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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 75-80

Rotating shift work, sleep, and accidents related to sleepiness in doctors


1 Research Associate at Vidya Cancer Hospital, Gwalior, India
2 Departments of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission04-Apr-2021
Date of Decision15-May-2021
Date of Acceptance20-May-2021
Date of Web Publication25-Aug-2021

Correspondence Address:
Kumar Gaurav Chhabra
Associate Professor and Head, Department of Public Health Dentistry Sharad Pawar Dental College and Hospital, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcdoh.jpcdoh_14_21

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  Abstract 


Background: Rotating shift work refers to a way of organizing daily working hours in which different persons or teams work in succession to cover more than the usual 8 h per day, up to and including the whole 24 h. Studies have been conducted for examining the effects of rotating shifts on an employee's performance and well-being. Hence, the aim of the present study was to evaluate the effect of rotating shift work, sleep, and accidents related to sleepiness in doctors. Methodology: A cross-sectional study was conducted on doctors of a Tertiary Care Hospital. A close-ended questionnaire containing 25 questions was distributed to doctors (residents and interns) who worked rotating shifts. Questions presented were regarding sleep disturbances, sleeping aids or countermeasures to get to sleep; and accidents or errors in the past year including automobile accidents and medical and procedural errors that the doctors had reported to have occurred because of sleepiness due to rotating shifts. The data collected were analyzed by SPSS version 21 (SPSS statistics IBM Corporation). Results: Doctors reporting to night shifts suffered from decreased and disturbed sleep, irritability, fatigue, and poor reflexes. According to our study, almost all the subjects suffered from poor work and sleep quality due to their changing work shifts. Conclusion: Rotating work shifts have a direct effect on workability and quality and amount of sleep in doctors.

Keywords: Doctor, fatigue, health behavior, hospital, rotating shift work, work schedule, working hours


How to cite this article:
Deolia S, Chhabra KG, Nimbhorkar GS, Pachuau CL, Yangad AS, Nimbulkar G, Basu SS. Rotating shift work, sleep, and accidents related to sleepiness in doctors. J Prim Care Dent Oral Health 2021;2:75-80

How to cite this URL:
Deolia S, Chhabra KG, Nimbhorkar GS, Pachuau CL, Yangad AS, Nimbulkar G, Basu SS. Rotating shift work, sleep, and accidents related to sleepiness in doctors. J Prim Care Dent Oral Health [serial online] 2021 [cited 2021 Oct 24];2:75-80. Available from: http://www.jpcdoh.org/text.asp?2021/2/3/75/324535




  Introduction Top


”Shift work” is essentially a work schedule involving irregular or unusual hours, compared to those of a regular daytime work schedule. It is a pattern of work outside the standard working day and week, usually associated with hospital practices, in which one employee replaces another in the same role within a 24-h period. It is not unusual for institutions to have work schedules which include rotating shifts.[1] Many operations in a hospital are not economically viable or are simply impossible to run without relying on round-the-clock monitoring thus making it essential for them to rely heavily on rotating shifts.[2],[3] Shifts can either be fixed or rotating including 2 shift or 3 shift systems. Continual shift systems provide cover for 24 h, 7 days a week while intermittent shift systems provide cover for less than the total hours available in a week.[2] Unwanted and unpleasant consequences in relation to loss of well-being both medically and socially have been a suggested outcome of shift work.[4]

Junior doctors enthusiastically undertake duties that necessitate working continuously on consecutive days, typically with reduced or no sleep, which may occur twice a week or more, despite being aware of the accumulated mass of evidence and opinion regarding the medical and social deleteriousness of shift work.[5] The resulting unwanted effects on performance and well-being have been attributed to disturbance of circadian rhythms and normal sleep patterns.[4] Several studies have also shown that chronic stress exerts a general immunosuppressive effect that suppresses or withholds the body's ability to initiate a prompt, efficient immune reaction.

Studies have been attempted to link changes in mental efficiency to circadian changes and body temperature in both, normal cycles and shift-work disturbed cycles of activity and rest.[6] Several reports have been made on sleep disturbance and consequent loss of sleep upon shift-working. The effects on circadian rhythms and sleep patterns of shift-work appear to be attenuated when adaptation to shift-work is allowed through a sufficiently long period of work on one shift. Thus adverse effects of shift work rotas may be due to the lack of opportunity for adaptation of circadian rhythms and sleep patterns to occur. Studies suggested that a rotating shift-work system is more likely to lead to lower performance efficiency and loss of well-being when weighed against a stabilized shift-work system.[4]

