The role of sleep in ensuring optimal patient care

“Sleep that knits up the ravelled sleeve of care. The death of each day's life, sore labour's bath, balm of hurt minds, great nature's second course, chief nourisher in life's feast.”

Those of you who regularly feel the pangs of sleep loss will identify with this quote from Macbeth by William Shakespeare.

Sleep enhances brain function, elevates moods, and maintains your overall health. Chronic sleep deficiency is linked to an increased risk of various conditions, including heart disease, stroke, obesity, and cognitive impairments like dementia. Long hours and high-stress levels make sleep deprivation among healthcare workers a global concern, and its effects impact professionals in every corner of the world. It can cause 36% more serious medical errors, and sleep-deprived healthcare workers commit five times more serious diagnostic errors. An article on Sleep and Safety among Healthcare Workers contends they experience 61% more needlestick/ sharps injuries after their 20th consecutive hour of work.

Insufficient sleep poses serious risks not only to patient safety but also to the health of medical practitioners. Evidence shows a clear link between sleep deprivation and an increased risk of conditions such as heart disease, obesity, diabetes, cardiovascular disease, and weakened immune response. The medical profession often underplays this issue, sometimes even romanticising the self-sacrificing nature of healthcare workers. There's an ingrained belief that doctors and nurses should endure exhaustive shifts, prioritising patient care at the expense of their own health—a mindset that equates fatigue with dedication. This can create a false sense of unity in enduring unsustainable working conditions.

Healthcare professionals must prioritise sleep to maintain their health, reduce errors, and prevent burnout. However, in a culture that often expects sleeplessness and demands erratic schedules, finding time to rest can feel unattainable. It's important that the medical sector shifts its perspective to recognise sleep as a fundamental aspect of wellness and begin advocating for systematic changes that allow for adequate rest for its workforce.

Understanding the science of sleep

Sleep is vital to wellbeing, but it’s only in the last fifteen years that research findings have been measurable and the importance of sleep truly understood. Medical schools, on average, only spend 2.5 hours teaching prospective medical professionals about sleep. While science doesn’t truly yet understand the full range of functions that occur, there is research that shows during sleep:

• Toxins are removed from your brain
• Short-term memories are converted into long-term memories
• Pulse and blood pressure lower during non-REM sleep, giving heart and blood vessels a chance to rest
• The hunger hormone ghrelin decreases
• Immune cells work harder

There are four stages of sleep. These stages cycle throughout the night, lasting 90-120 minutes.

• Stage 1 NREM Non-Rapid Eye Movement: This is a light sleep while waking up or falling asleep. Muscles relax, heart rate lowers, and breathing and brain waves slow.
• Stage 2 NREM: This is a deeper sleep, as everything slows down. This is the longest part of the sleep cycle.
• Stage 3 NREM: This is the part of sleep needed to feel refreshed the following day. All body functions are at their lowest levels, and the body is as relaxed as possible.
• Stage 4 REM Rapid Eye Movement: This is the dream stage, where the eyes may move under closed eyelids. The arms and legs are paralysed to prevent the sleeper from becoming physically active in response to dreams. The time spent in REM sleep increases throughout the night. It’s theorised that memory consolidation happens here.

The pace of research into sleep has tripled since 2005. As technology evolves, researchers can probe into the cellular and subcellular effects of sleep and the flow-on effects on a huge range of functions. Maybe soon, researchers can confidently understand the function of sleep, what happens to bodies at rest, and the impact that sleep deprivation has.

Sleep deprivation: Effects on the mind and body

While sleep processes are not fully understood, scientists can measure the outcomes from lack of sleep. The Institute of Medicine’s year 2000 report, To Err Is Human, estimated that up to 98,000 deaths occur every year in the US due to medical errors. Long work hours and extended shifts contribute to this.

Perhaps the most famous of cases was the 1989 death of 18-year-old Libby Zion in New York. The hearings after her death noted the junior resident treating her had already been working 18 hours, long after peak cognition and decision-making skills had degraded.

A loss of two hours of sleep is equivalent to a 0.045% breath-alcohol concentration, and a loss of four hours is equivalent to a 0.095% breath-alcohol concentration. This research suggests that if a doctor shouldn’t be working drunk, then they should not be working while sleep-deprived.

