Twelve-Hour Night Shifts of Healthcare Workers: A Risk to the Patients?

We assessed the impact of 12h fixed night shift (19:00–07:00h) work, followed by 36h of off-time, on the sleep–wake cycle, sleep duration, self-perceived sleep quality, and work-time alertness on a group composed of 5 registered and 15 practical nurses. Wrist actigraphy (Ambulatory Monitoring, Inc.), with data analysis by the Cole-Kripke algorithm, was applied to determine sleep/wake episodes and their duration. The sleep episodes were divided into six categories: sleep during the night shift (x¯=208.6; SD±90.6mins), sleep after the night shift (x¯=138.7; SD±79.6min), sleep during the first night after the night work (x¯=318.5; SD±134.6min), sleep before the night work (x¯=104.3; SD±44.1min), diurnal sleep during the rest day (x¯=70.5; SD±43.0min), and nocturnal sleep during the rest day (x¯=310.4; SD±188.9mins). A significant difference (p<.0001; T-test for dependent samples) was detected between the perceived quality of sleep of the three diurnal sleep categories compared to the three nocturnal sleep categories. Even thought the nurses slept (napped) during the night shift, their self-perceived alertness systematically decreased during it. Statistically significant differences were documented by one-way ANOVA (F=40.534 p<.0001) among the alertness measurements done during the night shift. In particular, there was significant difference in the level of perceived alertness (p<.0001) between the 7^th and 10^thh of the 12h night shift. These findings of decreased alertness during the terminal hours of the night shift are of concern, since they suggest risk of comprised patient care.     

IMPLEMENTATION OF 12-HOUR SHIFTS IN A BRAZILIAN PETROCHEMICAL PLANT: IMPACT ON SLEEP AND ALERTNESS

A recent worldwide trend in chemical and petrochemical industries is to extend the duration of shifts. Optimization of the labor force to reduce costs is one reason to increase the length of working time in a shift. Implementation of 12h shifts is a controversial decision for managers and scientists. Literature reviews show alertness is lower during the nighttime hours, and sleep duration is reduced and worse during the daytime. The main objective of this study was to evaluate the impacts of 12h shifts on alertness and sleep. To evaluate the duration and quality of sleep and alertness during work, 22 male shift workers on a continuous rotating schedule at a petrochemical plant completed activity logs and estimated alertness using analog 10-cm scales for 30 consecutive days, three times (at 2h, 6h, and 10h of the shift) every work shift. Statistical tests (analysis of variance [ANOVA] and Tukey) were performed to detect differences between workdays and off days. The shift schedule was 2 days/3 nights/4 off days, followed by 3 days/2 nights/5 off days, followed by 2 days/2 nights/5 off days. Sleep duration varied significantly (p <. 001) among the work shifts and off days. Comparing work nights, the shortest mean sleep occurred after the second night (mean = 311.4 minutes, SD = 101.7 minutes), followed by the third night (mean = 335.3 minutes, SD = 151.2 minutes). All but one shift (sleep after the first work night) were significantly different from sleep after the first 2 workdays (p <. 002). Tukey tests showed no significant differences in sleep quality between workdays and nights, with the exception of sleep after the third day compared to sleep after night shifts. However, significant differences were detected between off days and work nights (p <. 01). ANOVA analysis showed borderline differences among perceived alertness during day shifts (p =. 073) and significant differences among the hours of theshifts(p =. 0005), especially when comparing the 2nd hour of the first day with the 10th hour of all the day shifts. There were no significant differences in perceived alertness during night work among the first, second, and third nights (p =. 573), but there were significant differences comparing the times (2nd, 6th, 10th hour) of the night shifts (p ≤. 001). The evaluation of sleep (duration and quality) and level of alertness have been extensively used in the literature as indicators of possible performance decrements at work. The results of this study show poorer sleep after and significantly decreased alertness during night work. Shifts of 12h are usually implemented for technical and economic reasons. These results point out the necessity of a careful trade-off between the financial and technical gains longer shifts might bring and the possible losses due to incidents or accidents from performance decrements during work. (Chronobiology International, 17(4), 521–537, 2000)     

Can Melatonin Improve Shift Workers' Tolerance of the Night Shift? Some Preliminary Findings

The pineal hormone melatonin is potentially useful in the treatment of disorders, especially sleep disorders, associated with circadian rhythm disturbance. We have examined its effects on sleep, mood, and behaviour in a double-blind, placebo-controlled study of a small group of police officers working spans of seven successive night shifts. Compared to placebo, and to no treatment, melatonin (5 mg) taken at the desired bedtime improved problems related to sleep and increased alertness during working hours, especially during the early morning. In letter-target performance tests visual search speed and accuracy were either unchanged or slightly improved. Memory scanning speed and perception of mental load were adversely affected. This preliminary study suggests that melatonin has beneficial effects on sleep and alertness, but that its effects on performance need careful evaluation.     

