September 17, 2020

Episode 27: A sleep expert shares her best tips for nurses

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Podcast

Description

What is the ideal interval between shift rotations? Does splitting sleep work? How long is the ideal nap? What’s the difference between a power nap and a restorative nap? 

On this episode of The Handoff, Dan is joined by Washington State University Professor Lois James, who is an expert on the role of sleep in performance. She and Dan speak about the ways in which the culture of nursing is often in conflict with good sleep habits. She shares some very practical fatigue countermeasures, as well as strategies that hospitals and nurse leaders can take to optimize shift lengths for their staff. 

Dr. James’s other research interest is racism and implicit bias in healthcare, and she also speaks about the dangers of implicit bias in nursing, how those biases are formed and strategies for overcoming them. 

Links to recommended reading: 

Podcast

Transcript

Dan:

Lois, thank you for coming on the show.


Lois:

Thank you so much for having me. I'm excited.


Dan:

So, Lois, I'm sure you've heard this a lot, but I'm really interested how a person with a PhD in Criminal Justice ends up as a researcher in a college of nursing?


Lois:

Yeah, that's definitely not the first time I've heard that question. So my background is in Psychology and of course then in Criminal Justice and I have always been extremely drawn to the human response. And I think, more than any other discipline perhaps, nursing fits that so well, because it really is the treatment of the human response and with patient advocacy as a core goal. For me, that just fits so well with all of the work that I do. I try and understand human performance and what the limits of that performance are and how occupational health fits into all that. And the nursing profession has just been so incredibly welcoming to me and really embraced the work that I do. And that's how I ended up in the College of Nursing at WSU. And I really couldn't be happier about it.


Dan:

I love it. Yeah, nursing really is the intersection of so many different aspects of the world and healthcare. And I think it's a profession that opens its arms to the interprofessional collaboration. So I would expect nothing less than an awesome collaboration there. You've done research on police, you've done research on nurses, high performing athletes. Before we dive into the nursing side, I'm interested. From the high performing athletes side, what was your focus with them?


Lois:

So, the work that I did with athletes was primarily actually around jet lag management. So I worked with athletes who were traveling overseas. I did quite a lot of work around the Winter Olympics in Sochi in terms of developing travel plans and how to manage jet lag, when to sleep, when to eat, when to train, what the periods of real sleepiness were likely to be based on the time change, that kind of thing. That was some really, really fun work. Elite athletes are just such a great group to work with. And the entire teams that surround them, of course, is super interdisciplinary and was really welcoming and accepting of the advice that I was giving. So it was a fun period of time.


Dan:

I'm curious, because there's this idea, and I think Johnson & Johnson has what they call a corporate athlete, which is executives and high performing people in organizations have the same stressors as athletes do. And you should train your body and your mind similar to how athletes train in order to deal with the stressors of working in a corporate environment. And I've done a fair amount of travel across multiple times. I wonder what are a few of the key takeaways that you learned in that research?


Lois:

Well, I think that the biggest takeaway are not actually specific to jet lag management or to travel, but the biggest takeaway for me was that I think that so many professional groups should take lessons from the way elite athletes approach sleep management and fatigue management, because of just the cultural side of things. I mean, within that professional group. So for elite athletes, I mean, there's such an emphasis on self-care, care of the body, care of the mind and making sure that you are your absolute best.


Lois:

So it's not seen as a weakness. There's never this feeling of, "Oh, well, if you can't get by on four hours of sleep at night, then you're not cut out to be an elite athlete or if you're not okay with being tired, then you're weak." It seems a priority. You have to be the absolute best to give 100% all the time. You have to make sure you have enough sleep. You have to make sure you're monitoring your fatigue. And I think that is such an important lesson that we can take. And I know that the military has really started to do that, which is fantastic and started to take those lessons and treat yourself as if you were an elite athlete and not downplay the importance of your own health.


