Episode 54: Sleep in Healthcare Workers

Healthcare workers often have to work shifts that can incorporate long hours and working at times they would normally be sleeping. This can lead to fatigue, sleep difficulties and impact health and performance. To understand these factors and how research is working towards finding solutions we interview Dr Julia Stone of Monash University.

Dr Moira Junge (Health Psychologist) and Dr David Cunnington (Sleep Physician) host the monthly podcast, Sleep Talk – Talking all things sleep.

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Audio Timeline / Chapters:

  • 00:00 – 04:15 Introduction
  • 04:15 – 21:30 Theme – Sleep in Healthcare Workers
  • 21:30 – 22:11 Clinical Tip
  • 22:11 – 23:55 Pick of the Month
  • 23:55 – 25:25 What’s Coming Up?

Next episode: Sleep Medications in Pregnancy

Links mentioned in the podcast: 


Guest interview:

Dr Julia Stone is a Research Fellow in the Turner Institute for Brain and Mental Health, Monash University. Her research interests include individual variability in circadian rhythms and sleep, the role of circadian disruption on health and performance, and computational modeling approaches for circadian phase estimation in applied field settings. Julia completed her PhD at Monash University and Alertness CRC investigating modelling sleep and circadian factors in healthcare workers. Julia’s recent research papers are available via her Monash University profile.

Connect with Julia on Twitter – @JStone_247

Regular hosts:

Dr Moira JungeDr Moira Junge is a health psychologist working in the sleep field, who has considerable experience working with people with sleeping difficulties in a multidisciplinary practice using a team-based approach. Moira is actively involved with the Australasian Sleep Association (ASA) and a board member of the Sleep Health Foundation. She has presented numerous workshops for psychologists and is involved with Monash University with teaching and supervision commitments. She is one of the founders and clinic directors at Yarraville Health Group which was established in 1998. 

Connect with Moira on Twitter – @MoiraJunge

Dr David CunningtonDr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is an International Sleep Medicine Specialist, Diplomate Behavioral Sleep Medicine and Registered Polysomnographic Technologist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep.

Connect with David on Twitter – @DavidCunnington. David also regularly posts information on sleep to his Facebook page.

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Dr. David Cunnington: Welcome to Episode 54 of Sleep Talk, the podcast talking all things sleep, and welcome again, Moira.

Dr. Moira Junge: Hello, Dave. Hello, everyone.

Dr. David Cunnington: So in this episode, we’re going to talk about healthcare workers. We’re not quite yet at the finished product of how to get healthcare workers to be sleeping well and coping with shifts. But there’s been a lot of work going on, particularly in Melbourne in the last couple of years about understanding the challenges of sleep in healthcare workers, and beginning to develop an approach to improve things. So we’ll drill down on that a little later with Julia Stone from Monash University.

So what’s been happening for you this month, Moira?

Dr. Moira Junge: Well, I think the… I guess, because of the COVID 19 pandemic, it’s been a sort of unprecedented busy time both clinically but also with the media. There’s been really a great amount of interest in talking about sleep, disrupted sleep, and particularly vivid dreams. I’m sure you must have had some requests or comments on that as well.

Dr. David Cunnington: Yeah, corona dreams?

Dr. Moira Junge: Yeah. Yeah. What do you think about all that?

Dr. David Cunnington: My sort of hypothesis, you know, I really liked the Alan Hobson model of this AIM. So memory monoamine means the higher monoamine drive is, the more you recall your dreams. So it is a time when we got more circulating adrenaline monoamines. Because there’s that uncertainty and change, and so you’d expect dreams or be more recollection, a bit more vivid, you know. That’s my theory.

Dr. Moira Junge: Yeah. Yeah. And also, I think that I also think that people are just sleeping longer, and more likely to be having more REM, because not having the commute and not getting up early for school. I find that that’s sort of that probe of like a rebound, REM rebound, sort of phenomenon that we have on sort of annual leave usually, when you get to sleep a bit morning off too. I remember my dreams for the first time in ages.

Dr. David Cunnington: Yeah, because sleep is definitely different for people. You know, our daytime activities are very different, so sleep is understandably different as well.

