Sustained work, fatigue, sleep loss and performance: A review of the issues

The physiological and psychological stressors associated with sustained work, fatigue, and sleep loss affect worker performance. This review describes findings relating to sustained work stresses commonly found in our advancing technological world. Researchers report decrements in sustained performance as a function of fatigue, especially during and following one or more nights of complete sleep loss, or longer periods of reduced or fragmented sleep. Sleep loss appears to result in reduced reaction time, decreased vigilance, perceptual and cognitive distortions, and changes in affect. Sleep loss and workload interact with circadian rhythms in producing their effects. These interactions are a major source of stress in work situations requiring sustained work in continuous operations and have implications for theoretical models of sustained perceptual and cognitive functioning.     

The benefits of a nap during prolonged work and wakefulness

Prolonged work scenarios with demands for sustained performance are increasingly common. Because sleep loss inevitably compromises functioning in such situations, napping has been proposed as a countermeasure. The optimal timing of the nap relative to its benefits for performance and mood is not known, however. To address this issue, 41 healthy adults were permitted a two-hour nap at one of five times during a 56-hour period of intermittent work, with no other sleep. Naps were placed 12 hours apart, near the circadian peak (P) or trough (T), and were preceded by 6(P), 18(T), 30(P), 42(T), or 54(P) hours of wakefulness. Work test bouts occurred every few hours and consisted of a variety of psychomotor and cognitive tasks as well as mood scales completed at the beginning, middle and end of each bout. A total of eight performance and 24 mood parameters were derived from the bouts and compared between groups at all test points prior to and following the naps. An estimate of the extent to which each nap condition differed from the control (P54) condition was derived by totalling the proportion of test points that yielded statistically significant results relative to the total number of tests conducted both before and after naps.

Although all performance and most mood parameters displayed a circadian-modulated deterioration as the protocol progressed, a nap appeared to attentuate the extent of this change in all performance parameters but not in mood parameters. Overall, the timing of the nap across days and within the circadian cycle was irrelevant to its effect on performance, suggesting that it diminished the intrusion of sleepiness into behavioural functioning, even though subjects were phenomenally unaware of this benefit.     

Effects of sleep inertia on cognitive performance following a 1-hour nap

Abstract

This study investigated the effects of a 1-h nap on subsequent performance in spatial memory (SM) and logical reasoning (LR) tasks. The objective was to evaluate the duration of the effects of sleep inertia (SI). The performance was measured in two independent groups of subjects. The 1-h nap took place at 00:00 h in group 1 and at 03:00 h in group 2. In each task, the experimental design comprised one no-nap condition in which subjects had no sleep before the night tests, and a nap condition that comprised the 1-h nap followed by the test sessions. To measure the duration of SI effects, the subjects were tested in two 30-min sessions and the data in each session were analysed in sub-units of time of 3 min each. In each task the results showed no effects on accuracy, and no circadian effects of napping were found. In each task, analyses of pooled data of the two groups showed that the performance in the 1-h nap condition exhibited significant reductions of speed immediately following awakening, when compared with no-nap, reflecting SI effects. In SM, the slowing lasted 24 min, and 27 min in LR. Practical implications of the results are discussed.     

Effects of sleep inertia on cognitive performance following a 1-hour nap

This study investigated the effects of a 1-h nap on subsequent performance in spatial memory (SM) and logical reasoning (LR) tasks. The objective was to evaluate the duration of the effects of sleep inertia (SI). The performance was measured in two independent groups of subjects. The 1-h nap took place at 00:00 h in group 1 and at 03:00 h in group 2. In each task, the experimental design comprised one no-nap condition in which subjects had no sleep before the night tests, and a nap condition that comprised the 1-h nap followed by the test sessions. To measure the duration of SI effects, the subjects were tested in two 30-min sessions and the data in each session were analysed in sub-units of time of 3 min each. In each task the results showed no effects on accuracy, and no circadian effects of napping were found. In each task, analyses of pooled data of the two groups showed that the performance in the 1-h nap condition exhibited significant reductions of speed immediately following awakening, when compared with no-nap, reflecting SI effects. In SM, the slowing lasted 24 min, and 27 min in LR. Practical implications of the results are discussed.     

The benefits of a nap during prolonged work and wakefulness

Abstract

Prolonged work scenarios with demands for sustained performance are increasingly common. Because sleep loss inevitably compromises functioning in such situations, napping has been proposed as a countermeasure. The optimal timing of the nap relative to its benefits for performance and mood is not known, however. To address this issue, 41 healthy adults were permitted a two-hour nap at one of five times during a 56-hour period of intermittent work, with no other sleep. Naps were placed 12 hours apart, near the circadian peak (P) or trough (T), and were preceded by 6(P), 18(T), 30(P), 42(T), or 54(P) hours of wakefulness. Work test bouts occurred every few hours and consisted of a variety of psychomotor and cognitive tasks as well as mood scales completed at the beginning, middle and end of each bout. A total of eight performance and 24 mood parameters were derived from the bouts and compared between groups at all test points prior to and following the naps. An estimate of the extent to which each nap condition differed from the control (P54) condition was derived by totalling the proportion of test points that yielded statistically significant results relative to the total number of tests conducted both before and after naps.