Generally, the sequence of responses to increasing sleep loss begins from mood changes to cognitive effects finally causing performance deficits. Cognitive ability is the capacity to perform higher mental processes, reasoning, remembering, understanding, and problem-solving.[4] Cognitive function change throughout one's life and the change can be physiological or pathological occurring in one/more multiple cognitive domains.[7] The proposition that sleep loss exerts a significant effect on cognitive-energy supplies is based on evidence suggesting that sleep loss, totally or partially, results in impaired performance on cognitive tests requiring self-regulation, such as psychomotor tasks, and in a significant decrease in subjective assessment of energy levels. Moreover, the risks to patients increase when errors are made by tired doctors, who lack dexterity in making accurate decisions due to sluggish cognitive functions.[5] Surgeons operating after a disturbed night's sleep display lower levels of performance, as do hospital residents performing psychomotor tasks after being on call the previous night.[8] There is an extensive amount of literature indicating that sleep loss results in elevated subjective sleepiness, fatigue, and confusion lasting until the next day.[9] This provides strong support for the proposition that sleep loss affects cognitive-energy supplies.

Another growing concern is stress caused by lack of sleep and increased work schedule. Students these days turn a blind eye towards existing stress which may be the harbinger of serious mental and psychosocial problems.[10] Furthermore, longer study hours and extended time required to complete the professional degree, along with greater expectations from parents of the same background serving as role models, pose a greater degree of pressure on medical and nursing students resulting in stress and sleep loss which in turn affects their psyche.[10] This may result in hypertension among young doctors. Prehypertensive group have also been evidence for an exaggerated BP response to exercise stress testing. Studies have also found that there is a strong correlation between Prehypertension and body mass index, waist–hip ratio, and waist circumference suggesting a positive correlation between obesity and prehypertension.[11] Prehypertension is also associated with metabolic, inflammatory, and cardiovascular risk profiles.[12]

In several other cases, this might also result in mental disorders or maladjustments for which psychotherapy is used as a psychological technique.[13] The personal lives of the doctors are also compromised, which leads to psychiatric problems, alcohol or substance abuse to combat existing stress and depression, etc.[4],[14] The fate of many lives is in the hands of doctors and substance dependence in this profession is of major concern.[15] Nicotine dependence nowadays, is widely recognized as a chronic relapsing disease, which is characterized by craving and feeling the need of tobacco, and increased quantity of withdrawal symptoms during periods of abstinence.[7] Vincent and Roscenstock found that before hospitalization, patients with psychiatric disorders had suffered more stressful events have those with physical disorders.[16]

Change in sleep pattern in the form of either excessive sleep or having difficulty to sleep at night, getting irritated very frequently, losing temper, overreacting on little things, forgetfulness, poor concentration, feeling restless and tired most of the time, and change in eating pattern; losing appetite or eating a lot more are all symptoms of depression.[14] Denial of depression poses as another major issue. A study conducted by Pollack evaluated six areas of informational needs (self-management, understanding, managements of daily life, living in society, relating to others, and relating to self) of patients with bipolar disorder and found that denial of the disorder was the most prevalent obstacle in its management.[17] In some cases, alcohol or substance abuse occurs to combat existing stress and depression follows. In other cases, depression may present as a response to stress first and people try drugs (substance abuse) as a method to escape it. Hence, to deal with these upcoming struggles, it is very important that we talk about it more often.[14]

Since night shift sleepiness affects a large majority of the individuals engaged in it, the threat is quite real and has probably been underestimated in the past.[18]


  Methodology Top


A cross-sectional, observational study was conducted on doctors of Datta Meghe Institute of Medical Sciences. The purpose of the study was to evaluate the effect of rotating shift work, sleep, and accidents related to sleepiness in doctors.

The study was explained to and written consent was taken from the individuals who were willing to participate in the study. The questionnaire was self-administered and closed-ended. The study was approved by the institutional ethical committee following which it was conducted on interns and doctors ranging from age 22–35 years working in Acharya Vinoba Bhave Rural Hospital, Sawangi (M), Wardha. Data collection of the study was done from December 2018 to February 2019.

Before commencing the study, a pilot study was conducted to check the reliability and validity of the questionnaire on the sample size of 30 participants in November 2018.

Doctors who did not work rotating shifts or wish to be part of the study or were on leave were excluded from the study. Participants were doctors posted in Tertiary Care Hospital in a rural locality (residents and interns) who worked rotating shifts. A convenience sample of 300 participants was recruited.

Data was collected by all researchers, who provided instructions on how to fill the questionnaire and clarifying doubts regarding the questions before the working time. The test environment was similar for all the participants. A time period of 10–12 min was given to each participant to fill out the questionnaire, to reduce reporting bias.

The questionnaire contained 25 close-ended questions in the English language and was given to the doctors and interns. It collected information about the demographic details (name, age, and gender), specialization, and type of shift. Questions presented were regarding sleep disturbances, prescription or nonprescription medication, sleeping aids, or other kinds of drugs to get to sleep; nodding off at work or while driving to or from work in the past year; and accidents, errors, and “near-miss” accidents in the past year including automobile accidents, medication errors, on-the-job procedural errors, and on-the-job personal injuries that the doctors had reported of due to sleepiness caused by rotating shifts.