Dr. Moira Junge: Yeah.

Dr. David Cunnington: And you’ve been busy, Moira, and you’ve got some webinars coming up as well.

Dr. Moira Junge: Yeah, I’ve done so many webinars. I’ve done sort of unprecedented amounts of webinars. And yes, certainly, with ASA, I’ve got a new webinar series, which is fantastic. It’s free for members, and it’s $45 for non-members, kicking off on May 27, with Elise McGlashan. And next month, I’m doing the one with – about mid June, talking about Hypersomnia with Simon Frenkel.

And in this case on narcolepsy, talking about a lovely woman with narcolepsy who has been very generous of her time over the years. In fact, she was on our podcast many years ago, talking about her narcolepsy experience with narcolepsy. So Jackie will be joining us for that webinar, too. So yeah, it’s been, it’s been really busy. I’m really happy to do that. It’s a… I’ve got one next week too, another ASA one based on WA Group, just talking about our own, how we’re all going as practitioners without sleep ourselves, and how to promote better sleep in our patients and clients. I’m looking forward to that one.

Dr. David Cunnington: And you’re trying to master Twitter, so welcome to Twitter, Moira.

Dr. Moira Junge: Thank you. Yes, and listeners, you can now follow me. I don’t know. I mean, even I’ve been on Twitter, I’ve had a Twitter handle for years, I just haven’t had the… I don’t know what it is. I just haven’t been very brave. I haven’t had the inclination. And sometimes, just the time. I didn’t want to do until I could do it well. I have tweeted for the first time the last couple of weeks and I’m a bit nervous about it. But I’m happy to… I’d really want to engage with as many people as possible. So, I mean, to have followers, is it good to build up your… how many followers you have, so, or it doesn’t really matter?

Dr. David Cunnington: It’s about the quality of your followers.

Dr. Moira Junge: The quality.

Dr. David Cunnington: It doesn’t have to be a big group, a small well-curated group is often a bit better.

Dr. Moira Junge: Oh, listeners, feel free to follow me. It’s…

Dr. David Cunnington: So what your… Come on, you’re going to provide what’s your Twitter handle.

Dr. Moira Junge: Oh! Just add Moira Junge, which I didn’t even know anything about doing that years ago. I shouldn’t probably had something about sleep in the title, I guess. I don’t know. But anyway, at the moment, it’s just add Moira Junge, as simple as that.

Dr. David Cunnington: OK, we’ll follow you on Twitter.

So the theme for this month’s podcast is Sleep in Healthcare Workers. And it’s a really important topic, because healthcare is a fatigue sensitive industry. And funnily enough, it’s one of the least regulated fatigue sensitive industries. It’s always been a bit mysterious to me that once I graduated as a specialist, medical practitioner, there was no one saying to me, well, you can’t work more than X hours per week. If I wanted to work, I could work, yet I’m susceptible to fatigue. And the effects of not getting enough sleep as everybody else, well, you know, we’re human after all.

And Moira, you know, you’ve certainly done your time as a nurse in your day. How did you go with shift work?

Dr. Moira Junge: Well, yeah, I did a lot of shift work, obviously, as a nurse, and then as a sleep technologist for many, many years of staying, literally staying up all night. And I think back then I was in my 20s and it was fine. You know what, like, it was tough. But you’re so… you know, you would respond, you’re sleeping and on your days off, you’d recover pretty quickly, didn’t have the responsibilities of family, et cetera, et cetera.

But probably, I mean, it’s probably fair to say I think it’s a very big factor in why I’m not still a nurse, and why I’m not staying up all night being a sleep scientists anymore, and why I do my daytime job as a psychologist but still staying in sleep. It’s easy because I don’t cope very well with all that erratic nurse and not– and short sleep duration and then they’re not that predictability. Yeah. What about you? Would you… I mean, could you go back to your rotating shifts at the moment?

Dr. David Cunnington: No, I’m not in my 20s anymore. And you know, as I got older, it got harder. You know, I think one of the things I found really hard is about my first 10 years working as a specialist, I was on call, and would get multiple calls per night that I’d have to be often quite complex, quite… people that are quite unwell.

