As evidence grows on sleep problems among employees, Dr Paul J Nicholson examines the research to find how best employers can support workers.
A previous article in Occupational Health & Wellbeing reported on the link between poor sleep and work performance; and postulated that improving employees’ poor sleep may not only boost employee health and wellbeing, but may give employers a competitive advantage (Culpin, 2016).
This is eminently plausible since sleep deficit is associated with many immediate and lasting adverse health effects. In otherwise healthy adults, short term consequences include reduced quality of life, emotional distress and mood disorders, and cognitive, memory and performance deficits (Medic, 2017).
Sleeping for less than seven hours a night on a regular basis is associated with impaired immune function, obesity, type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke and depression (Consensus, 2015; Medic, 2017).
Sleeping less than seven hours per night is also associated with impaired performance, increased errors and greater risk of accidents (Consensus, 2015). Hence it is prudent for both employees and employers to be concerned about the consequences of sleep problems.
Topics to include in a workplace sleep education programme
- Prevalence of sleep problems
- Sleep needs
- Causes of poor sleep
- Effects of poor sleep
- Self help
- Help from others
The most recent occupational accident study is among 949 Italian lorry drivers in whom sleep debt increased the odds of road traffic accidents and near miss incidents by 45 and 49% respectively (Garbarino, 2016).
Excessive daytime sleepiness was a greater risk, increasing the odds of an accident by 73%. In those who took naps and rest breaks accidents and near misses were reduced by about 40% and 50% respectively.
There appears to be increasing awareness and reporting of sleep problems by employees, particularly when they are asked or surveyed. We should also recognise that sleep problems are highly prevalent in the general population. It is by no means a problem that is confined to western civilisation or modern lifestyles (Stranges, 2012), although for the purpose of this article it is useful to look at data from developed countries.
A US survey reported inadequate sleep in 26% of adults – with difficulty concentrating (25%) or remembering (18%) (Ram, 2010). A more recent Australian survey reported inadequate sleep, of either duration or quality, with daytime consequences in 33-45% adults (Adams, 2017). In the 2012 Great British Sleep Survey of over 20,000 people 49% of men and 56% of women reported long term poor sleep problems.
Sleep problems could be considered to be an endemic public health problem; indeed, Public Health England launched the OneYou website in 2016 to help adults avoid future diseases caused by modern day life and included information on how people can sleep better.
The scale of the problem, the role of occupational risk factors (eg shift work and transmeridian travel) and the potential occupational consequences are good reasons for employers to address sleep deficit in workplace health and wellbeing programmes to encourage employees to obtain adequate sleep. The remainder of this article outlines the support that employers and occupational health professionals might provide and the information to include in workplace health promotion programmes (Box 1).
Prevalence of sleep problems
It is reassuring for employees to know that sleep problems (difficulty getting to sleep, waking up early, or waking for prolonged periods during the night) are common and affect a third to a half of all adults at some time.
Likewise they should know that fatigue is also common and affects around a fifth to a quarter of the general population (Dawson, 2012). They may be reassured by being told that short periods of waking each night are not abnormal and that a normal sleep pattern often resumes after a few days. This advice alone may help break the vicious circle of someone going to bed and being kept awake by the fear that they will have yet another sleepless night.
Employees should be advised that sleeping is an important part of our lives and helps the body and mind to recover from every day activities. Expert consensus for those aged 18-60 years is that “adults should sleep seven or more hours per night on a regular basis to promote optimal health” (Consensus, 2015).
Just like other personal characteristics, the amount of sleep people need to function well is individual. What matters is that employees know how much sleep they need – and then try to achieve it – provided they are being realistic and do not believe that needing less sleep is macho.
Employees should also understand that there are times when they may need more than the usual amount of sleep each night, eg during pregnancy, following over-exertion or when living with or recovering from illness.
The expert consensus is that sleeping more than nine hours per night on a regular basis may be appropriate for young adults, individuals recovering from sleep debt, and individuals with illnesses (Consensus, 2015).
The causes of poor sleep
Employees should understand that poor sleep most commonly develops for no apparent reason (primary insomnia). It is important to explain that insomnia may be associated with a medical condition (secondary insomnia) eg pain, leg cramps, breathlessness, hot flushes, anxiety, depression or sleep apnoea. If someone has a medical condition which affects their sleep they should be advised to discuss this with their GP.