Impaired decision making

Sleep-restricted people may show increased risk-taking behaviour and exhibit problems making reasoned choices while not considering the complete situation. Sleep deficits impair planning, problem-solving, and coping skills. In particular, situations where creative or complex solutions are required are affected the most.

Dr Christopher Landrigan, an associate professor at Harvard Medical School, recalled working a 36-hour shift in an ICU where a nurse woke him to advise that a nine-year-old girl was deteriorating rapidly. Landrigan, dazed and confused, started brushing his teeth. Luckily, another doctor put the girl on a ventilator, saving her life.

Variability and low mood

Irritability, low frustration tolerance, sadness, and nervousness were all found to be a result of sleep restriction. In an ER setting, emotions are heightened, and there can be a wide range of variables across patients, systems, and other staff that contribute to this. Being able to realise and regulate emotions helps to guard against negative influences on clinical decision-making.

Slowed and inaccurate reflexes

Insufficient sleep, equivalent to 5.6 hours of sleep in a 24-hour period, has been shown to double neurobehavioral reaction time. Two studies found that surgical residents who were sleep-deprived made twice as many errors in simulated laparoscopic surgery.

Burnout

There’s a cyclical correlation between burnout and sleep disorders. A study in nurses showed the higher the burnout, the higher the level of sleep disorders. Physicians in another study showed that sleep impairment resulted in lower levels of professional fulfilment and increased burnout. More than half of physicians in the US self-report burnout, making this a priority to address.

Poor health

Altruistic by nature, medical professionals sometimes put patient needs before considering their own health. But causal relationships between lack of sleep and some physical disorders include:

• Cardiovascular disease
• Increased susceptibility to infectious illness
• Hypertension
• Diabetes type 2
• Obesity
• Migraines
• Cancer, especially breast cancer

Sleep’s role in patient care

One study found that sleep and fatigue were implicated in a 300% increase in medical errors resulting in patient deaths. Another study reported residents who had self-reported falling asleep while talking to patients. While the outcome of poor sleep can contribute to death in patients, it also means errors in diagnosis, treatment, medication, and a loss of trust in the medical system.

A research study administered a Multiple Sleep Latency Test (MSLT), a measure of sleepiness during the day, to residents. When the residents were asked if they had fallen asleep during the test, 68% of those who thought they had stayed awake had actually fallen asleep during their shifts.

Rested health professionals offer better quality care. Studies have shown that implementing work-hour legislation resulted in a decrease in deaths in US hospitals. A maximum shift of 16 hours, with a maximum of 61 hours worked per week rather than the traditional 77 to 81 hours, results in residents making half the number of failures of attention at work.

The challenge for healthcare professionals

Sleep deprivation was a major cause of Three Mile Island, Chernobyl, and the Exxon-Valdez oil spill. Maximum working hours have been specified for pilots, truck drivers, and marine operators.

Yet, such regulations are glaringly absent in the healthcare sector, where sleep deprivation is pervasive, fueled not only by lengthy shifts but also by the stressful and sometimes traumatic nature of medical work which itself can disrupt sleep patterns. It begs the question: isn't it time for medical professionals to receive the same consideration for rest?

The healthcare industry is besieged with contributors to sleep deprivation:

• High patient burden and long working hours. Long hours enable doctors to see the evolution of an illness and retain continuity of care, and this becomes an excuse for long shifts
• Trauma and distress that hinder the ability to sleep
• Normalised attitude towards sleep deprivation starting at medical school
• Shift work that requires people operating outside normal circadian rhythms
• Poor handover practices with inadequate information shared, which harms the patients and perpetuates the myth that longer working hours are somehow better for patient wellbeing
• Emergencies which require long hours and irregular periods of work
• The overworked, sleep-deprived hero doctor is a glamourised archetype seen in movies and TV. William Halstead, the first chief of surgery at Johns Hopkins, required his residents to be on call 362 days a year. He used cocaine and morphine to maintain his work ethic and level of patient care.

How much sleep should adults be getting? Research findings indicate that when sleep drops below seven hours in a 24-hour period, problems start to creep in. The average adult should be aiming for between seven and seven and a half hours.