Then I have to try and get back to sleep only for the page to go again, and then another complex person, and then try and get back to sleep, then front up to work all the next day. And I did that for seven or eight years, and you know, I had enough of that. Thank you very much. And it’s seriously impact on performance the next day.

So to help us better understand the issues about sleep and performance related to shift work in healthcare workers, we have got Dr. Julia Stone from Monash University joining us. So thanks a lot for joining us, Julia on helping us with talking about sleep in healthcare workers.

Dr. Julia Stone: Thank you so much for having me.

Dr. David Cunnington: And congratulations on getting your PhD. That’s a great achievement.

Dr. Julia Stone: Thank you. Thank you very much. I was very excited to get that.

Dr. David Cunnington: So how did you come to looking at sleep in healthcare workers?

Dr. Julia Stone: I’ve always been very interested in sleep. Growing up, I quickly worked out that if I didn’t get nine hours of sleep, I’d be very cranky and irritable the next day. But it wasn’t really until I was working in sleep research during my Honors year at the University of Melbourne that I really discovered an interest in understanding how sleep impacts on our waking function, and the implications of not getting enough sleep or getting poorly timed sleep.

It was really, when I was looking for my PhD program that I knew I wanted to work in a really applied research context. And I heard about this thing called the CRC for learner safety and productivity, which was in its early stages at that point. And they were funding a project looking at sleep in shiftworkers. And I was really drawn to that project for a couple of reasons.

One, I had experienced shift work myself during my Honours year in the research lab and I was very well acquainted with how physically and mentally challenging and exhausting it can be. Secondly, because healthcare is such a critical profession, and it’s one where the consequences of making a mistake can literally be life and death.

So I really wanted to understand the physiology underlying the sleep in healthcare workers, both out of curiosity and then I suppose, also, partly a morbid fascination and horror really about how sleep deprived they can be during their rosters.

Dr. David Cunnington: Yeah, absolutely. There’s really good research on error rates and the sort of mistakes or surgical errors, medical errors, decision-making errors that occur in healthcare workers. What are some of the impacts of shift work on sleep and performance in healthcare workers?

Dr. Julia Stone: Shift work can be really disruptive to sleep and performance. Often, shiftworkers are required to be at work when they’re biologically programmed to be asleep. And then, to try and sleep when they’re biologically programmed to be awake, which is a real challenge and it can lead to sleep loss and alertness impairment across the board.

Sleep during the biological day can often be shorter, more fragmented, and any way of that with sleep deprivation due to the long work hours and the insufficient time between shifts, or even early starts cutting sleep short. And then working against the body clock can lead to that impaired cognitive performance, your poor alertness, your increased sleepiness, which can then lead to all kinds of mistakes at work. You can have trouble staying awake, and increased rates of accidents and driving on the commute home as well.

Dr. Moira Junge: So can you outline some of the common rosters and rotations that you typically see in the healthcare setting?

Dr. Julia Stone: Often, you’ll see a mixture of different shift types thrown in together. So there might be a mixture of day or early shifts, late shifts, long shifts, night shifts, or put together in some sort of rotating roster. So for example, you might see a series of seven-day shifts, seven days off, seven night shifts, seven days off, and repeat.

Or you might see a series of day and evening shifts put together followed by a series of consecutive nightshifts. Or, you might see what’s known as a slam shifter, which is a late-early combination where you have a late shift to say finishing at 9:30 PM, and then you’re back on shift at 7:00 AM the next morning. But really, they’re so variable between hospitals, between different roles, between people. Even within people, they can change so frequently, and there are lots of different combinations.

Dr. Moira Junge: What about some of the… I mean, there’s so many individual differences within the shiftworkers. Obviously, there’s different types of shiftworkers, you know, and not everyone responds. It’s not this a one-size-fits-all solution. It’s, well, I find at least. And what are some of the factors contributing to this do you believe?

Dr. Julia Stone: Yeah, it’s interesting, isn’t it that it’s really so variable when you talk to shiftworkers, whether they are coping or not to shift. But if like some people seem quite resilient to sleep loss and the other stresses around trying to manage different rosters, and some people just find it completely overwhelming.