The questionnaire included questions such as the amount of times/for how long in a month they had night shifts and the options given were, for half of a week, half of a month, every alternate day or random (depending upon emergencies); hours of comfortable sleep on usual days with options, 4–5 h, 6–8 h, 8–10 h or more than 10 h; whether they felt tired the whole day due to less sleep or if they had ever injured themselves at their workplace due to lack of sleep, with options of always, sometimes or never, what measures they took to wake themselves up from feeling drowsy, with options caffeinated beverages, physical exercise, medication (eye drops, tablets, etc) or no measures taken and how does lack of sleep affect their daily routine. The likert scale was used for certain questions. Data entry was done followed by statistical analysis to achieve the end result. Analysis was done using the Chi-square test by IBM Statistical Package for Social Sciences (Statistics for Windows, Version 16.0. Armonk, NY: IBM Corp.).

The total number of positive responses was calculated and significant differences in values were noted. The results obtained were tallied with similar older studies and sleep patterns, disturbances in sleep, etc. were evaluated.


  Results Top


The participants were 300 doctors, including residents and interns of age group ranging from 22 to 35 years, out of which 46% were males and 54%females. While 164 (54.7%) were posted in the day shift and 136 (45.3%) were posted in the night shift.

In frequency distribution of different hours of sleep [Table 1], the Chi-square value and P value in day shift was 7.189, 0.066, respectively, similarly for night shift 10.664,0.014, respectively, and for days off, 3.156 and 0.368, respectively.
Table 1: Frequency distribution of hours of sleep on day shift, night shift and days off

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As shown in [Table 1], out of 24 h, 198 doctors out of 300 were able to get 6–7 h sleep on a day shift, 135 doctors out of 300 slept for 4–5 h on night shift, while 178 doctors slept for 8–10 h on a day off. Here, we saw a significant difference which was marked during night shift.

According to [Table 2], out of 300, a total of 204 doctors from a day off reported very good quality of sleep, 218 doctors from day shift reported good quality of sleep, whereas, from night shift, 177 doctors reported to have experienced bad quality of sleep.
Table 2: Frequency distribution of quality of sleep on day shift, night shift and on days off

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Furthermore, we observed that rotating shift work affected more doctors during night shift. A total of 141 doctors reported to have been less vigilant during night shifts, wherein a significant difference was noted. While 128 reported to have suffered from fatigue due to changing work shifts, and 153 participants observed a change in their eating habits and schedules with no significant difference [Table 3].
Table 3: Frequency distribution of effect of rotating shift on doctors' health and daily routine

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In addition, [Table 4] suggested rotating shift work to have affected the work and surroundings of the doctors especially more during the night shift, 135 doctors out of 300 felt their work pace slowing due to lack of sleep, while 139 doctors observed the performance of the working team going down, similarly 111 doctors noted that people surrounding them were negatively affected due to their working shift, all of which resulted in a significant difference.
Table 4: Problems Associated with Sleeplessness

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Coming to [Table 5], we saw that symptoms and problems faced by the highest number of doctors due to lack of sleep in the day shift (58 doctors) were lack of interest in work, and in night shift (46 doctors) was irritability, which did not result in a significant difference.
Table 5: Frequency distribution of symptoms and problems faced due to lack of sleep

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Moreover, in [Table 6], a significant difference was noted as the highest number of doctors i.e. 88 doctors, reported of being called for emergency management at random hours during the night (sleep hours) in their respective field of specialization.
Table 6: Frequency distribution of emergency management call in the participants' field of specialization during night/sleep hours

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According to [Table 7], maximum people working in rotating shifts tended to use caffeinated beverages to prevent drowsiness and stay awake during work hours.
Table 7: Difference between categories of work shifts in using various measures to prevent sleep/drowsiness

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[Table 8] suggested that while very less doctors reported any serious automobile accidents or caused any medication errors due to sleepiness, still a high number of them agreed to have made procedural errors on the job or have suffered from personal injuries due to sleepiness caused by rotating work shifts.
Table 8: Frequency distribution for categories of work schedules of accidents and errors by doctors in different work shifts

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  Discussion Top


Shift work is associated with impaired alertness and performance due to sleep loss and circadian misalignment.[19] Various work schedules include rotating shift work. The present study was done to assess the effect of rotating shifts on doctors and the accidents caused by sleepiness.

