The Matter of Sleep Deprivation in Clinical Settings

Sleep plays a pivotal role in recharging, refreshing and restoring our bodies. According to Suni and Callendar, sleep allows the brain and body to slow down and engage in processes of recovery, promoting better physical and mental performance the next day and over the long term. Receiving an appropriate number of hours of sleep can have a plethora of benefits, such as: lowering one's risk of developing diseases like diabetes and heart disease, boosting the immune system, preventing weight gain and increasing productivity. Therefore, sleep deficiency is particularly detrimental as it can have adverse effects on an individual's physical and mental health. The theme of sleep deprivation in a clinical setting is presented in this argumentative essay where we will understand why lack of sleep can greatly lengthen a patient's recovery period, putting them at greater risk of exacerbating their illnesses.

Stages of Sleep Deprivation

Try to imagine yourself in a sleep deprived state: After missing 24 hours of sleep, you start to feel tired and irritable. You feel drowsy and your brain feels foggy. You accidentally put salt in your coffee instead of sugar. After missing 36 hours of sleep, you feel exhausted. You begin to doze off subconsciously, jolting yourself awake after a particularly enticing microsleep. You need to pay attention, but you can't. You forget what you were just told and feel inexplicably down. You doze off while driving.

After missing 48 hours of sleep, you are stressed beyond comprehension, and the anxiety plaguing you is debilitating. You can't help the explosive anger you feel when someone bumps into you. You can barely control your emotions.

After missing 72 hours of sleep, the walls confining our reality begin to crumble and you struggle to define what is real and what isn't. Why do your hands look larger than usual?Why do you feel like a stranger in your own body? You begin to undergo depersonalisation. After missing 96 hours of sleep, you are so tired you feel like dying. Its unbearable. You are unable to interpret reality and experience extreme sleep deprivation psychosis. Now imagine how dangerous this would be for a recovering patient or the healthcare staff in charge of them.

Sleep Deprivation in Clinical Health Settings - How It Effects the Staff

Sleep deprivation decreases the ability to discern and mirror emotions, which may decrease a member of staff's capacity for empathy and interpersonal engagement. In a study, researchers explored the effects of sleep deprivation on emotional empathy. The results revealed that after a night of sleep deprivation, participants were less emotionally empathetic than those who had slept, indicating that a night of sleep loss impairs the ability to share the emotional state of others, which is a vital skill that all healthcare staff must have when interacting with their patients. 

As aforementioned, sleep deprivation can also affect performance amongst healthcare workers meaning that sleep-related impairment can pose an occupational hazard in healthcare settings. A cross sectional study, conducted in the US, used the wellness survey data of doctors from 11 academic-affiliated medical centres, to assess the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout. The proportion of doctors who self-reported a clinically significant medical error within the past year, by category of burnout and sleep-related impairment, is illustrated in Figure 1. If the cause of the self-reported error had been due to sleep-related impairment and burnout, then the 37.7% of attending doctors (116 of 308) and 39.9% of trainee doctors (221 of 553) who had admitted to making a medical error resulting in patient harm, could have easily avoided making these mistakes in the absence of high sleep-related impairment and high burnout. 

The data shows how deadly sleep deprivation in clinical settings truly is. It can significantly reduce the quality of care given by healthcare professionals. With their alertness and attentiveness at jeopardy, professionals that suffer from sleep deprivation are at higher risk of making fatal mistakes. How are they supposed to guide patients back to perfect health if they are not in perfect condition themselves? How are they supposed to treat patients if they can barely keep their eyes open?

In addition to placing patients at potential risk, high levels of sleep-related impairment place healthcare staff at elevated personal health risk. The plethora of negative side effects of sleep deprivation is well established with a multitude of studies providing evidence for this. Chronic sleep loss can weaken an individual's immune system, increasing the risk of several conditions such as diabetes, obesity and cardiovascular disease. Nurses working rotating night shifts for over 15 years have been found to be 1.79 times and 1.35 times at risk of developing breast and colorectal cancer, respectively. 

As well as physical issues, sleep deprivation can induce and exacerbate mental health issues amongst the already stressed-out healthcare staff. A study was conducted to show that during the peak of COVID-19 cases in New York in April 2020, healthcare workers were exuding high levels of psychological symptoms with 57% of participants screening positive for acute stress, 48% for depressive symptoms, and 33% for anxiety symptoms. The lack of sufficient sleep paired with the psychological toll of handling a pandemic would have played a significant role in the deterioration of their mental health. Such treatment of our frontline workers is unacceptable. To ignore the health and wellbeing of our healthcare staff is immoral and unjust.

So, how can we reduce sleep deprivation amongst healthcare staff? Simply reducing work hours has proven to be quite controversial. Although reducing work hours would mean that interns and workers would have the opportunity to rest and recuperate, workers may still come in tired despite this, due to competing side interests outside of the workplace. Furthermore, long hours offer a valuable educational experience: healthcare staff can see the evolution of disease, retain continuity of patient care, and have adequate time to learn more about the profession. Rigorous schedules can also build confidence and prepare trainee doctors for the demands of practice.