One thing that we’ve been looking at closely from the research perspective is the variability in body clock timing that you see in shiftworkers. Often what we see is shiftworkers end up working against their internal body clock, which can lead to all kinds of problems. And we also know that the way the body clock responds to a given roster can vary quite a lot between people.

So in theory, you can adapt your biological clock to night shift schedules by shifting your melatonin peak into that daytime sleep episode, similar to what would happen if you went overseas and eventually adapted to that new time zone. However, what we tend to see is this kind of adaptation is quite rare in shiftworkers, particularly those working in health care or in other professions where they have to also fit in everyday life around their work schedules.

Instead, what we tend to say is, firstly, that they don’t tend to adapt to the night schedules after multiple night shifts even. So things like working four night shifts in a row and still being in a state of essentially exhaustion, because you’re working against your body clock and not getting enough sleep. And we also say that that varies quite a lot between people.

So the biological response that you see from one person on the same roster might be completely different in somebody else. One person might shift their melatonin rhythms slightly to those night shifts and some people might shift by hours. That becomes really difficult when you’re trying to provide interventions or feedback, or advice for shiftworkers, because most of our interventions work best if they’re timed according to that person’s body clock. And if it’s all over the place, and you have no way of knowing where that is, then it can be really difficult.

Dr. David Cunnington: So that was some of the work that you’ve published earlier as part of your PhD is trying to get it that some way of measuring where the body clock is. What sort of things did you look at and what are some of your insights around that?

Dr. Julia Stone: One way that really helps you focus, we think is to provide recommendations based on the individual’s circadian timing. So for things like light therapy to work best, you want to time in according to their body clock. Or similarly, we know that shiftworkers are at most high risk for accidents or alertness failure during their biological night.

So really being able to monitor that individual’s circadian timing would be hugely beneficial for things like personalized treatments or providing recommendations or even providing safer work rosters from an operational level. The problem at the moment is though, to measure circadian timing, you really need to either bring someone into the lab overnight or have them collect saliva samples or urine samples in quite controlled conditions, and then send those samples out for ASA and analyze them in it.

By the time you’ve done all of that shift work out, they’re on a different roster and their body clock has moved somewhere else, what we were looking at in my PhD is whether there are alternative ways to track or predict circadian timing using some mathematical models, and wearable sensors. And there are a few approaches that exists to do this. However, none of them have been validated in shiftworkers, where the sleep patterns and circadian rhythms are so much more variable than people who have the luxury of staying on a regular sleep schedule during the week.

So we trialed two different approaches, both that take information that you can collect over time just using wearable sensors. So things like light exposure, skin temperature and activity. One of the approaches was a machine-learning algorithm, which we trained to predict melatonin rhythms. And another one is an oscillating model of the human circadian clock, which is based on the neurophysiology of the body clock and how we know it responds to light.

We did find that that model tended to be more robust for shiftworkers in terms of predicting their body clock timing based on their light exposure patterns.

Dr. David Cunnington: So what does it look like, Julia? You say wearables, is it a wearable that is practical? Or is it wearable that’s practical in a clinical trial sense for a short period of time at the moment?

Dr. Julia Stone: It depends on the modeling approach that you take. So for example, the first one we tried, the machine learning approach, the people who originally developed that method had people wearing all kinds of different sensors. So, little skin temperature sensors. All over the body, you’d have glasses, kitted out with a light sensor, heart rate monitors, all sorts of different things.

But we were able to distill that down to a couple of more practical sensors. So monitoring light from Actigraphs, which are like watch devices, kind of like a Fitbit, and a small temperature sensor, which was worn on the wrist. So at the moment, these are all research-grade equipment. There’s no specific commercially available sensor that does this at the moment. But it definitely could be something that could be developed quite easily. Same with how we’re so used to wearing sensors that track our activity, our steps, our sleep, it would be a similar kind of thing.

Dr. Moira Junge: This real-world research, like, you know, doing a research on real-life, healthcare workers. Give us some of the insights into some of the problems that can be encountered during this type of research.

