Nurse, Heal Thyself!

By Julia Worrall RN

I have been a nurse for over 20 years. And I’ve been exhausted just as long.

Unfortunately I am not alone. Nurses are called upon  to be superheroes…impervious to niggly details like hunger, pain, sadness and fatigue. 

We keep going. I mean what choice do we have? As the years go by we become crusty and curt, a ‘Nurse Ratched’ if you will.  But we keep showing up. Putting aside our fatigue to care for you because, for the most part, in our profession the need for sleep is considered a character flaw…only for the weak. A ‘good’  nurse can churn out shift after shift, even on minimal sleep, because we will never abandon you, our patient. 

Patience with our Patients

We know that hospitalization can be one of the most physically and psychologically stressful events in one’s life, and that this stress has the potential to reduce our patients’ sleep quality, impair recovery and delay discharge. Because patients notoriously complain about the noise we make at the nursing station, their roommates’ snoring, and about how hard it is to get a good night’s sleep, we hand out sleep aids like candy. 

Understandably then, this legitimate concern has made nurses experts at teaching their patients about sleep, sleep hygiene and sleep disorders. 

Right?

Wrong! How I wish this were true, but in general nurses consider sleep promotion a very low priority in their busy practice. Might the shocking fact that the typical nursing student receives just an average of 60 minutes of education about sleep during their entire 4-year program have anything to do with it?

Yes, SIXTY MINUTES. Think about that…. We spend a grand total of one hour discussing what occurs during ONE-THIRD of our patients’ lives! 

No wonder nurses do not place a high priority on sleep! Nurses consider insufficient sleep knowledge as a major barrier to effective sleep management in the clinical setting. In addition, they view discussions about sleep with their patients to be impractical due to a perceived lack of time.

Since nursing is considered to be the most trusted profession, and nurses are the largest group of healthcare professionals, are we not perfectly positioned to effect change for both our patients and ourselves?

Nurses who adopt healthy behaviours themselves act as positive role models. In fact, nurses who enjoy higher quality sleep are more knowledgeable about sleep in general, have a positive attitude toward sleep hygiene, and are much more likely to broach this important subject with their patients.

So before we can address the sleep health of our patients, we need to address our own sleep. 

Nurse, Heal Thyself! 

Many times I have reported for a shift only to hear the nurses lamenting their extreme sleep deficits. We wear our sleep deprivation as a badge of honor. This is foolhardy and explains the lack of resiliency that is creeping into our profession. It is hard to be compassionate toward our patients while we are exhausted, yet managing a never-ceasing flow of patients through our department. Sadly, it is our own lackadaisical attitudes about sleep, our own habits, that are harming our patients. 

It is true that we are pressed in every way for time, but how fantastic would it be if we could have a dedicated Sleep Technologist/Educator to provide inservice training for nurses and to be a resource for the inevitable sleep issues our patients face once admitted? Those issues, in fact, often the root cause of why they are admitted. 

My dream for the future is that sleep education be extensively taught to nurses and that Sleep Techs/Educators be an integral part of the in-hospital multidisciplinary team.  

As the world’s attention turns to consider that occult one-third of our lives, I call upon nurses to collaborate with the sleep educators to discuss strategies for helping  patients’ achieve a solid eight or so hours of restful life-enhancing sleep. 

Poor Sleep and Behavior

We are living in a society that thrives on an excess of hard work and lack of sound sleep all in the name of success. As this approach to our daily habits is widely accepted, it has become second nature for those trying to achieve their goals, to abide by the unwritten rule of working instead of giving your body what it needs, such as rest and nutrition. While many praise the idea, there are those who are aware of the effects of sleep deprivation. Over the past 10 years successful media mogul, Arianna Huffington of the Huffington Post, has become an advocate for getting adequate sleep after passing out at her desk and waking up in a pool of blood to see her daughter’s face. 