Although all performance and most mood parameters displayed a circadian-modulated deterioration as the protocol progressed, a nap appeared to attentuate the extent of this change in all performance parameters but not in mood parameters. Overall, the timing of the nap across days and within the circadian cycle was irrelevant to its effect on performance, suggesting that it diminished the intrusion of sleepiness into behavioural functioning, even though subjects were phenomenally unaware of this benefit.     

Auditory evoked potentials as a function of sleep deprivation

Event-related brain potentials (ERPs) were studied in subjects deprived of sleep over a 48-h test period to assess the effects of different durations of continuous wakefulness on ERP components and to determine whether changes in the ERP components were related to changes in performance. Forty subjects were randomly assigned to either an experimental (sleep deprived) group (n = 30) or a control (not sleep deprived) group (n = 10). For the experimental subjects, ERP and performance measures were obtained in four-h test blocks throughout the 48-h period. Performance was assessed using the Walter Reed performance assessment battery. The control subjects were tested at the same times except during designated sleep periods. Both performance and evoked potential measures showed systematic changes over the experimental test period in association with sleep deprivation, time of day, and repeated testing. The latency of the N2 component of the evoked potential covaried with throughput measures on the performance assessment battery across the 12 four-h test blocks of the experiment. These data suggest that ERPs reflect central processes that change across the sleep deprivation period and that ERP measures might be useful in assessment and prediction of performance degradation under adverse conditions such as sleep loss.     

Polyphasic sleep strategies improve prolonged sustained performance: A field study on 99 sailors

In situations where continuous prolonged work demands exist, the habitual nocturnal monophasic (6-8h duration) sleep pattern can rarely be accomplished, and performance effectiveness may sometimes be severely compromised by accumulation of sleep debt. Several studies have shown that naps can be disproportionately effective in recovering functioning during continuous work (CW).

In this study, sleep-wake patterns and their relationship to performance were studied for 99 sailors involved in solo and double-handed ocean sailing races (a model of a highly demanding CW situation). Most sailors spontaneously adopted multiple nap sleep-wake schedules and adapted without major difficulties to such polyphasic patterns. 66.5% had mean sleep episode durations (SEDs) ranging from 20 min to 2h. Overall mean Total Sleep Time (TST) per 24h was reduced from a baseline of 7.5 to 6.3h. Race performance correlated negatively and significantly with mean SEDs and TSTs. Best performance results were obtained by those sleeping for periods of between 20 min and 1 h and for a total of 4.5 to 5.5h of sleep per day.

The results are discussed together with several chronobiological, phylogenetic and experimental studies and issues, all of which suggest that adult humans may have a damped polyphasic sleep-wake tendency. It is also proposed that polyphasic sleep schedules could become promising and feasible solutions for the management of sleep requirements under prolonged CW situations.     

Shiftwork effects in nuclear power workers: A field study using portable computers

This field study of nuclear power shiftworkers reports the use of hand-held computers to record alertness levels, cognitive task performance and workload ratings. Subjective ratings and performance tasks (Search and Memory-5 (SAM-5); Choice Reaction Time (CRT) were completed on the computers at 2-h intervals during selected shifts in the work schedule by maintenance crews and reactor operators. Sleep duration and quality data were also obtained during the 35-day shift cycle. Workload remained relatively stable across shifts. The night-shift was associated with shorter sleep durations and poorer sleep quality. Significantly lower levels of alertness and poorer perforniance for components of the performance tasks were also observed on the night-shift. Tinic-on-shift effects on alertness were evident, where by for the night-shift, especially, alertness dropped dramatically during the early hours. Components of SAM-5 performance showed differential time-on-shift patterning relative to each shift whereas CRT was unresponsive to time-on-shift effects. Significant variations were observed in alertness and performance components during the 12-h night-shift. Perhaps paradoxically, performance on the 12-h night-shift appeared to improve rather than deteriorate during the early-hour period that was associated with the greatest drop in alertness. This was suggestive of extra effort expenditure during this critical period.     