A Psychometric Evaluation and Validation of the Preferences Scale

The Preferences Scale (PS) is a new measure of morningness and therefore requires intensive investigation to establish its measurement properties and validity. A confirmatory factor analysis (CFA) of Smith and colleagues (2002) posited model structure was not optimal in both a student (n=731) and working sample (n=218). However, significant differences (p<0.01) were found for times to sleep and wake between morning and evening types. Principal components and reliability analyses were used to develop a 6‐item model comprising 2 factors using a student sample (n=368). Cronbach's α for the PS was 0.73 and the factors explained 61% of the variance. The revised model was replicated via CFA in a separate student sample (n=363). A subsequent CFA confirmed the model structure in the working sample. Cronbach's α was 0.74 and the factors explained 64% of the variance. Significant differences (p<0.01) in self‐reported alertness ratings between morning and evening types were obtained by time‐of‐day. These results provide preliminary support for the PS. The predictive efficacy of the PS requires further validation against a number of health and work‐related variables.     

Association between ABCB1 gene polymorphisms and fentanyl's adverse effects in Turkish patients undergoing spinal anesthesia

The ATP-binding cassette transporter (ABCB1) gene product, P-glycoprotein plays an important role in the prevention of intracellular accumulation of potentially toxic substances and metabolites in various tissues. Single nucleotide polymorphisms in this gene are claimed to be correlated with changes in the function of P-glycoprotein. There is evidence that fentanyl, may be a substrate for P-glycoprotein. The aim of the study was to assess whether an association exists between ABCB1 gene polymorphism and early respiratory and sedative adverse effects of intravenous fentanyl in Turkish patients who underwent spinal anesthesiaIn all 83 unrelated Turkish patients were enrolled in this study. In this study, spinal anesthesia was provided and a single dose of intravenous fentanyl (2.5 μg.kg⁻¹) at the beginning of surgery was used as a sedative agent. Bispectral index, respiration rate and peripheral oxygen saturation were measured continuously and recorded throughout the study.The allele and genotype frequencies were similar to previous data from Turkish population.Respiratory rate (RR) and SpO₂ parameters of the patients did not show any significant difference according to the genotype distribution for C1236T and C3435T SNPs. Fentanyl-induced decrease in respiration rate was most remarkable at 15 min (23%) in CC genotype of C1236T, whereas in TT genotype of C3435T (18%) polymorphism. SpO₂ parameters in allele distribution were also not significant among the groups (p = 0.374, p = 0.985, respectively). For the C1236T polymorphism, patients carrying T allele showed a significant decrease in pH, and a significant increase in pCO₂ (p < 0.001).ABCB1 polymorphisms did not seem to have a significant effect on sedation and respiratory depression caused by intravenous fentanyl in spinal anesthesia in Turkish patients.     