During an interview with CNBC, Huffington explained, “I can tell you with authority that when I’m exhausted. When I’m running on empty, I’m the worst version of myself,” says the entrepreneur. “I’m more reactive. I’m less empathetic. I’m less creative. And all of us can testify to that.” Even for everyday people who are not in the public eye, losing hours of sleep in an effort to perform better, complete necessary or desired tasks, or due to other internal or external factors can have serious negative consequences.

Getting sufficient sleep goes beyond following a schedule and just getting rest; our quality of sleep is strongly connected to our physical health, emotions, and behavior. The general population undergoes numerous adverse behavioral responses as a result of sleep deprivation, and the experience is significantly increased right now due to the current shelter-in-place environment. It is vital to understand how the loss of sleep affects us at the best of times and identify steps to reverse these effects during this current situation.

Poor sleep impacts daytime function and mental health.

How Sleep Deprivation Affects Us

What is sleep deprivation? Simply put, it is when the body is deprived of the amount of sleep it requires to repair and restore itself. Full-sleep debt occurs when a person is kept awake for a full 24-hour cycle and partial-sleep debt is when someone has limited sleep for several days or even weeks. Sleep debt is triggered by a host of agents including, but not limited to:

  • Environment
  • Sleep habits
  • Work
  • Study
  • Stress
  • Illness or ailments
  • Use of stimulants such as coffee or alcohol
  • Sleeping disorders (i.e. obstructive sleep apnea, insomnia, narcolepsy, etc.)

After a loss of needed sleep, you may find yourself highly irritable, intensely reactive in situations you normally wouldn’t be, or oblivious to the fact you put your keys in the freezer instead of on the key hook. In regards to sleep, most people have personally experienced a change in mood, energy, and the ability to handle stress when we get even one hour less than the optimal amount. Sleep deprivation is directly connected to our behavior and can be a key factor in the display of actions we would normally avoid.

Though sleep debt may seem like a minor thing, universally it is linked to significant social, financial, and human costs, resulting in a whole array of physiological and behavioral effects that range from excessive yawning to reduced reaction time. According to the American Sleep Association, drowsy driving is responsible for 1,550 fatalities and 40,000 non-fatal injuries in America annually, which, according to the Department of Transportation, cost more than $45 billion USD in 2015 alone. Shift workers, truck drivers, medical residents, and airline pilots working long hours or late shifts have shown an increased risk for crashes and near misses. Studies also show that adequate sleep is one of the most crucial factors in learning. Meta-analysis shows, on average, partial sleep-deprived subjects performed two standard deviations below their non–sleep-deprived counterparts, meaning sleep deficit does not The Effects of Sleep Deprivation on Inmates

Consider the effects of sleep deprivation during normal circumstances. Now intensify it. Families today struggle with the same causes and effects of sleep debt but now have the added element of a highly stressful environment that they cannot escape 24 hours each day. Additional influences on sleep include:

  • Living in a chaotic environment
  • Crowded living/sleeping space
  • Prescribed and non-prescribed drugs
  • Hypervigilance
  • Taking frequent naps during the day
  • Interacting with sleep-deprived family and co-workers

If you are dealing with full- or partial-sleep debt, it makes sense that one might respond irrationally at times.

Reversing the Effects of Sleep Deprivation

When it comes to improving sleep quality the resources are plentiful and generally application is realistic; however, we must consider the factors that hinder a more effective sleep situation and invest in creating a more sleep-conducive environment. Change is not something that occurs overnight but is the result of a series of steps in the right direction.

Sleep rehabilitation is pertinent to the holistic wellbeing of all people regardless of their situation and environment. We go in-depth and explore what rehabilitation looks like in our “Sleep and Rehabilitation” article. Providing better sleeping environments is both necessary and possible, leading us to offer suggestions that could be implemented for success within as well as outside of our own four walls.

