The effectiveness of an individualized sleep and shift work education and coaching program to manage shift work disorder in nurses: a randomized controlled trial

Dysfunction of large-scale brain networks underlying cognitive impairments in shift work disorder

It has been demonstrated that shift work can affect cognitive functions. Several neuroimaging studies have revealed altered brain function and structure for patients with shift work disorder (SWD). However, knowledge on the dysfunction of large-scale brain networks underlying cognitive impairments in shift work disorder is limited. This study aims to identify altered functional networks associated with cognitive declines in shift work disorder, and to assess their potential diagnostic value. Thirty-four patients with shift work disorder and 36 healthy controls (HCs) were recruited to perform the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and resting-state functional scans. After surface-based preprocessing, we calculated within- and between-network functional connectivity (FC) using the Dosenbach atlas. Moreover, correlation analysis was done between altered functional connectivity of large-scale brain networks and scores of cognitive assessments in patients with shift work disorder. Finally, we established a classification model to provide features for patients with shift work disorder concerning the disrupted large-scale networks. Compared with healthy controls, increased functional connectivity within-networks across the seven brain networks, and between-networks involving ventral attention network (VAN)-subcortical network (SCN), SCN-frontoparietal network (FPN), and somatosensory network (SMN)-SCN were observed in shift work disorder. Decreased functional connectivity between brain networks was found in shift work disorder compared with healthy controls, including visual network (VN)-FPN, VN-default mode network (DMN), SMN-DMN, dorsal attention network (DAN)-DMN, VAN-DMN, and FPN-DMN. Furthermore, the altered functional connectivity of large-scale brain networks was significantly correlated with scores of immediate memory, visuospatial, and delayed memory in patients with shift work disorder, respectively. Abnormal functional connectivity of large-scale brain networks may play critical roles in cognitive dysfunction in shift work disorder. Our findings provide new evidence to interpret the underlying neural mechanisms of cognitive impairments in shift work disorder.

SleepSync: Early Testing of a Personalised Sleep-Wake Management Smartphone Application for Improving Sleep and Cognitive Fitness in Defence Shift Workers

Shift work, long work hours, and operational tasks contribute to sleep and circadian disruption in defence personnel, with profound impacts on cognition. To address this, a digital technology, the SleepSync app, was designed for use in defence. A pre-post design study was undertaken to examine whether four weeks app use improved sleep and cognitive fitness (high performance neurocognition) in a cohort of shift workers from the Royal Australian Air Force. In total, 13 of approximately 20 shift-working personnel from one base volunteered for the study. Sleep outcomes were assessed using the Insomnia Severity Index (ISI), the Patient-Reported Outcomes Measurement Information System (PROMIS), Sleep Disturbance and Sleep-Related Impairment Scales, the Glasgow Sleep Effort Scale, the Sleep Hygiene Index, and mental health was assessed using the Depression, Anxiety, and Stress Scale-21. Sustained attention was measured using the 3-min Psychomotor Vigilance Task (PVT) and controlled response using the NBack. Results showed significant improvements in insomnia (ISI scores 10.31 at baseline and 7.50 after app use), sleep-related impairments (SRI T-scores 53.03 at baseline to 46.75 post-app use), and healthy sleep practices (SHI scores 21.61 at baseline to 18.83 post-app use; all p < 0.001). Trends for improvement were recorded for depression. NBack incorrect responses reduced significantly (9.36 at baseline; reduced by -3.87 at last week of app use, p < 0.001), but no other objective measures improved. These findings suggest that SleepSync may improve sleep and positively enhance cognitive fitness but warrants further investigation in large samples. Randomised control trials with other cohorts of defence personnel are needed to confirm the utility of this intervention in defence settings.

Nurse rostering: understanding the current shift work scheduling processes, benefits, limitations, and potential fatigue risks

BACKGROUND

Implementing appropriate shift work schedules can help mitigate the risk of sleep impairment and reduce fatigue of healthcare workers, reducing occupational health and safety risks. In Australia, the organisation has a responsibility to make sure all reasonable measures are taken to reduce fatigue of staff. Therefore, it is important to assess what the current rostering processes is for staff responsible for creating the rosters for nurses.

AIM

The aims of the project were to understand (1) who creates the rosters and what the process is, (2) what training and knowledge these staff have in establishing rostering schedules that optimise the sleep and wellbeing of staff, and (3) what the benefits and limitations are of current rostering practices.

METHODS

Findings were generated through semi-structured interviews, using cluster coding to form categories. Twenty four nurses responsible for rostering staff were interviewed from three different sites in Victoria (one metropolitan and two regional/rural hospitals). Data was analysed using selected grounded theory methods with thematic analysis.

