 years vs 18-30 years}=0.47, 95% CI 0.35-0.63), and those with elevated heart rate (OR_{>78 bpm vs ≤61 bpm}=1.18, 95% CI 1.04-1.34) and high systolic blood pressure (OR_{>133 mm Hg vs ≤116 mm Hg}=1.22, 95% CI 1.04-1.43). A direct association with weight was observed for total sleep duration exclusively.

CONCLUSIONS

Wearables can provide useful information to target individuals at risk of poor sleep. Future alert or mobile phone notification systems based on poor sleep determinants measured with wearables could be tested in intervention studies to evaluate the benefits.

Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work

BACKGROUND

Shift work is often associated with sleepiness and sleep disorders. Person-directed, non-pharmacological interventions may positively influence the impact of shift work on sleep, thereby improving workers' well-being, safety, and health.

OBJECTIVES

To assess the effects of person-directed, non-pharmacological interventions for reducing sleepiness at work and improving the length and quality of sleep between shifts for shift workers.

SEARCH METHODS

We searched CENTRAL, MEDLINE Ovid, Embase, Web of Knowledge, ProQuest, PsycINFO, OpenGrey, and OSH-UPDATE from inception to August 2015. We also screened reference lists and conference proceedings and searched the World Health Organization (WHO) Trial register. We contacted experts to obtain unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) (including cross-over designs) that investigated the effect of any person-directed, non-pharmacological intervention on sleepiness on-shift or sleep length and sleep quality off-shift in shift workers who also work nights.

DATA COLLECTION AND ANALYSIS

At least two authors screened titles and abstracts for relevant studies, extracted data, and assessed risk of bias. We contacted authors to obtain missing information. We conducted meta-analyses when pooling of studies was possible.

MAIN RESULTS

We included 17 relevant trials (with 556 review-relevant participants) which we categorised into three types of interventions: (1) various exposures to bright light (n = 10); (2) various opportunities for napping (n = 4); and (3) other interventions, such as physical exercise or sleep education (n = 3). In most instances, the studies were too heterogeneous to pool. Most of the comparisons yielded low to very low quality evidence. Only one comparison provided moderate quality evidence. Overall, the included studies' results were inconclusive. We present the results regarding sleepiness below. Bright light Combining two comparable studies (with 184 participants altogether) that investigated the effect of bright light during the night on sleepiness during a shift, revealed a mean reduction 0.83 score points of sleepiness (measured via the Stanford Sleepiness Scale (SSS) (95% confidence interval (CI) -1.3 to -0.36, very low quality evidence). Another trial did not find a significant difference in overall sleepiness on another sleepiness scale (16 participants, low quality evidence).Bright light during the night plus sunglasses at dawn did not significantly influence sleepiness compared to normal light (1 study, 17 participants, assessment via reaction time, very low quality evidence).Bright light during the day shift did not significantly reduce sleepiness during the day compared to normal light (1 trial, 61 participants, subjective assessment, low quality evidence) or compared to normal light plus placebo capsule (1 trial, 12 participants, assessment via reaction time, very low quality evidence). Napping during the night shiftA meta-analysis on a single nap opportunity and the effect on the mean reaction time as a surrogate for sleepiness, resulted in a 11.87 ms reduction (95% CI 31.94 to -8.2, very low quality evidence). Two other studies also reported statistically non-significant decreases in reaction time (1 study seven participants; 1 study 49 participants, very low quality evidence).A two-nap opportunity resulted in a statistically non-significant increase of sleepiness (subjective assessment) in one study (mean difference (MD) 2.32, 95% CI -24.74 to 29.38, 1 study, 15 participants, low quality evidence). Other interventionsPhysical exercise and sleep education interventions showed promise, but sufficient data to draw conclusions are lacking.

AUTHORS' CONCLUSIONS

Given the methodological diversity of the included studies, in terms of interventions, settings, and assessment tools, their limited reporting and the very low to low quality of the evidence they present, it is not possible to determine whether shift workers' sleepiness can be reduced or if their sleep length or quality can be improved with these interventions.We need better and adequately powered RCTs of the effect of bright light, and naps, either on their own or together and other non-pharmacological interventions that also consider shift workers' chronobiology on the investigated sleep parameters.