Dr. Julia Stone: As challenging as it can be, I do think it’s important to state at the beginning that real world research is really so important. It’s from a research perspective, in a lot of ways, a lot easier to do things in the lab where everything’s perfect and controlled, and you can really get it, what the physiology and mechanisms are. But I do think that it’s really valuable to look at how we can apply things in field settings.

That said, it can be very challenging. We were very lucky that we had a hospital that was very onboard with helping us conduct the research. But she focused at the end of the day, are very busy, and they’re very tired and we were asking a lot of them. For some reason, they didn’t want to collect urine samples for days at a time and come in and do tests. We did have some cases of life simply getting in the way.

So for example, one monitoring device was quite literally chewed up by a participant’s dog. We had another who had an accident, who then had a broken arm and wasn’t at work on the roster we needed. Probably one of the biggest challenges, which I imagine is a huge challenge for shiftworkers as well as but their rosters could change in a moment’s notice.

We might have their rosters that were planned for a month, and then the day of testing, they swapped with someone else. So we had to do a double shift or something like that. It’s just the rosters are just so variable. It can also be very challenging to interpret sleep diaries from shiftworkers, because they’re quite literally sleep at any time of day. I would caution anyone trying to collect sleep diary information in shiftworkers to get a really good idea of what the date is that they’re talking about.

Dr. David Cunnington: Based on what you learned in that study and the modeling data that you showed, what have you moved on to working on now?

Dr. Julia Stone: One of the main findings from testing these modeling approaches into focus was that while they are really quite good at predicting the group average level performance, so say, if you had a group of workers, you could predict somewhere in the middle, they all come out at this particular phase. But they aren’t particularly good at predicting the individual level phase or individual level circadian timing.

Something that I’m very interested in working on now is trying to develop ways to individualize the models to better track at the individual level, someone’s circadian timing, and then subsequently, their performance and their sleep timing.

Dr. Moira Junge: Do you think that there’d be data in your models available for people doing the rosters, let alone the workers themselves, but predicting the best roster for some people based on their circadian phase, or based on their… just based on their individual preferences, I guess? Because it doesn’t really work like that in the real world, does it? But I think the shifts are based on a whole other stuff, rather than the biology. I think it’s a really, I think a lot of practical reasons, a lot of things that need to happen in the routines of the hospital that haven’t been challenged for a long time.

So do you think that you know, do you have hope for… you know, what kind of changes do you think we could see practically in your lifetime or way before, you know, in the next five years, for instance, like 5, 10 years? What kind of things could we see that could really be useful?

Dr. Julia Stone: I would really hope that we can start seeing some changes in the rostering and the way that rosters are developed, and to be informed a little bit more around what we know from a safety perspective, as well as from a biological perspective on the kinds of rosters people should be doing.

There is work being done to develop tools that can help develop rostering systems and scheduling systems that take into account, rules around how many night shifts should you allow for one person, how long do you need between shifts. So that someone has enough time to go home and to wind down and to get to sleep before getting up, and starting all over again, as well as trying to build in some of those predictions around circadian timing.

So I am hopeful that those will start to be implemented. But of course, it is one of many competing demands faced by people trying to develop these rosters. So I hope that we can really call their attention to it and demonstrate the improvements from, at the bottom line, but also from a health and wellbeing point of view.

Dr. David Cunnington: Thanks very much for those insights. Julia.

Dr. Julia Stone: Thank you so much for having me. It’s been a… it’s been fun.

Dr. David Cunnington: So Moira, what did you make of Julia’s responses and the information that she goes?

Dr. Moira Junge: Oh, it’s fantastic. It’s very interested in the work that she’s doing with her group. I think there’s such a… there’s so much potential, there’s so many things we’re going to know that will help, really help healthcare workers and their families. Like, you know, they’re coping much better with shift work. And the individualization of it, I think, is what I was particularly interested in. What about you?