Health professionals should advise people with insomnia to:
- Establish fixed times for going to bed and waking up (and avoid sleeping in after a poor night’s sleep).
- Try to relax before going to bed.
- Maintain a comfortable sleeping environment: not too hot, cold, noisy, or bright.
- Avoid napping during the day.
- Avoid caffeine, nicotine and alcohol within six hours of going to bed.
- Consider complete elimination of caffeine from the diet.
- Avoid exercise within four hours of bedtime (although exercise earlier in the day is beneficial).
- Avoid eating a heavy meal late at night.
- Avoid watching or checking the clock throughout the night.
- Only use the bedroom for sleep and sexual activity.
Source: National Institute for Health and Care Excellence
The National Institute for Health and Care Excellence (NICE) provides a comprehensive list of the causes of secondary insomnia for health professionals (NICE, 2015).
Occupational causes of poor sleep
Where occupational health professionals can add distinctive value is in identifying and assisting with occupational factors that interfere with sleep. These will be familiar to readers, eg shift work, occupational stressors, or getting stuck in traffic commuting to work.
Working in a global business might mean that people sometimes participate in virtual meetings out of normal local business hours and they may travel across times zones. Staying in hotels, getting used to strange beds and adjusting to different time zones all make it more difficult to sleep normally.
Business travellers and those who work from home might use laptop computers, tablets or smart phones late at night (as might domestic users). Intrinsically photosensitive retinal ganglion cells involved in the modulation of circadian rhythm are most sensitive to short wavelength (blue) light (LeGates, 2014).
Light emitting diodes used in energy saving bulbs, TV and computer screens and handheld electronic devices (tablets, readers and smartphones) have peak emissions in the blue light range (400-490 nm) ie the type of light likely to cause the most disruption to sleep as it most effectively suppresses melatonin and increases alertness (Gringras, 2015; Tosini, 2016). It has been shown recently that use of smartphones at night may negatively influence sleep even without changes in serum melatonin (Heo, 2017).
The effects of poor sleep
Employees should be informed that while an occasional night without sleep will make them feel tired and irritable the next day; several sleepless nights makes it more difficult to concentrate and make decisions.
All employees, but especially those engaged in safety-sensitive work, should be made aware that they are at increased risk of making errors that may lead to accidents at home, at work and on the road.
Employees should be encouraged to report any such problems to their supervisor, manager or occupational health professional. Managers may need to be reminded of their duty of care, not only for the health, safety and wellbeing of the individual worker, but also for others who might be at risk where there are concerns about an employee’s fitness for duties.
Employees who suffer from sleep problems should be made aware of self help techniques. While there is insufficient evidence to assess the effectiveness of sleep hygiene as a single intervention, its use is widely supported by expert opinion (NICE, 2015).
Likewise the evidence for daytime physical activity is variable, but most studies report that it improves sleep quality or duration, the evidence being strongest in middle-aged and older adults, especially in those suffering from disease (Dolezal, 2017).
NICE defines the advice that health professionals should give regarding good sleep hygiene in order to make people aware of factors that may negatively or positively affect sleep (see panel). NHS Choices provides a lay version of ten helpful tips for a more restful night at:
Additional tips for shift workers
The Health and Safety Executive (HSE() has a webpage ‘Hints and tips for shift-workers’ which can be a useful resource for employees who work shifts. http://www.hse.gov.uk/humanfactors/topics/shift-workers.htm Of course, proper shift design is the highest priority.
Although the quality of studies varies, results generally support the benefits of rapid forward rotating shifts, simultaneous use of timed bright light, and physical activity, healthy diet and health promotion (Neil-Sztramko, 2014).
Additional tips for business travellers
Advise travellers to plan ahead and avoid leaving things to the last minute in order to reduce stress. Advise on sleep kits eg ear plugs, sleep masks, favourite soothing music.
For longer stays recommend employees book a suite to avoid using the bedroom for work, eating or watching television. While it may not be common practice among many employers, travellers crossing several time zones should arrive at least a day before meetings to adjust, at least to some extent, to the time difference.
When checking in to the hotel, travellers should ask for a room away from the bar, or restaurant. A common cause of waking up in a hotel (apart from the bowels still being on home time) is the alarm clock being set to go off at some unearthly hour by the previous occupant who needed to catch a red-eye flight, so remind travellers to check the alarm before going to bed.