RESULTS

The common themes that came out of the interviews were that rostering staff were under prepared, unaware of fatigue and safety guidelines and polices from governing bodies and had not received any education or training before taking on the role. The most common rostering style was self-rostering, where staff could submit preferences. However, there were concerns about staff fatigue but were divided as to who should be responsible, with many saying it was up to staff to preference shifts that they could cope with. The final theme was cultural barriers to change.

CONCLUSION

While self-rostering resulted in staff having more freedom and flexibility,  shift preferences may be influenced more so by a need to fit with lifestyle rather than to minimise fatigue and increase safety in the workplace. Greater consideration of the impact of shift work schedules on fatigue is required to ensure that the layers of clinical governance in health care organisations minimise the risk of occupation health and safety issues for employees delivering direct patient care.

Sleep and fatigue management strategies: How nurses, midwives and paramedics cope with their shift work schedules-a qualitative study

AIMS

To understand the benefits and challenges of shift work, and the coping strategies used by nurses, midwives and paramedics to manage the impact of shift work on sleep and fatigue from shift work.

DESIGN

A single case study with embedded units.

METHODS

Twenty-seven participants were interviewed exploring their shift work experiences, coping strategies used to improve sleep, and what their recommendations are for improving shift work management. Interviews were completed between November and December 2022.

RESULTS

Participants enjoyed the lifestyle, flexibility and financial rewards offered by working shift work. However, fatigue and sleep deprivation undermined these benefits, as it impacted their ability to enjoy social and family events. There were also concerns of long-term health consequences of shift work and delivery of care. Changes to rostering practices and sleep and shift work education were common recommendations.

CONCLUSION

This study provides insights on how healthcare professionals manage sleep and fatigue due to shift work and the inadequate support. There is absence of adequate policies, processes and training at an organizational, academic and personal level on how to best manage sleep and fatigue when working shift work. Future research is needed to explore how to equip healthcare shift workers with the skills to successfully manage their schedules to mitigate the negative impact that poor sleep and fatigue has on the health and safety of themselves and their patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Understanding the specific challenges of shift work and how workers manage their shift work schedules is critical for improving the health and safety of themselves and their patients. This study identified that there is insufficient training regarding sleep and shift work management strategies, potentially leading to occupational health and safety concerns. Further education and training to equip staff with the necessary information, training and guidance to staff on how to reduce fatigue risk is required.

PATIENT OR PUBLIC CONTRIBUTION

This study involved healthcare shift workers in semi-structured interviews. Data gathered from a previous survey that participants were involved in helped shape the interview topics and the study design.

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.

Pilot feasibility testing of biomathematical model recommendations for personalising sleep timing in shift workers

Sleep disturbances and circadian disruption play a central role in adverse health, safety, and performance outcomes in shift workers. While biomathematical models of sleep and alertness can be used to personalise interventions for shift workers, their practical implementation is undertested. This study tested the feasibility of implementing two biomathematical models-the Phillips-Robinson Model and the Model for Arousal Dynamics-in 28 shift-working nurses, 14 in each group. The study examined the overlap and adherence between model recommendations and sleep behaviours, and changes in sleep following the implementation of recommendations. For both groups combined, the mean (SD) percentage overlap between when a model recommended an individual to sleep and when sleep was obtained was 73.62% (10.24%). Adherence between model recommendations and sleep onset and offset times was significantly higher with the Model of Arousal Dynamics compared to the Phillips-Robinson Model. For the Phillips-Robinson model, 27% of sleep onset and 35% of sleep offset times were within ± 30 min of model recommendations. For the Model of Arousal Dynamics, 49% of sleep onset, and 35% of sleep offset times were within ± 30 min of model recommendations. Compared to pre-study, significant improvements were observed post-study for sleep disturbance (Phillips-Robinson Model), and insomnia severity and sleep-related impairments (Model of Arousal Dynamics). Participants reported that using a digital, automated format for the delivery of sleep recommendations would enable greater uptake. These findings provide a positive proof-of-concept for using biomathematical models to recommend sleep in operational contexts.

Effect of an Internet-Delivered Cognitive Behavioral Therapy-Based Sleep Improvement App for Shift Workers at High Risk of Sleep Disorder: Single-Arm, Nonrandomized Trial

BACKGROUND

Shift workers are at high risk of developing sleep disorders such as shift worker sleep disorder or chronic insomnia. Cognitive behavioral therapy (CBT) is the first-line treatment for insomnia, and emerging evidence shows that internet-based CBT is highly effective with additional features such as continuous tracking and personalization. However, there are limited studies on internet-based CBT for shift workers with sleep disorders.