Dan:

I think there's a lot of takeaways specific to nursing there as well I think. What you mentioned is the culture of nursing is you got to get by, just put up with that fourth 12-hour shift in a row, just drink some more coffee and you'll get through the night shift. And I was a night shift ER nurse. So I totally did those things. Why do you think nurses have that flip where it's like putting up with it rather than training to be a lead... I mean, I would argue there's more at stake for nurses being tired on the job than there is for a lead athlete, not scoring a goal or being at their peak performance for one game.


Lois:

Absolutely. Absolutely. And I think with nursing in particular, part of the cultural issue that you run into is it's so ingrained in the psyche to care for others, that I think that the care of oneself gets pushed to the side and it's considered to be secondary. And what we're really trying to do is teach and kind of learn from all the research and all the scientific studies that have occurred that really show that in order to be your best for others, in order to help others, in order to advocate for your patients, you have to take care of yourself first.


Lois:

And I think that that's where the cultural piece comes into it, because there's this feeling, I mean, for a very good reason, this idea of the superhero nurse. They can kind of do anything and survive no matter what. And although, that's wonderful, and in so many ways, that's true. But unfortunately we just see, I mean, if you're operating at 70% or 80% capacity, your risk of mistakes is going to increase, your risk of accident, of injury, of illness and unfortunately, of longterm health and wellness problems. So all of those are going to impact your ability to actually care for your patients.


Dan:

That's definitely there. And I know there's research out there and you've done some of it on error rates and sleep deprivation, but there's still that culture of, and one of the perks of the job, honestly, that we hear as well is, "Well, I can just work my three 12-hour shifts, I get four days off potentially. Or I can pick extra shifts at another hospital or whatever and actually make more money or do whatever." What are some of the key findings in your research around nurses that may contradict that cultural belief?


Lois:

Yeah. I mean, shift work, no matter what, shift work is challenging. I mean, it's extremely challenging to work nights, we're not nocturnal animals. So, we're designed to sleep at night and be awake during the day. So, we're fighting that anyway with my shifts, on top of that, in healthcare and honestly in a lot of shift working professional groups, 12s are often favored. You know what I mean? They're easier from a scheduling perspective, workers oftentimes, not always, but oftentimes like them, like you said, because of the consolidated days off. I mean, there's this idea of continuity of patient care.


Lois:

So often we get met with, "Whoa, why are you doing research around 12-hour shifts? Don't take away our 12s." But at the same time, we have to really understand and quantify what are the risks that are associated with working extended hours. Because if you think about it, a 12-hour shift, really isn't just 12 hours. When you think about time that you're coming in, handing over and whatnot. You're probably looking at closer to 13, if not a little bit more in some cases, and that's before you even get into the concept of overtime.


Dan:

Right. And I can definitely hear a nurse say, "Don't take away my 12s." Because I definitely have heard that too. What are some of those biggest risk factors or biggest impacts to safety that you found?


Lois:

Some of the big ones related to patient care are just kind of the cognitive effectiveness or the estimated risk of making a mistake. So, that's one big component of this. We have a way of predicting cognitive effectiveness and measuring based on the amount of sleep that you've had, the time since you last slept and the time of day it is, what time it is across the 24-hour period. There are some very, very clear signs that on nights after about the nine-hour period, that number, that percentage of yourself that you can actually give starts to tank. So, that has definite risks for patient safety. It has risks for increased likelihood of making an error. It also has some pretty strong risks of nurse safety, occupational safety as well.


Lois:

We're just concluding this big study. So we haven't really dug into the data yet, but it certainly seems the risk of driving safety is definitely there in the study that we're running at WSU. We put nurses in a driving simulator at the end of their test session where we test them in our nursing sim lab. After that point, we put them in a driving simulator to see what are the risks of a day versus night shift nurse working 12s as they drive home? Because anecdotally we hear time and time again, these tragedies, these awful cases where nurses will literally fall asleep at the wheel as they drive home and what does that mean for liability for the hospital? What does it mean? And trying to really understand all of that, to maybe influence some policy around that. So we do see that there is certainly some risk there.


Dan:

Yeah, I definitely can relate to that. I remember coming home from a night shift once and I don't think I fell asleep, but I forgot how I got home. And yeah, it's not optimal. So what are some of the strategies that healthcare systems nursing leaders can take to optimize shift length or scheduling so that they can reduce that risk of error, safety, those types of things?


