SPE 98130

Optimal Strategies for Dealing With Shift Work and Insomnia

W.H. Kuo, SPE, Saudi Aramco Healthcare
Copyright 2006, Society of Petroleum Engineers
This paper was prepared for presentation at the SPE International Conference on Health,
Safety, and Environment in Oil and Gas Exploration and Production held in Abu Dhabi, U.A.E.,
2-4 April 2006.
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Abstract
Shift work is associated with many major chronic health
problems; moreover, night shift carries increased risk of
attention lapses and accidents, and reduced productivity.
Insomnia, circadian rhythm, age-related sleep changes, health
effects and shift work, and useful night shift accommodation
strategies are discussed.
Introduction
The rotating work shift and permanent night shift are fraught
with danger. The infamous incidents of the late 20th century
Three Mile Island (4:00 a.m.), Exxon Valdez (12:01 a.m.),
Chernobyl (1:23 a.m.) all occurred in the midnight to predawn hours.
For workers, shift work is associated with higher rates of high
blood pressure, elevated blood cholesterol, stomach digestion
problems, weight gain, insomnia, depression, heart disease,
etc. Moreover, female shift workers are at higher risks of
spontaneous abortions, premature births, and low birth weight
babies. Night shift carries an increased risk of attention lapses
and accidents, as well as reduced productivity.
Yet, in our 24/7 society, a growing proportion of workers must
work a rotating shift or are on a permanent night shift. It is
estimated that 15% to 20% of U.S. workers are in a rotating
shift or on permanent evening and night shifts. This is an
issue that employers must tackle to prevent catastrophic
accidents and productivity loss.
Insomnia
Insomnia, a non-specific complaint, can mean difficulty
falling asleep, staying asleep, or premature early morning
awakening.

One third of all adults complain of insomnia at least

occasionally. Of those, 74% classify themselves as
occasional (once or twice a week) insomniacs; the
remaining 26% are frequent (at least four nights a week)
insomniacs. Risk factors for insomnia include older age,
females, being divorced or widowed, lower socioeconomic
status, previous history of insomnia, snoring, and health
problems.
Insomnia is associated with daytime drowsiness, impaired
concentration and memory, inability to enjoy social and family
relationships, chronic pain, poor health, higher rates of
accidents, and higher utilization of healthcare resources. More
specifically, a sleep loss of 1.5 hours decreases daytime
alertness by one third.
Many classes of medications can cause insomnia. These
classes include stimulants (including many decongestants,
stimulating antidepressants, and some attention deficit
disorder medications), anti-hypertensive medications (namely
beta blockers and calcium channel blockers), and sedating
medications (causing daytime sleepiness, such as allergy
antihistamines, tranquilizers, and some classes of
antidepressants).
Caffeine keeps people awake. While alcohol helps induce
sleep, once it is metabolized by the body, a person may
awaken in the middle of the night.
Circadian Rhythm
Our sleep-awake cycle follows a 24-hour biological rhythm
called the circadian rhythm, which also regulates our core
body temperature and hormone secretion. Our core body
temperature drops at night, usually between 10 p.m. 11 p.m.,
causing sleepiness, and rises eight hours later, usually between
4 a.m. 5 a.m., inducing awakening.
With aging, our core body temperature drops earlier at night,
around 7 p.m. Therefore, an older worker may get sleepy at 7
p.m. and fall asleep by 8 p.m. But then he wakes up at 3 a.m.,
unable to sleep anymore.
On the other hand, if an older worker resists sleepiness at 7 p.m.
and goes to bed at 10 p.m., his core body temperature still rises
at 3 p.m. (eight hours after its initial drop at 7 p.m.). He only
gets five hours sleep and his inadequate sleep leads to poor
performance at work. This problem may be ameliorated by
using evening light exposure using artificial bright light boxes.

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SPE 98130

Heart attacks and strokes, following the circadian rhythm, are

more common in the morning, soon after arising.

evidence does not show either approach being superior in job

performance or accident prevention.

Age-Related Sleep Changes

In addition to a change in the circadian rhythm, when we grow
older, our ability to sleep decreases, but our need for sleep
does not decrease significantly. Older people have more night
time awakening and are sleepier during the day. They fall
asleep quicker than young people and take more daytime naps.
Nevertheless, daytime sleepiness is not normal. It is a sleep
disorder resulting from insufficient sleep at night.

Night-Shift Accommodation Strategies

Using bright-light boxes or keeping lighting very bright helps
resynchronize circadian rhythm for night workers and keeps
them awake longer. Properly timed bright light exposure can
facilitate rapid adaptation to night work.