Dr. David Cunnington: Yeah, that’s an important thing for me, because it does reinforce that it’s just not as simple as, right, “Everyone do this. Follow this protocol.” Unfortunately, that means, you know, we can’t present a finished product of right, this is what we should do to fix fatigue and issues from shift work in all healthcare workers moving forward. But with some of that information on individualization that’s being worked on at the moment, I think that’s where we’ll be just a few more years down the track. I did love the term slam shift. I reckon you would have done a few of those in your day.

Dr. Moira Junge: Oh, I do. I think we didn’t call them that. But you know, you take that slammed.

Dr. David Cunnington: So people are looking for more information on the this topic. I’ll put links to Julia’s papers and some other papers from the Alertness CRC on this topic in the show notes. There’s a great factsheet from the sleep health foundation about shift work, and some blog posts on sleep pattern.

So what’s our clinical tip for people working with healthcare workers?

Dr. Julia Stone: I think something to keep in mind when working with healthcare workers is really taking a personalized approach and thinking about what their upcoming roster is as much as possible. And working on a plan with them to help manage when they’re going to sleep, when they’re going to seek or avoid light and how they’re going to fit everything else that they need to fit into their lives in, as well as thinking about things like planning sleep, in anticipation of the rosters. So things like if you’ve got a night shift coming up in a couple of days starting to sleep later and having a nap before you go in.

Dr. Moira Junge: OK, Dave, we’ve come to the pick of the month. What’s caught your eye this month?

Dr. David Cunnington: Keeping with podcast as a pick, so Narcolepsy 360 podcast is a podcast series, and they’ve produced a special series of interviews for the pandemic. So people with narcolepsy and sleepiness and how to sort of manage during the pandemic is a really nice episode with Dr. Jason Ong. He’s been on our podcast and we’ve spoken about before, from Northwestern in Chicago, who’s done some really nice work on some of the non-drug strategies for helping to manage symptoms of narcolepsy and sleepiness.

And also, we’ve collaborated with him on some of the mindfulness work in insomnia and other sleep disorders. So yeah, check that out.

Dr. Moira Junge: Oh, great.

Dr. David Cunnington: What about for you, Moira?

Dr. Moira Junge: You know, that sounds good. My pick of the month, it’s been around for a little while, I just keep forgetting to draw everyone’s attention to it. But, so this is the month to promote it. It’s a really neat little video. It’s on Vimeo, it’s on YouTube, and I’ll put the link to it. And it’s done by Hailey Meaklim, who’s doing her PhD at the moment at Monash University. She was, she started at RMIT.

And lastly, she got this fantastic, a small amount of money, a small grant to put together a short little video, which outlines the true process model of sleep processes and processee. And it’s just been a really, it’s just a really handy video. It’s very neatly done and it’s come up really nicely. So I’m going to put the link to that, because it’s freely available for everyone to use. I use it all the time, the last six months or so in any education I’m doing, the webinars I do.

Because it’s… sometimes, it’s a bit, you know, it’s hard talking about the processes and processee, particularly to a group, a non-sleep group. They don’t really know anything about those two processes, so it’s highly recommended.

Dr. David Cunnington: Look out for our next episode where we’ll talk about use of medications during pregnancy, particularly in women with narcolepsy, because that’s something that I get asked a fair bit about in my clinical practice. And there are really no good resources out there, so I wanted to develop a resource for that. And of course, Moira will be looking out for you on some of the Australasian Sleep Association’s webinars and the series on sleep that they’re running.

Dr. Moira Junge: Yeah, fantastic. I’m looking forward to that. And we’re also going to try and get some sleep health foundation webinars going as well that they probably be more community facing. Like, getting them out into schools and corporations, and organizations. But that’s something I’ll… when that happens, I’ll certainly be promoting that as well and ways in which you can book one in for your organization.

Dr. David Cunnington: So, thanks very much for listening to the podcast. And if you’ve got suggestions for episodes, email us at podcast@sleephub.com.au.

Dr. Moira Junge: And don’t forget if you like the podcast, tell your friends and colleagues. You can also write a review on Apple Podcasts and subscribe by any podcast streaming service or app. Catch you on Twitter!

Dr. David Cunnington: Thanks a lot.

This podcast is not intended as a substitute for your own independent Health Professionals advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.



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