Lois:

Sure. Part of it is taking a good, hard look at the length of shifts. So I mean, like I said, and 12s can be very popular, but there certainly seems to be a difference between 12-hour days, which are not as problematic and 12-hour nights. So part of it is really thinking about what's going to work for the organization. Is there the ability to of split shift lengths, to have days work longer and nights work shorter? And then rotate in some way.


Lois:

Another thing is managing fatigue while on shift. So, I mean, I'm a huge advocate of strategic and scheduled napping. And again, part of it is a huge cultural thing. The barriers around napping on duty for nurses are entirely cultural. Because there are plenty of other professional groups that not just allow, but encourage napping during downtime on shift. That's a part of it as well. And then of course there are other fatigue countermeasures that can certainly play in, in terms of just helping you through.


Dan:

So the large Starbucks and the humongous energy drink is probably not the best strategy there.


Lois:

Probably not the... Caffeine when used strategically and when monitored in terms of your tolerance to it, I mean, does remain one of the very useful fatigue countermeasures, but the big thing there is monitoring tolerance to it, many of us have some level of caffeine addiction. And so you have to be careful because you want to know that when you have your coffee, let's say at 1:30 AM anticipating that the 2:00 to 4:00 AM phase is going to be really, really rough. I mean, that's the ultimate low in our circadian rhythm. So knowing that when you have that coffee at 1:30 AM, it's actually going to have an effect. I mean, that's pretty important. So you don't want to be pounding coffee throughout the shift up until that point.


Dan:

Right. Yeah. And that's what I learned as I trained for some triathletes personally, the strategic intake of caffeine through a long Iron Man Triathlon actually peaks back and get you some energy to finish the race, but taking it longterm just made my heart rate go through the roof and I'd actually fatigue faster than if I did it in smaller doses throughout when I was feeling those lows like you mentioned.


Lois:

Another great fatigue countermeasure that isn't as widely known as caffeine and isn't used as often, but can be very effective is actually light therapy. So exposure, exposure to light when you want to feel alert and then avoiDance of light when you want to wind down, that's a really useful one. And I know obviously that during a night shift exposure to sunlight is not an option. But that's why many hospitals and many groups are moving towards investing in light boxes, for example, where you can just have one at the nurses station and it can just give an alerting dose of life that can give you a bit of a boost.


Dan:

Interesting. So one of the questions that I've got from some of my colleagues in the ER as well, I have asked, is it better to stay on a shift, like be night shift all the time, every time, or is it better to rotate back and forth, whether that's in a week or over several weeks where you go day shift and night shifts back and forth, what are your thoughts on that?


Lois:

There's actually some really interesting findings around kind of looking at what's the optimal rotation schedule. And although there's a little bit of conflict in terms of the results, what we do know is the medium pace rotation. So, where you rotate every week or every couple of weeks, that seems to actually be the most damaging and the hardest to acclimate to. So most of the science at this point says to keep rotations either to longer term. So you rotate no quicker than every month or longer, which allows you to have a proper acclimation period. Or there's some research that shows forward rapid rotation can be quite effective.


Lois:

So in other words, you'd work a day, you'd work an evening, you'd work a night, then you'd have time off. You definitely want to avoid backward rapid rotation. So a night, an evening and a day, because that's harder for the body to adjust to. But forward rapid rotation, there has been some work that shows that that's actually pretty effective.


Dan:

Interesting. And as far as sleep goes, is it better to get eight good hours or 10 good hours, six good hours? Or could you consolidate sleep in spurts of two-hour blocks? I know one of the things that, as a night shift nurse, it was near impossible to sleep past 2:00 PM for me, after a shift, getting off at 7:00 AM, but I could take a nap maybe in-between 2:00 PM and my next shift starting at 7:00. So just wonder what the findings are related to that.


Lois:

Yes. Splitting sleep, especially for night shift workers, can be very, very effective because just like you said, I mean, the Danger when you try and consolidate sleep is, let's say, you'll get off work, you'll get home, you'll get a couple of good hours. And then you'll limp along trying to sleep a bit more and then you'll call it good. And really you've only gotten, let's say, five hours or so, which is just insufficient sleep.