Insufficient sleep causes inattention, prolonged response time,

memory and concentration problems. All of them can cause
impaired work performance.
Shift Work
As we travel across many time zones by air, our circadian
rhythm adjusts to new time zones, usually after 2 to 14 days.
Research shows that permanent night shift workers do not
make such circadian rhythm adjustments because their
weekend leisure time is still in sync with the normal day
population, and their exposure to daylight also synchronizes
their circadian rhythm.
Experimental studies show that exposure to bright lights
during night working hours in conjunction with wearing dark
sunglasses to minimize light exposure in daylight helps with a
circadian rhythm adjustment. Such an adjustment takes
several weeks to occur. Most rotating shift cycles are less
than three weeks long and do not reap the full benefits.
The direction of progression in rotating shift work is
important. Clockwise shift (dayeveningnight) is better
than counterclockwise progression, because it is easier to go to
bed later than trying to fall asleep earlier than normal sleep
time. Or, in other words, it is easier to get up later than
earlier. Thus, clockwise progression put less strain on our
internal clock adaptive mechanism.
The frequency of scheduled rotations is more controversial.
One school of thought favors a slow rotation schedule that
gives workers at least five days to adjust to the new schedule.
The idea is that workers perform better once they have a
chance to adjust to the new schedule physically and socially.
The other school of thought prefers a shorter rotation schedule
of only one to three days, because it is thought that workers
never completely adapt to night shifts and shorter night
rotation periods cause less disruption to their circadian
rhythms.
Research shows that long-cycled forward shift rotations of at
least 21 days before rotation is better physiologically, as
evidenced by more sleep (an average of 6.72 hours) for
workers on long-cycled or permanent night shifts, than those
on weekly rotations (average sleep of 5.79 hours).
Nevertheless, most workers tend to prefer rapid rotations
because of more frequent periods of normal social and family
life. Adding days off work between shift rotations allow
workers to recoup their lost sleep. So far, the available

Moreover, a short period of exercise raises core body

temperature and dispels sleep for two or more hours. Night
workers should wear dark glasses (in bright daylight) while
traveling home to help prepare them for sleep. Caffeine
should be avoided in the second half of their shift.
It is advisable to use black-out curtains in their bedrooms,
which should be the quietest room in the house and without a
telephone. Social and family interruptions during sleep should
be kept to a minimum.
Health Effects and Shift Work
Rotating shift work and permanent night work not only disrupt
the circadian rhythm, but also cause problems with initiating
and maintaining sleep, which may be interrupted by daytime
activities such as the telephone ringing, street noise, and social
activities. The quality of sleep may also be poor, with less
rapid eye movement sleep and deep sleep.
Gastrointestinal complaints such as changes in appetite and
increased constipation are often caused by delayed gastric
emptying due to circadian rhythm disruption, which may be
further aggravated by more tobacco and caffeine use among
shift workers.
More importantly, shift work complicates the management of
chronic illnesses in which timing and dosing of medications
are important. Blood sugar control in diabetes may become
less than optimal due to inconsistent meal time and increased
food consumption. Insulin efficacy also has circadian
variations. Epileptics are more prone to having seizure attacks
due to inadequate sleep. Asthmatics have increased symptoms
at night.
Many studies report increases in high cholesterol and high
blood pressure in shift workers. Moreover, perhaps due to the
higher prevalence of elevated cholesterol and blood pressure,
there is a 40% increase in risk of cardiovascular disease in
shift workers.
Pregnant shift workers have more spontaneous abortions,
premature births, and smaller infants. These are potential
reproductive risks from shift work.
Shift work interferes with normal social and community
interactions. In addition, the rotating shift schedule or night
shift can cause periods of decreased interactions with other
family members. Such interference in shift workers social
and family life is particularly detrimental in those with
psychiatric disorders such as major depression and bipolar
disorder, which may be exacerbated by shift work.

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SPE 98130

There is a higher risk of errors for routine and boring night

work. If such work involves safety, shorter work shifts,
administrative measures and engineering methods to protect
against catastrophes should be instituted.
Older workers and those with a history of sleep problems are
particularly pone to shift work intolerance. A subset of
workers is inherently intolerant to shift work, perhaps due to
their circadian rhythm resynchronization difficulties.
People with a history of heart disease, stroke, gastrointestinal
problems, sleep disorders, diabetes, asthma, epilepsy, poor
night vision, and other chronic disorders need to undergo
medical evaluation for fitness prior to night or shift work.
Conclusion
Night work and rotating shift work are associated with many
adverse health effects, particularly cardiovascular,
gastrointestinal, and reproductive disorders. In addition, there
are productivity and safety problems caused by sleep
disturbance.
The optimal rotating shift strategy is one that rotates forward
in a clockwise fashion, from day to evening, and to night,
preferably with long cycles of at least 21 days before a
forward rotation.
Strategies to accommodate night work include bright-light
boxes, short periods of exercise, wearing dark glasses while
traveling home in bright daylight, caffeine avoidance in the
second half of a shift, using black-out curtains in the bedroom,
and avoidance of noise and family interruptions during sleep.
Workers with a history of heart disease, stroke,
gastrointestinal problems, sleep disorders, diabetes, asthma,
epilepsy, poor night vision, and other chronic disorders may
not be able to tolerate night work or rotating shift work, and
medical evaluation for fitness for duty should be required.
References
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3.

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5.

Ancoli-Isreal, S.: Sleep Problems in Older Adults AudioDigest Internal Medicine, 50:22 (November 21, 2003).
Seward, J.: Chapter 32: Occupational Stress, Occupational &
Environmental Medicine (Editor: Joseph LaDou), 3rd Edition,
McGraw-Hill, New York, NY (2004) 608-611.
Czeisler, C., Winkelman, J., and Richardson, G.: Sleep
Disorders, Harrisons Principles of Internal Medicine, 16th
Edition, McGraw-Hill, New York, NY (2004) 153-162.
National Sleep Foundation (www.sleepfoundation.org).
Society for Light Treatment and Biological Rhythms
(www.sltbrorg).

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