Further Assessments of the Relationship Between Jet Lag and Some of Its Symptoms

The disruption of circadian rhythms following time‐zone transitions gives rise to the syndrome of jet lag. The power of some of the symptoms of jet lag to predict the amount of jet lag measured at the same and at different times of the day has been investigated. Eleven healthy subjects were studied in an Isolation Unit for two days after a simulated flight from the UK to Beijing (8 time zones to the east). At six time‐points (08:30, 11:00, 14:00, 17:00, 20:00, and 23:00 h), the subjects recorded their jet lag, and the differences from “normal” (that is, from days in which there is no jet lag) of alertness, hunger, indigestion, concentration, motivation, and irritability. They recorded at 08:30 h the type of food they had eaten since rising at 08:00 h and, at the other times, the type of food eaten in the last three hours. Assessments were made by visual analogue scales or, in the case of type of food, by a nominal scale. Following the time‐zone transition, the adjustment of meals appeared to be complete almost immediately. Jet lag and its symptoms were present during both experimental days. Jet lag tended to rise during the course of the daytime, accompanied by falls in alertness, motivation, and concentration. Correlation matrices between jet lag and each of the other variables were produced, using lags between the variable (from up to 5 time‐points before the assessment of jet lag to 5 time‐points afterwards) and pooling the results from both days. These matrices indicated that significant correlations existed only between jet lag and alertness, concentration, and motivation, and then only when these other variables were assessed at the same time as jet lag or 1 or 2 time‐points earlier. Jet lag was then treated as the dependent variable and the symptoms as covariates in analysis of covariances (ANCOVAs), with the days treated as a random effect. This analysis enabled the significance of potential predictors of jet lag, together with their β‐coefficients (the relationship between a unit change of each significant predictor and the change in jet lag), to be calculated. Falls in alertness and motivation were significant predictors of increased jet lag, provided that they were measured at the same time, when they accounted for about 50% of the jet lag; when measured at other time‐points, they did not act as significant predictors. It is concluded that the amount of jet lag varies during the course of the day and that it can be predicted from contemporaneous assessments of alertness and motivation—but not from assessments made at other times of the day, nor from other variables that are symptoms of jet lag, even though these other variables are significantly increased. In considering the results of this and our previous study, we reiterate the view that the exact meaning of “jet lag” is complex and that the particular combination of factors that contribute to it might vary with the time of day that the assessment is made. Inferences about any decrements due to time‐zone transitions cannot be made reliably at times of the day that differ from the time when jet lag is assessed.     

Effect of Menopause on Melatonin and Alertness Rhythms Investigated in Constant Routine Conditions

Although studies have reported the effects of the menstrual cycle on melatonin rhythmicity, none has investigated the effects of menopause on the melatonin rhythm. The circadian rhythm in melatonin and its relationship to subjective alertness was investigated in pre‐ and postmenopausal women under constant routine conditions (controlled posture, dim lighting, calorie intake, temperature, and prolonged wakefulness). Eleven healthy pre‐menopausal (42±4 yr) and 10 postmenopausal women (55±2 yr) participated in the study. Salivary melatonin samples and subjective measures of alertness and sleepiness were assessed hourly during the 22 h constant routine protocol. Postmenopausal women had a significantly earlier melatonin acrophase (1.1±0.5 h clock time in decimal h; mean±SEM, p<0.05) compared to the pre‐menopausal women (2.3±0.3 h). There was no significant difference between melatonin onset and amplitude between the pre‐menopausal and postmenopausal women. Self‐rated alertness declined in both study groups as the length of sleep deprivation increased. Melatonin onset preceded the onset of self‐rated sleepiness in both groups. The time interval between melatonin onset and the onset of sleepiness and alertness offset was significantly greater in the postmenopausal women compared to the pre‐menopausal women. In conclusion, under controlled experimental conditions the timing of the melatonin rhythm was advanced in postmenopausal women altering its phase relationship to subjective alertness and sleepiness.     

Morningness or Morning Affect? A Short Composite Scale of Morningness

The Composite Scale of Morningness (CSM) is a widely used measure of behavioral temporal preference, and it is highly reliable across cultures. There are several competing models concerning its factor structure. We used confirmatory factor analysis (CFA) to replicate the two‐and three‐factor models, and, in addition, we examined the utility of the four‐item morning affect scale as a proxy for the full CSM. We tested these models in a large student sample (N=1396). The chi‐square result for the two‐ and three‐factor models indicated they did not adequately fit the data, and the modification indices suggested some items could be correlated. Allowing these items to correlate failed to produce a non‐significant chi‐square result, but some improvements to the incremental fit indices and root mean square error of approximation (RMSEA) were found. In particular, the three‐factor model seemed satisfactory. CFA of the morning‐affect scale also failed to fit the data, but the incremental fit indices and RMSEA were strong. For each of these three models, there was no significant difference between the invariant (no sex difference) and variant (sex difference) models. However, in each model, a critical ratio difference was found on the standardized regression weights between males and females on item 12. The morning‐affect scale had high reliability (0.83) and demonstrated satisfactory construct validity against the preferences scale and time to sleep and wake. In addition, high and low morning‐affect groups reported significant sleepiness differences by time of day. These results suggest the morning‐affect scale may be a useful proxy for the full scale. Furthermore, the items make no reference to time‐of‐day and may better facilitate cross‐cultural research. Studies using population‐based samples are recommended to further test the efficacy of the morning‐affect scale.