A culture change is required in medicine. But individuals can do a range of things to improve their sleep practices:

• Where possible around shifts keep regular bedtimes and wakeup times
• The bedroom should only be for sleep; no working, no TV, no eating
• Mental relaxation techniques can be helpful, especially when the medical professional is on call and has a sleep opportunity. Apps like Calm and HeadSpace can help here.
• Alcohol, nicotine, and caffeine need to be used wisely so they don’t affect sleep routines. Caffeine can be timed to boost alertness at appropriate times and should be avoided before sleep.
• 30-minutes of exercise or a brisk walk helps sleep, but it must be at least three hours before bedtime as it inhibits the sleep initiation process
• The use of modafinil or other stimulants does not replace the benefits of sleep, and medications are only short-term treatments to avoid dependence
• Use days off to catch up on sleep
• Chronic insomniacs may benefit from CBD. CBD, if legal in your country or state, may be effective for helping relax before sleep
• Melatonin can be useful in the short term, but long-term use can alter natural melatonin production
• Hyptnotherapy can be a great way to reset neural pathways and foster good sleeping patterns.

Some resources on sleep include:

• Why We Sleep: The New Science of Sleep and Dreams by Matthew Walker
• White Noise, a sleep medicine podcast
• Talking Sleep – An AASM Podcast
• Sleeping with Science - A TED Series

Napping: A short-term solution

Power naps can be extremely beneficial for medical professionals. The optimal length is 45 minutes for a short nap and two hours for a long nap. This is to avoid the slow-wave sleep stage, which starts after 45 minutes and lasts 90 minutes—waking up in slow-wave sleep results in grogginess and disorientation, known as sleep inertia. It is impossible to predict when someone will be needed in a healthcare emergency setting, so having set times for naps is very useful. While some circumstances don’t allow for naps, it can be made workable in a team. Members can relieve each other to nap. The use of naps requires a shift in attitude; there’s a belief that napping is for old and ill people. However, hospitals that have implemented napping strategies have shown benefits in staff wellness.

Hospitals and clinics: Steps towards change

Because of the systematic attitudes and expectations of medical staff, employers must lead the way in enabling better sleep. This can be done in a few different ways.

• Using warmer lights in hospitals during night shifts to help foster a sense of relaxation (this will also help patients get better sleep)
• Smaller numbers of patients for doctors by hiring ‘hospitalists’. This improves the quality of care and lowers the stay length for patients
• Thoughtful structure of night shifts to allow for micronaps
• Sleep spaces that allow for comfortable and quiet naps
• Optimal schedules using circadian principles. Shifts should not exceed 17 hours. Rest periods of 10 hours allow for the best recovery sleep. At least one full day off a week to allow physiological recovery, especially for night shift workers
• Better handover procedures so patient information is communicated well. A trial at a children’s hospital using computer-generated patient summaries and a structured handoff resulted in a 40% decrease in medical errors.

The impact of good sleep is hugely positive

Adequate sleep is fundamental to a doctor's wellbeing. It contributes to improved mental sharpness, emotional balance, and physical health. Without proper rest, doctors face increased risks of burnout, clinical errors, and personal health crises. Sleep recharges the brain, heals the body, and fortifies the spirit, enabling physicians to provide the highest standard of care.

Prioritising sleep is not an indulgence—it’s an important aspect of medical professionalism and patient safety. Encouraging a culture that respects sleep is imperative in maintaining a sustainable healthcare system where doctors can thrive professionally and personally.

Sleep is a vital part of the puzzle in improving medical systems and people’s lives. Individuals can take steps to manage their sleep better, working within the limitations of their roles and family demands.

On a wider scale, organisations and workplaces need to recognise the importance of sleep and start prioritising it, not only as a wellness concern but also as an occupational safety and health consideration. Hospitals where limited working hours are implemented, and sleep is encouraged have experienced positive outcomes. Changing the industry and systems will take time, resulting in better patient health outcomes and improved physician wellness.

This article aims to shed light on sleep challenges facing healthcare, acknowledging systemic roots. Despite these hurdles, we hope we have offered insights to enhance your sleep quality during off-duty hours for improved health and wellbeing.