Lois:

So instead one option is to come home sleep for as long as you comfortably can, which is usually anywhere between four and six hours, let's say, and then get a couple more hours before you go back out on shift. So that's a split sleep schedule that does work for a lot of people.


Dan:

And that's one of those fatigue countermeasures, which you've mentioned before. If you had to pick the one most effective fatigue countermeasure, what would it be?


Lois:

Definitely napping. If you think about it, napping is the only fatigue countermeasure that actually addresses the problem. Everything else is some kind of a bandaid. But sleep related fatigue, which is when we talk about fatigue, I should specify that I'm talking about sleep related fatigue, because there are lots of different types of fatigue. But tiredness from not having enough sleep, the only thing that's really going to make a true difference is napping. Because it's going to give you what you need. I mean, light therapy, caffeine, melatonin, hydration. There are lots of other things that can be great. But like I said, it's just a bandaid and not fixing the underlying problem.


Dan:

I love naps by the way. So I love that piece of advice. We need more nap rooms within healthcare facilities for nurses. I think that'd be great.


Lois:

Absolutely. And just a quick point on naps. Because I get asked so frequently, "Well, when I nap, how long should I nap for?" There are actually two very distinctive different types of nap. There's your restorative nap, an ideal time for that is about 90 minutes. And that's because that's about the amount of time it takes you to get through a sleep cycle or just a little bit shy of that. Or there's the power nap, which is about 20 minutes. And the timing of those is quite deliberate because what you want to avoid when you have a nap is you want to avoid being awakened from really deep slow-wave sleep.


Lois:

And so, everybody has experienced that feeling when your alarm goes off and you're dragged up from the depths of hell and you think that no profession is worth feeling like this. That's that sleep inertia and it does wear off, but it takes a little while. So if you nap, the best thing to do is try and avoid that. So, like I said, the 20 minute power nap, which is great, it'll give you a boost. It won't really give you as much restoration as a longer 90-minute nap. But of course, a 90-minute nap might not be feasible if you're on shift.


Dan:

That makes sense. Yeah. I remember I definitely have taken a few 20-minute naps on my lunch break interspersed between care episodes. So, that's great piece of advice. I want to switch a little bit up to your work with bias and specifically in the healthcare realm. Can you give us an overview of your research related to bias in healthcare?


Lois:

Yeah. My research on bias and healthcare is actually in its infancy, because most of my work with bias has been around policing. But what I'm in the process of doing, I developed a simulation-based implicit bias training platform for policing, which I'm in the process of translating to a healthcare setting. So again, I mean, using the same philosophy, using simulation to allow nurses and other healthcare practitioners to become aware of what drives their behavior and drives their decisions. So bringing those implicit biases and implicit bias is the idea of unconscious or semi-conscious associations that we have. We might not even be aware of them. And that's what makes them so problematic, because we might not even be aware of how our attitudes and our perceptions drive how we treat different types of people. So I'm in the process of translating that over to the healthcare setting. And I hope, I've got a couple of studies that are pending, but if they're selected for funding, that I'll be able to really launch that line of work.


Dan:

So in the implicit bias side, in my own research, I looked at organizational culture and how groups develop their values as a team over time, specifically around leadership and healthcare leadership. How is implicit bias formed? Is it a gradual build of experiences over time? Is it one experience that someone has that then leads to something? What is the evidence around that?


Lois:

I mean, it can be either. So, from a evolutionary perspective, implicit bias is a survival heuristic. It's just the associations that we make that will ultimately keep us safe. And in the ancestral realm, sure, that could be very useful. That could be beneficial. So, I mean, fearing people from across the river that looked different from you was probably beneficial back then. What we have to ask ourself is how useful or beneficial is that today? And of course it's not, because we've got very, very diverse cultures now where fearing people who don't look like you is both not useful for survival, but also massively discriminatory.