OBJECTIVE

This study aimed to evaluate the impact of a 4-week, physician-assisted, internet-delivered CBT program incorporating machine learning-based well-being prediction on the sleep duration of shift workers at high risk of sleep disorders. We evaluated these outcomes using an internet-delivered CBT app and fitness trackers in the intensive care unit.

METHODS

A convenience sample of 61 shift workers (mean age 32.9, SD 8.3 years) from the intensive care unit or emergency department participated in the study. Eligible participants were on a 3-shift schedule and had a Pittsburgh Sleep Quality Index score ≥5. The study comprised a 1-week baseline period, followed by a 4-week intervention period. Before the study, the participants completed questionnaires regarding the subjective evaluation of sleep, burnout syndrome, and mental health. Participants were asked to wear a commercial fitness tracker to track their daily activities, heart rate, and sleep for 5 weeks. The internet-delivered CBT program included well-being prediction, activity and sleep chart, and sleep advice. A job-based multitask and multilabel convolutional neural network-based model was used for well-being prediction. Participant-specific sleep advice was provided by sleep physicians based on daily surveys and fitness tracker data. The primary end point of this study was sleep duration. For continuous measurements (sleep duration, steps, etc), the mean baseline and week-4 intervention data were compared. The 2-tailed paired t test or Wilcoxon signed rank test was performed depending on the distribution of the data.

RESULTS

In the fourth week of intervention, the mean daily sleep duration for 7 days (6.06, SD 1.30 hours) showed a statistically significant increase compared with the baseline (5.54, SD 1.36 hours; P=.02). Subjective sleep quality, as measured by the Pittsburgh Sleep Quality Index, also showed statistically significant improvement from baseline (9.10) to after the intervention (7.84; P=.001). However, no significant improvement was found in the subjective well-being scores (all P>.05). Feature importance analysis for all 45 variables in the prediction model showed that sleep duration had the highest importance.

CONCLUSIONS

The physician-assisted internet-delivered CBT program targeting shift workers with a high risk of sleep disorders showed a statistically significant increase in sleep duration as measured by wearable sensors along with subjective sleep quality. This study shows that sleep improvement programs using an app and wearable sensors are feasible and may play an important role in preventing shift work-related sleep disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24799.

Effectiveness of Workplace Interventions to Improve Health and Well-Being of Health and Social Service Workers: A Narrative Review of Randomised Controlled Trials

Health and social service workers face high levels of workload and job stressors, which can affect their health and well-being. Therefore, it is important to evaluate the effectiveness of workplace interventions that aim to improve their mental and physical health outcomes. This review summarizes the findings of randomized controlled trials (RCTs) that examined the impact of different types of workplace interventions on various health indicators among health and social service workers. The review searched the PubMed database from its inception to December 2022 and included RCTs that reported on the effectiveness of organizational-level interventions and qualitative studies that explored barriers and facilitators to participation in such interventions. A total of 108 RCTs were included in the review, covering job burnout (N = 56 RCTs), happiness or job satisfaction (N = 35), sickness absence (N = 18), psychosocial work stressors (N = 14), well-being (N = 13), work ability (N = 12), job performance or work engagement (N = 12), perceived general health (N = 9), and occupational injuries (N = 3). The review found that several workplace interventions were effective in improving work ability, well-being, perceived general health, work performance, and job satisfaction and in reducing psychosocial stressors, burnout, and sickness absence among healthcare workers. However, the effects were generally modest and short-lived. Some of the common barriers to participation in workplace interventions among healthcare workers were inadequate staff, high workload, time pressures, work constraints, lack of manager support, scheduling health programs outside work hours, and lack of motivation. This review suggests that workplace interventions have small short-term positive effects on health and well-being of healthcare workers. Workplace interventions should be implemented as routine programs with free work hours to encourage participation or integrate intervention activities into daily work routines.

Efficacy of lifestyle medicine on sleep quality: A meta-analysis of randomized controlled trials

OBJECTIVES

Randomized controlled trials (RCTs) on the efficacy of multicomponent lifestyle medicine (LM) interventions for improving sleep quality have yielded inconsistent findings. This study marks the first meta-analysis to evaluate the efficacy of multicomponent LM interventions in improving sleep quality.

METHODS

We searched six online databases for RCTs that compared multicomponent LM interventions to an active or inactive control group in an adult population and assessed subjective sleep quality as a primary or secondary outcome using validated sleep measures at any post-intervention time-point.

RESULTS

A total of 23 RCTs with 26 comparisons involving 2534 participants were included in the meta-analysis. After excluding outliers, the analysis revealed that multicomponent LM interventions significantly improved sleep quality at immediate post-intervention (d = 0.45) and at short-term follow-up (i.e., <three months) (d = 0.50) relative to an inactive control group. Regarding the comparison with active control, no significant between-group difference was found at any time-point. No meta-analysis was conducted at the medium- and long-term follow-up due to insufficient data. Subgroup analyses supported that multicomponent LM interventions had a more clinically relevant effect on improving sleep quality in participants with clinical levels of sleep disturbance (d = 1.02) relative to an inactive control at immediate post-intervention assessment. There was no evidence of publication bias.