In the present study 177 (59%) doctors reported bad quality of sleep which was in accord with the study conducted by Ganesan et al. which demonstrated that in intensive care workers, the duration of sleep and wake between shifts was significantly affected due to alternating between different shift types.[19] A similar study conducted by Wali et al. presented that more than 87% of the participants slept for 5 h or less while working an on-call shift resembling in the current study which suggested (45%) of participants could get sleep for about 4-5 h during a night shift.[20] Contrary to this, in another study conducted on Icelandic nurses by Sveinsdóttir, not much disruption in the quality or length of sleep was reported. However, a plausible explanation was provided on a closer look at the Icelandic context. Here, all the workers were supposed to have a minimum of 11 h rest period between shifts as stated by the European Working Time Directive, which is effective in Iceland.

Furthermore, in the present study, a total of 244 (81.3%) doctors suffered from gastrointestinal disorder and 24.3% suffered musculoskeletal distress due to working in the night shift, which was in contrast with the study conducted by Sveinsdóttir. This might have been due to changes in food quality and composition fatigue because of changing work shifts respectively.[21]

It was also observed that caffeinated beverages were most commonly used by participants (44.8%) over other measures to alleviate sleepiness during work hours, especially during night shifts as they have a short onset time of 15–30 min effective for 3–4 h, which again was in accord with the study of Ganesan et al.[19],[22]

Our results showed that 46 (34.3%) participants complained irritability, 37 (27.6%) complained of loss of interest in work during the night shift, 45% of doctors felt their work pace slowing and their team performance dropped due to lack of sleep. 76.5% also agreed to have made procedural errors on the job or suffered from personal injuries due to sleepiness caused by rotating work shifts. Similar results were obtained in the study conducted by Gold et al. wherein sleep deprivation due to rotating shift work lead to increased reaction time and frequent lapses of attention, leading to increased error rates in performance.[23] This was also in accord with a study conducted by Akerstedt where the results clearly demonstrated that shift work was associated with increased subjective, behavioral, and physiological sleepiness. These effects were particularly pronounced during the night shift and would cause actual incidents of falling asleep at work resulting in hazards endangering human lives and large socioeconomic consequences.[18]

Serious automobile accidents or medication errors due to sleepiness were reported by 24 (17.9%) number of doctors in the present study due to sleepiness, while in a Japanese study, participants reported no accidents and errors while working and driving caused by rotating shifts or night shifts. However, this might have been because the target group of nurses in their study worked under a three-shift working system, unlike in the current scenario wherein the doctors worked on a two-shift system.[24]

Limitations

The findings of the present cross-sectional study may have been influenced by the reporting bias although the option of anonymity was provided to all participants. Furthermore, only doctors were included in this study, whereas, it could have presented with a more varied range of results if we had included other hospital staff working night shifts as well.


  Conclusion Top


This study demonstrated that alternating between different shift types had a significant effect on the duration of sleep and wake between shifts in intensive care workers (doctors). A variety of countermeasures can be adopted concerning additional rest breaks for meals and naps, early morning shifts after night shift work, supplementary rest days, and periodic transfers to improve recovery may be implemented to reduce the hazards of shift work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Nary FC, Santos RD, Laurinavicius AG, Conceição RD, Carvalho JA. Relevance of prehypertension as a diagnostic category in asymptomatic adults. Einstein (Sao Paulo) 2013;11:303-9.  Back to cited text no. 12
    
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Tendolkar V, Sarode R. Knowledge about ill effects of alcoholism and drug dependence: A survey among drivers. J Datta Meghe Inst Med Sci Univ 2012;7:105-9.  Back to cited text no. 15
    
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Ganesan S, Magee M, Stone JE, Mulhall MD, Collins A, Howard ME, et al. The impact of shift work on sleep, alertness and performance in healthcare workers. Sci Rep 2019;9:4635.  Back to cited text no. 19
    
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Wali SO, Qutah K, Abushanab L, Basamh R, Abushanab J, Krayem A. Effect of on-call-related sleep deprivation on physicians' mood and alertness. Ann Thorac Med 2013;8:22-7.  Back to cited text no. 20
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Sveinsdóttir H. Self-assessed quality of sleep, occupational health, working environment, illness experience and job satisfaction of female nurses working different combination of shifts. Scand J Caring Sci 2006;20:229-37.  Back to cited text no. 21
    
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Howard SK. Sleep deprivation and physician performance: Why should I care? Proc (Bayl Univ Med Cent) 2005;18:108-12.  Back to cited text no. 22
    
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Gold DR, Rogacz S, Bock N, Tosteson TD, Baum TM, Speizer FE, et al. Rotating shift work, sleep, and accidents relatedto sleepiness in hospital nurses. Am J Public 1992;82:1011-4.  Back to cited text no. 23
    
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Arimura M, Imai M, Okawa M, Fujimura T, Yamada N. Sleep, mental health status, and medical errors among hospital nurses in Japan. Ind Health 2010;48:811-7.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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