The Tragic Toll of Sleeplessness on First Responders

Sleep, or lack thereof, has also been found to be a critical factor in the ability of our First Responders to do their jobs. We rely on them to respond in emergencies of the highest severity: to be on top form, able to save lives, and fight through the trauma. But first responders too, are only human. Firefighters, police officers, correctional officers, paramedics, and nurses are all susceptible to sleep-related disorders just like the rest of us. With unhealthy long and irregular shift patterns, these life-saving professions have been shown to have detrimental effects on the lives of heroic individuals.

In addition to that, first responders’ job roles result in physical and mental strain on the body–even when functioning at a level of optimum sleep–so the knock-on effect of poor performance can lead to a multitude of mental health concerns. Many workers in first responder positions are, at some point in their career, likely to be involved in some form of event which could lead to PTSD: a harrowing condition that could ultimately lead to a higher risk of suicide.

Dangerous Livelihood

Those working in potentially life-threatening environments are often exposed to harmful fumes, chemicals, and dangerous scenarios, and are trained to protect themselves against these elements. For the first responder, the one area of their professional lifestyle that is often overlooked for needing care is the access to a good night’s sleep. A study by the Journal of Clinical Medicine found that nearly 40% of 7,000 firefighters tested were found to suffer from insomnia, work-shift disorder, sleep apnea, or a combination thereof. Although most of these individuals were likely all too aware that their sleeping life was less than ideal, nearly 80% of these firefighters didn’t know that their lack of shuteye time had resulted in a medical disorder. 

Around 103 firefighters and 140 police officers in the U.S. tragically took their own lives in 2017. These figures far exceed the death tolls relating to incidents actually occurring on the front line. And with suicide figures notoriously underreported, it’s likely that these figures are actually much higher. With such common exposure to gun crime, it’s unsurprising that 90% of police suicides are by firearm. Figures relating to suicide in firefighters are also incredibly shocking: 44% of full-time firefighters and over 50% of volunteer firefighters had experienced suicidal ideation, nearly 17% and 31%, respectively, had made suicide plans, while more than 15% and almost 27%, respectively, had made suicidal attempts.

You give so much of yourself to keep us safe, now let us return the favor.

Killer Fatigue

Many emergency responders, including those in the police force and medical services, work between 16- and 24-hour shifts, and even when rest time is encouraged, it is likely that these individuals will be disrupted and called out at unsociable hours. In 2015, a study referenced by the National Highway Traffic Safety Administration reported that around 50% of emergency medical service workers surveyed were suffering from fatigue. This inadequate state of awareness can lead to fatal errors in medical operations, poor driving quality, and slow reactions which could lead to injuries or death. Having very little sleep can also impair judgment and memory retention, making even the most experienced workers likely to face difficulties in high-pressure and fatal scenarios. When the body suffers from prolonged periods of sleep deprivation, cognitive functionality decreases and results in impairment similar to an ‘over-the-limit’ blood alcohol level of 0.1%. And with the amount of emergency calls increasing year on year, first responders continue to live under crushing amounts of pressure, which leads to even less chances of quality sleeping time.

Just because you have time to sleep doesn’t mean you’ll be able to!

Shift Workers and The Circadian Rhythm

The Circadian rhythm is the natural physical, mental, and behavioral changes in the body that take place in most living things on a daily basis. Natural circadian rhythm in humans makes us sleep at night and stay awake during the day. Understandably, shift work disrupts the circadian rhythm, and we are just beginning to understand the vast significance of the health consequences this can have on the body. Circadian misalignment, as it’s called when someone isn’t able to follow the natural circadian rhythm of sleeping at night and staying awake during the day, affects cardiovascular and mental health, and increases one’s risk of cancer, as well as a host of other potential problems. Furthermore, it increases the risk of workplace accidents and injuries, and increased errors in the workplace. Addressing and treating the sleep issues that shift workers face will have tremendous positive consequences for the health of these workers, while improving the efficacy and efficiency of their work output.