Lois:

Unfortunately, something that's so very deeply ingrained is not all that easy to change. And especially, if it's operating outside of our conscious awareness. And to give you an example of how easy implicit bias can be to form, I mean, there are two examples that I like to use. A couple of years ago, there were two media stories that were essentially running at the same time about men who had killed somebody. And they were very, very widely publicized. Both of them. One was a father who had some kind of psychotic break and who had killed his wife and children. The other was a man who had experienced a similar thing, who had killed somebody else.


Lois:

And I'm not making any kind of judgment as to which was worse, but one of these men was white and one was black. And when you looked at how extreme the differences were in how these men were portrayed in the media, that is a very, very clear example of how implicit bias can form, because you really wouldn't have, unless you'd been actively thinking about it, you wouldn't even have made this comparison. But it was just so clear, when you put them side by side, how differently society sees different types of people.


Dan:

That experience the way they're portrayed then can lead to potentially others adopting a similar or developing a similar bias over time.


Lois:

Absolutely. Yeah. So I mean, bias is informed. It's informed by what we see in the media. It's informed by our own personal experiences, by our family values and beliefs and so on. So, I mean, it really can form very easily. My daughter's 11 now, but when she was, goodness, I think she was about three and a half or maybe four, we were at the gym, we got back. She had been in the daycare at the gym. We got home and we were playing with Lego friends, little Lego characters that are a bit bigger and have skin tones.


Lois:

And I was playing with her and I handed her one and she said, "I don't want to play with that one." And I said, "Well, sweetheart, why not?" And she said, "I don't, I don't like her. She has dark skin." And of course my heart is absolutely dropping. I'm a bias researcher. And so, I'm thinking, "What in the world?" So anyway, I try not to freak out and I talked to her a little bit and it turns out that one of the minders in the daycare at the gym had said something like that to her earlier that day, "Oh, don't play with that doll. She's not as nice. She's got dark skin."


Lois:

And nobody would blame my four year old daughter, nobody would look at a four year old and say, "Well, they're racist." And yet it is so easy, it's so easy to impress these deep-felt prejudices onto an innocent or a young mind. So again, just another example of how easy it is to form implicit bias and why it is so critical for us both individually and as a society to understand implicit bias and to address it.


Dan:

And that's definitely been top story in the news for the last several months. And one of the confusions that I hear and that I have myself too is what is the difference between implicit bias and systemic racism?


Lois:

Yeah. So there's three different elements. I mean, there's the implicit bias, there's the blatant bigotry or racism, and then there's systemic racism. And for healthcare, the great news is the explicit bigotry is not particularly widespread. I mean, if you asked healthcare providers about their beliefs, they're likely to come up pretty low on any blatant prejudice scales. That doesn't mean that implicit bias isn't necessarily at play. So, the next piece, of course, the implicit bias much more widespread and that creeps in, in ways like associating different types of people with drug seeking, for example. So, if you have somebody come in and they're homeless, for example, do you have that implicit bias that's going to tell you, "Well be careful about pain medication because they could be drug seeking."


Lois:

That's an implicit bias. And we see that not just with socioeconomic status, we see that with race as well. So, it's very, very important to become aware of those because it can have these huge follow-on effects. It can lead to biased healthcare delivery in the sense of both potentially reduced pain medication administration, but also in development of a therapeutic relationship in making that person feel comfortable and feel welcome and feel advocated for. Because if they don't, perhaps the next time they won't want to come to the hospital and that can have huge health outcomes. So, I don't think that implicit bias on the part of healthcare providers is the sole cause of inequity and health outcomes, but it's certainly a cause.


Dan:

Even the words we use. I mean, in the ER, a common terminology is frequent flyer or someone who comes to the ER frequently, and that changes the way you interact with them, whether you acknowledge it or not, even just using that term changes the mindset and how you approach the care of that individual. And we have to be aware of those things. I think the words we use, the labels we put on people. And I remember in nursing school, you'd say, "Well, the diabetic patient." Instead of, "The patient with diabetes." Or, "Room 232 needs XYZ," not, "Mrs. Jones or whatever in the room over there." So even just the way we frame things can lead to changes in how we interact with our patients.