Despite this, in 2003 the European Working Time Directive (EWTD) was executed in order to prevent healthcare staff from working excessively long hours. The EWDT limited the number of hours healthcare staff (such as junior doctors and consultants) worked to an average of 48 hours per week with the purpose of improving the quality of care given by staff. Whilst the effects of the EWTD haven't been sufficiently evaluated, a study conducted in the Netherlands showed that the EWTD did not adversely affect the operative experience of surgeons, showing that reducing the number of hours worked in order to accommodate a healthier lifestyle among staff- wouldn't necessarily deter an individual's career. 

As well as this, smaller scale procedures can be implemented in hospitals in order to ease the burden of sleep deprivation. For example, encouraging the use of 'prophylactic' naps amongst staff, before and during shifts, can help improve the performance of shift workers by providing them with temporary relief from the effects of sleep loss and fatigue. In addition to this, hospitals can also promote the strategic consumption of caffeine. Caffeine is a stimulant used to counteract the effects of sleep deprivation, however, prolonged used of caffeine can induce tolerance to its stimulatory effects. Therefore, the use of caffeine must be timed to boost alertness and effectiveness' for example, before the circadian low point. 

Sleep Deprivation in Clinical Health Settings - How It Effects the Patient

There is evidence that sleep deprivation in hospitals jeopardises patients' physical and mental recovery. The ability to sleep is important for somatic and cognitive processing, and physiological recovery. Sleep disturbance has deleterious effects on immunological function, the hypothalamic-pituitary-adrenocortical and somatotropic systems, and can decrease responsiveness to hypoxic states and inspiratory muscle strength, putting patients in life threatening and dangerous positions. As well as this, sleep deprivation disrupts connectivity and processing within and between the amygdala, anterior cingulate, and medial prefrontal cortex, resulting in emotional dysregulation. This can cause individuals in clinical settings to experience mood swings, extreme behaviour and delirium. It can exacerbate a patients already negative emotions making them more susceptible to extreme behaviour i.e., lashing out at staff or even having suicidal thoughts during recovery.

These effects have been reported to persist even after recovery sleep has been obtained, negating the idea that the effects of sleep disturbance can be overcome once patients are discharged from hospital or high acuity areas, showing that it is pivotal for patients to gain sufficient sleep during their recovery in the hospital. For treatments to be optimised, having quality rest is extremely important.

So, what factors contribute to poor sleep for patients in clinical settings? It is a known fact that hospitals are not conducive settings for encouraging sleep amongst patients. Environmental and non-environmental factors play a major role in sleep deprivation. Patients in a variety of acute care settings report difficulty falling and staying asleep, not feeling rested, increased daytime napping, and a reduction of sleep quality.

Environmental Factors

Noise has been the most studied sleep disturbing factor with reported noise levels frequently exceeding the World Health Organization (WHO) recommended nocturnal noise levels of less than 30 dB in the clinical environment. Studies report ambient noise levels ranging from 50 to 60 dB in intensive care, and 40 to 55 dB in the general ward environment.

Care interactions: patients may be woken up by healthcare staff to do mandatory checkups. This can hinder transitions between sleep cycles and reduce time spent in deep, restorative sleep.

Light exposure: while in the hospital, especially in an intensive care unit, patients are exposed to relatively high levels of artificial light during the night and low levels of light during the daytime. Light exposure can disrupt the production of melatonin in the pineal gland. Melatonin plays an important role in regulating our sleep wake cycles so an exposure to artificial light during the sleep phase, can adversely affect a patient's perception of the quality of their sleep as well as misalign an individual's circadian rhythm. This can worsen metabolism, increasing the risk of obesity and elevate their risk of developing cancer.

Non-Environmental Factors

Non-environmental factors such as medications and patient factors are also known to contribute to sleep deprivation in patients. Medications such as benzodiazepines, glucocorticoids and steroids can have adverse effects on an individual's sleep cycle. Furthermore, psychological issues such as anxiety and depression found in patients with chronic illnesses contribute to sleep disturbances. Studies have shown that conditions such as congestive heart failure and asthma are associated with complaints of poor sleep.

While not every factor is the fault of the hospitals, it is important to understand all the factors that play a role in sleep deprivation amongst patients in order to combat the issue. Raising awareness of the importance of sleep among recovering patients is crucial, as it can help reduce the prevalence of environmental factors acting as a hinderance. There are many appropriate, cost-effective measures that can be put in place to encourage sleep amongst patients, such as: providing earplugs, minimising evening hour light, implementing techniques which promote good sleep hygiene (i.e., encouraging patients to exercise during the day).

Conclusion

Ultimately, sleep deprivation in clinical settings is an incredibly prevalent issue that must be tackled in order to minimise the risk of patients and workers falling prey to the injurious side effects associated with it. A clinical setting is supposed to be a place of wellness and rehabilitation; however, it falls short of its purpose if the issue of sleep deprivation continues to be ignored. A large-scale revolution of the public's attitude towards sleep must commence in order to improve the livelihoods and quality of sleep amongst vulnerable patients and the healthcare staff looking after them.

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