CONCLUSION

Our findings provided preliminary evidence that multicomponent LM interventions were efficacious in improving sleep quality relative to an inactive control at immediate post-intervention and at short-term follow-up. Additional high-quality RCTs targeting individuals with clinically significant sleep disturbance and long-term follow-up are warranted.

Is cognitive behavioral therapy for insomnia (CBTi) efficacious for treating insomnia symptoms in shift workers? A systematic review and meta-analysis

Shift workers commonly report insomnia symptoms. Cognitive behavioral therapy for insomnia (CBTi) is the first line treatment for insomnia, however efficacy in shift workers is not well understood. This systematic review and meta-analysis evaluates existing trials of CBTi in shift working populations. A systematic literature search was conducted across seven electronic databases (n = 2120). Fifty-two full-text articles were reviewed and of these, nine studies (across ten publications with a total of 363 participants) were deemed suitable for inclusion. Heterogeneity was considerable between studies, with variability in study design, style and delivery of intervention, and follow-up times. Small sample sizes were common and attrition was high. Some studies modified aspects of CBTi for use in shift workers, while others were limited to psycho-education as part of larger intervention studies. Mean differences (MD) pre and post CBTi were modest for both the insomnia severity index (ISI; MD: -3.08, 95% CI: -4.39, -1.76) and the Pittsburgh sleep quality index (PSQI; MD: -2.38, 95% CI: -3.55, -1.21). Neither difference was of a magnitude considered to reflect a clinically significant improvement. Tailored approaches to CBTi are needed for shift workers to improve efficacy, ideally including co-production with workers to ensure interventions meet this population's needs.

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.

Mobile app for personalized sleep–wake management for shift workers: A user testing trial

Objective

Development of personalized sleep–wake management tools is critical to improving sleep and functional outcomes for shift workers. The objective of the current study was to test the performance, engagement and usability of a mobile app ( SleepSync) for personalized sleep–wake management in shift workers that aid behavioural change and provide practical advice by providing personalized sleep scheduling recommendations and education.

Methods

Shift workers ( n = 27; 20 healthcare and 7 from other industries) trialled the mobile app for two weeks to determine performance, engagement and usability. Primary outcomes were self-reported total sleep time, ability to fall asleep, sleep quality and perception of overall recovery on days off. Secondary performance outcomes included sleep disturbances (insomnia and sleep hygiene symptoms, and sleep-related impairments) and mood (anxiety, stress and depression) pre- and post-app use. Satisfaction with schedule management, integration into daily routine and influence on behaviour were used to determine engagement, while the usability was assessed for functionality and ease of use of features.

Results

Total sleep time ( P = .04), ability to fall asleep ( P < .001), quality of sleep ( P = .001), insomnia ( P = .02), sleep hygiene ( P = .01), sleep-related impairments ( P = .001), anxiety ( P = .001), and stress ( P = .006) were all improved, with non-significant improvements in recovery on days off ( P = .19) and depression ( P = .07). All measures of engagement and usability were scored positively by the majority of users.

Conclusions

This pilot trial provides preliminary evidence of the positive impact of the SleepSync app in improving sleep and mood outcomes in shift workers, and warrants confirmation in a larger controlled trial.

Mobile phone sleep self-management applications for early start shift workers: A scoping review of the literature

Poor sleep has significant impacts on both mental and physical well-being. This is especially the case for shift workers who rely on good sleep practices to manage the disruption caused by their working conditions. In recent years there has been a proliferation of sleep-focused mobile phone applications, some of which may be suitable for use by shift workers. There is limited evidence however, on whether these applications are sufficient in managing the sleep needs of the early start shift working population (i.e., those whose work schedules begin pre-dawn). This scoping review aims to identify and discuss peer-reviewed literature on mobile sleep applications used by early start shift workers for sleep-self management. Four databases (Scopus, EBSCOhost, CINAHL and PsycInfo) were searched for relevant literature using a pre-determined search string. The initial search using the term early start shift work returned no papers, however a broadened search on shift work in general found 945 papers for title and abstract screening, of which 21 were deemed eligible for full text screening. Two of these papers met the inclusion criteria for this review. The results highlight, firstly, the paucity of research on the use of mobile phone applications for sleep self-management amongst early start shift workers, and secondly, the need for further research on the effectiveness of mobile applications for sleep self-management amongst shift workers in general. A working definition of early start shift work that can be used to stimulate research in this understudied population of shift workers is also proposed.