Lois:

Yeah, absolutely. And then the systemic racism piece obviously comes in. That's quite a lot broader than just healthcare, but it certainly can lead to some real barriers and challenges around access to good quality healthcare. It all factors in, it all plays a part.


Dan:

Yeah. What are some of the strategies that nurses can use to check themselves related to bias and even systemic racism as they go about their care in hospitals?


Lois:

I think a huge one and the first major step is just being self-aware. In today's society, ignorance is no longer an excuse. Not knowing better is no longer an excuse. I think that anybody working with people, where there is the potential for discrimination, there's the potential for implicit bias to creep in, has got to be aware of what their motivations are when they make decisions. And whether that's for nursing or policing or for whichever professional group, that's just the critical first step, being self-aware constantly, if you feel uncomfortable, if you feel the hairs on the back of your neck stand up, ask yourself, "Why?"


Lois:

And that's not, of course, that's not to say don't compromise personal safety. There are plenty of situations where having a threat response is warranted, but just really be mindful about what the drivers of your behavior are.


Dan:

Great advice. And what role can nurses play in the larger system to help address and prevent biased in healthcare delivery?


Lois:

I think a huge role. I think nurses are the linchpin of the system. I mean, they spend the most time with patients. And I think that, again, in terms of that therapeutic relationship, in terms of making a patient feel heard and feel valued and feel like they matter, I think that's an exceptionally important role that nurses play, arguably more than anybody else. That's why I'm actually pretty hopeful that some of these issues can be addressed. Because I do think that nurses, as a professional group, are extremely mindful of their patient's feelings and their patient's voice. So I think that with even a little bit of self-awareness and of effort, some kind of fairly big changes could be observed.


Dan:

Yeah, the nurses are definitely the connectors of the system and most information flows through them. And so, being the intentional translators of how things are perceived, how information gets translated and then the advocacy back out, I think, is a key role nurses can play that change the way the whole system interacts with patients. One of the things we like to do here is hand off that one nugget of information that you'd like to pass on to our listeners about how they can improve the healthcare system. So what would you like to hand off to our listeners?


Lois:

It has to be just one?


Dan:

Well, it could be several. We could have several handoffs.


Lois:

I think I just probably have two. The first is to make sure you take care of yourself and make sure that you don't ignore your own health, your own wellness, your own quality of life in the name of putting patients first, of course, I mean, putting patients first is a wonderful attribute that so many nurses have, but you really do, in order to care for people to the best of your ability, you have to be the best version of yourself. And that's only going to happen if you're getting proper sleep and if you're managing your fatigue and taking care of yourself. So I think that's the first big one is don't ignore your own health and wellness.


Lois:

And then the other big one I think is related to implicit bias and related to how we can all make a difference. And I really hope that this is the time. If this isn't the time, I don't know when will be. But I think remembering that there's a difference between intentions and impact, and you're not just responsible and you're not just accountable for the intentions that you have, you're also responsible for the impact. So just because you don't intend to let bias creep in, you're still responsible if it does and if that has a negative outcome. So I think being really, really mindful of what you're putting out into the world and how it's being received is so important.


Dan:

Two great nuggets of advice, and Lois, I just really appreciate you being on the show. Thank you so much for all the insights. Where's the best place that people can find you and learn more about all the great work that you're doing.


Lois:

The Washington State University College of Nursing website. Likely if you Google my name, that'll be the first one that comes up, but that's got links to the research that we're doing and the ultimate goals and vision of the work.


Dan:

Awesome. Are you on Twitter? Social media? LinkedIn?


Lois:

Yes. Yes. I certainly am. I'm trying to remember what they are.


Dan:

That's okay. We'll put them in the show notes. [inaudible 00:30:39] we'll put it on the show notes to connect to you, but just really appreciate all the work you're doing and your passion for working with nurses and finding out these deep-seated problems within our healthcare system and providing great insights on how we can innovate to build a better system and ultimately provide better patient care, which is really the outcome. Thank you so much for being on the show.


Lois:

Thank you so much for having me. I really appreciate it.



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