The Sleep RN: It’s Time to Help our First Responders

With the nation facing these major issues, many of which can be traced back to improper sleep, there is no one better positioned to step in than Julia Worrall, The Sleep RN. With her innovative and cutting-edge research tools and methods, combined with a team of world-renowned professionals who are all leaders in their fields, she’ll work with medical professionals, first responders, corrections officers, veterans, and inmates to heal the nation by implementing inventive approaches to correcting unhealthy sleep patterns. With The Sleep RN at the helm, those who want to see real change and results can, in every sense of the word, rest easy.

Sleep and Medical Issues

Sleep has a foundational healing effect on the body. When we sleep, our bodies replenish, heal, and grow in a variety of ways. Sleep boosts our immune system, helps us recover from injury, and improves our mood. When we are feeling ill, we are told to “sleep it off.”  It is our body’s natural means of survival, and although humans can live for weeks without food and days without water, we can only last approximately 36 hours without sleep before our bodies begin to shut down. 

This is important because, for a number of people, sleep can be incredibly difficult to achieve. Chronic insomnia affects 25 percent of adults and 50 percent of the elderly, with 95 percent of Americans experiencing insomnia at some point in their lives. In addition, people with insomnia who sleep less than six hours per night on average have a much higher risk of negative health outcomes. It is not so easy for them to just “sleep it off,” and not only because of psychological or environmental reasons.

Sleep disorders are defined by the Mayo Clinic as a change in the way you sleep, and they affect 50 to 70 million US residents, according to the Centers for Disease Control and Prevention. The CDC has asserted that sleep disorders are connected to many chronic illnesses, including cardiovascular problems and diabetes. The link between sleep and medical issues is undeniable, but let us examine more specific ways in which they relate. 

Breathing: It’s Kinda Important…

One of the most common sleep disorders is sleep apnea, in which breathing during sleep is interrupted by pauses, or apneas, which can last 10 seconds or more. These apneas may occur five to 30 or more times per hour, reducing the amount of oxygen that circulates to the brain. According to the National Institutes of Health, more than 12 million Americans suffer from sleep apnea. It is more common in men, overweight people, and the elderly, as well as African-Americans, Latinos, and Pacific Islanders as compared to Caucasians.

Obstructive sleep apnea is a specific type of sleep-disordered breathing, in which the airway is blocked or collapsed, often by the soft tissue in the back of the throat. In particular, obstructive sleep apnea has been associated with nighttime heart attacks (91 percent), drug-resistant hypertension (83 percent), obesity (77 percent), congestive heart failure (76 percent), diabetes (72 percent), pacemakers (59 percent), and atrial fibrillation (49 percent). The estimated economic cost of undiagnosed obstructive sleep apnea in the United States was nearly $150 billion in 2015

Sleeplessness has very direct results on the body. Sleep insufficiency changes the balance of hormones that regulate appetite and results in greater risks factors for type 2 diabetes, including excessive eating for energy and increased glucose levels and insulin resistance. A lack of sleep may also produces stress hormones that cause people’s bodies to remain in a state of alertness and increases blood pressure. 

Poor sleep makes you more susceptible to illness.

Sleep also produces white blood cells that protect the body from infectious diseases and viruses. A poor night’s sleep could mean catching a cold or something much worse. After only one night with four to five hours of sleep, critical anti-cancer immune cells decrease by 70 percent. In fact, the connection between sleep deficiency and cancer is so strong that the World Health Organization classifies nighttime shift work as a probable carcinogen.

In addition, the role of sleep in cardiovascular health cannot be overstated. During non-REM sleep phases, our heart rate drops and our blood pressure is reduced, which provides the organ with a much-needed break from its vital daytime work. Consequently, insufficient sleep causes blood pressure to increase, and sleeping six hours or less a night makes your risk of a fatal heart attack or stroke skyrocket 200 percent.

Julia Worrall is The Sleep RN, a critical care nurse of 20 years and the program director of the Airway Advocacy group, Foundation for Airway Health. Julia has presented her findings on sleep to the National Commission on Correctional Health Care and continues to push for more comprehensive sleep programs for frontline staff and people in the criminal justice system.