Employees, especially business travellers and those who work from home, should be advised that daylight modulates the body’s biological clock and sleep-wake cycle. The light emitted from energy saving bulbs, laptops and handheld electronic devices has the same effect. They should be advised that prior to bedtime it is best to avoid bright light, sitting too close to the TV or using computers and handheld devices.
Seeking help for sleep problems
Employees should understand the arrangements at work for them to access occupational health care, the services provided and how to arrange a consultation.
Where there is no obvious and remediable occupational cause people who are concerned they are sleeping too little or too much should be advised to consult their GP (Consensus, 2015).
For secondary insomnia the most consistently identified risk factors for sleep disturbances are depressed mood and physical illnesses (Smagula, 2016). Sleep disturbances may also worsen depression and some physical illnesses. (Smagula, 2016).
The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness and indicates to patients when it might be appropriate to seek medical help. It is designed to be self-completed and may be downloaded from the internet.
Occupational health professionals may be asked for advice about sleeping tablets, especially by business travellers and shift workers. Observational studies suggest an association of hypnotics with driving impairment and infrequent but serious harm including cognitive and behavioural changes, (Brasure, 2015).
Employees should be advised of the risks associated with sleeping tablets, eg daytime drowsiness affecting their ability to drive or to operate machinery, as well as the risk of tolerance and dependence from use for more than just a week or so.
We should remember that employees can buy sedating antihistamines over the counter and caution about the risk of drowsiness.
For Valerian and other herbal remedies that can be purchased in health food shops there is very little evidence to show that they work. A previous article in this journal warned about the significant risks of internet purchases of the prescription-only wakefulness drug Modafinil, particularly when used for unlicensed indications (Nicholson, 2017).
In this internet age some employees may have researched melatonin – or an international colleague may have recommended it. Possibly the most practical advice that occupational health professionals can provide is that melatonin is an unregulated product that has a small impact on sleep latency and can produce residual sedation (Schroek, 2016).
Managing sleep problems
When an employee reports sleep problems at work the OH practitioner should, in addition to asking about their work, enquire about any other identifiable causes of insomnia, referring to NICE guidance (NICE, 2015).
The practitioner should also provide advice to the employee in relation to managing the problem, and if necessary, their fitness for their job and any workplace assessments or work restrictions that may be appropriate, until they feel recovered. It may also be appropriate to advise the person not to drive to and from work if they feel sleepy.
NICE recommends that for long-term insomnia, ie lasting more than four weeks, GPs should refer patients to psychological services for a behavioural or cognitive intervention. Of course, where the cause is confirmed to be work the employer should consider providing this.
Cognitive behavioural therapy
Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment for adults with persistent insomnia and has clinically meaningful effect sizes (Trauer, 2015).
CBT-I addresses underlying problems without the risks of medication (Reynolds, 2017). It aims to examine and change the individual’s beliefs and attitudes about insomnia and is combined with a behavioural intervention (NICE, 2015).
Digital platforms for delivering CBT-I (Luik, 2017) including internet-based CBT-I (Seyffert, 2016) are also effective in improving sleep in adults with insomnia.
There is insufficient evidence for or against the use of complementary therapies, although such interventions are unlikely to do harm, and in some people may exert a placebo effect.
Systematic reviews thus far indicate that there is low evidence of no effect or insufficient evidence of any effect of meditation programmes on sleep (Goyal, 2014). There is mixed evidence for older adults for the effect of yoga (Patel, 2012), and weak evidence that Tai Chi exercise has a beneficial effect on self-rated sleep quality (Du, 2015).
There is some evidence that inhalation of essential oil vapour may be considered for people with mild sleep disturbances. A review reported that the majority of studies suggested a positive effect without adverse effects, lavender being the most frequently studied oil. However, further larger and more robust studies are needed (Lillehei, 2014).
Sleep problems are commonplace in the general population and among working populations. Performance at work can be impaired in employees who have sleep problems, making the common problem a concern for employees and employers alike.
Employers need to be aware of the occupational causes and should assess and manage risks to avoid employees being fatigued at work. Given the potential impact on the business there is also a good case for employers to facilitate workplace sleep education programmes and provide access to occupational health services for further support.
Dr Paul J Nicholson is an occupational physician.
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