Shiftwork effects in nuclear power workers: A field study using portable computers

Abstract

This field study of nuclear power shiftworkers reports the use of hand-held computers to record alertness levels, cognitive task performance and workload ratings. Subjective ratings and performance tasks (Search and Memory-5 (SAM-5); Choice Reaction Time (CRT) were completed on the computers at 2-h intervals during selected shifts in the work schedule by maintenance crews and reactor operators. Sleep duration and quality data were also obtained during the 35-day shift cycle. Workload remained relatively stable across shifts. The night-shift was associated with shorter sleep durations and poorer sleep quality. Significantly lower levels of alertness and poorer perforniance for components of the performance tasks were also observed on the night-shift. Tinic-on-shift effects on alertness were evident, where by for the night-shift, especially, alertness dropped dramatically during the early hours. Components of SAM-5 performance showed differential time-on-shift patterning relative to each shift whereas CRT was unresponsive to time-on-shift effects. Significant variations were observed in alertness and performance components during the 12-h night-shift. Perhaps paradoxically, performance on the 12-h night-shift appeared to improve rather than deteriorate during the early-hour period that was associated with the greatest drop in alertness. This was suggestive of extra effort expenditure during this critical period.     

An objective measure of fatigue derived from a set of brief tasks

Seventy-three soldiers who had lost three nights sleep and 45 unfatigued soldiers completed a 25-minute computerized set of tasks derived from the pencil-and-paper kit of factor referenced ability tests. The fatigued soldiers produced more long-reaction times than die unfatigued group, but their accuracy was unaffected, in accordance with the 'lapse hypothesis' of sleep-loss effects. Two scores were derived from the data, one representing accuracy, and the other fatigue. A second study using 21 unfatigued students showed that differences in ability affected both of these scores, but that practice effects from repeated administration of the tasks improved only the fatigue score, not the accuracy score. The set of tasks could, with refinements, be used to obtain an objective measure of fatigue if used with experimental and control groups drawn from the same population.     

Policies and management of reproductive risk in the workplace

Abstract

Seventy-three soldiers who had lost three nights sleep and 45 unfatigued soldiers completed a 25-minute computerized set of tasks derived from the pencil-and-paper kit of factor referenced ability tests. The fatigued soldiers produced more long-reaction times than die unfatigued group, but their accuracy was unaffected, in accordance with the ‘lapse hypothesis’ of sleep-loss effects. Two scores were derived from the data, one representing accuracy, and the other fatigue. A second study using 21 unfatigued students showed that differences in ability affected both of these scores, but that practice effects from repeated administration of the tasks improved only the fatigue score, not the accuracy score. The set of tasks could, with refinements, be used to obtain an objective measure of fatigue if used with experimental and control groups drawn from the same population.     

Dealing with shift work: Physical fitness, temperature, and napping

This paper reviews the effects of generally controllable factors such as physical conditioning, ambient temperature, and amount of prior sleep in adjustment to night work periods and shift work. One can expect a 5-10% decline in capacity for work in nocturnal work periods as compared to daytime work periods. This decreased capacity would dissipate if workers maintained a consistent sleep-wake routine for 8-16 days after moving to a new shift. Proven means for accelerating this adaptation are currently not available. The ability to perform work also declines as the length of the work period increases but depending upon individual tasks. Physical conditioning improves mood and general well-being, but no strong evidence currently indicates that conditioning increases tolerance or adjustment to shift work.

Increased ambient temperature increases the stress of work, although studies do not address heat as a factor in adjustment to shift work. While lower nocturnal temperature would be assumed to reduce heat stress during night shifts, supporting data does not exist. Studies have not addressed the negative consequences of cold stress or of rotating from night to day shifts with added heat stress.

The proper use of short sleep periods either as preparation for or as a response to a shift change can ameliorate some effects of shift rotation. Data indicate that performance on 'graveyard' shifts can be maintained close to baseline levels following true prophylactic naps while performance may decline by up to 30% when such naps are not taken. While there is evidence that naps or even rest periods without sleep are beneficial in improving mood in normal young adults, these data do not apply to 'replacement' naps. Studies of interjected naps imply that such naps do reduce sleep debt but do not imply that such naps are more beneficial than longer sleep periods. Naps appear to be most advantageous when the accumulated sleep debt is least.     

Performance, alertness, and sleep after 3·5 years of 12 h shifts: A follow-up study

Control room operators at a continuous processing plant have been working a 12 h/3-4 day rotating shift schedule for over 3 years. After 7 months on this schedule, our initial assessment indicated decrements in performance and alertness, and a mild to moderate sleep debt, when the 12 h shift schedule was compared to the previously-worked 8 h shift schedule. In an effort to track long-term adaptation to the schedule, we conducted a 3 & 5 year follow-up evaluation using the same set of measures. Long-term follow-up testing revealed persistent decrements in performance and alertness attributable to 12 h shifts, and 1-3 h reductions in total sleep time after 12 h night shifts. Little deterioration in performance or alertness was observed across the workweek, which suggested day-to-day recovery from the extended workshift. The popularity of the 12 h shift schedule at this worksite indicates that the workers are willing to tolerate extra fatigue to derive other benefits from this schedule.     

Work stress and attentional difficulties: An initial study on burnout and cognitive failures

Professional burnout is a stress-related disorder, having mental exhaustion due to work stress as its most important characteristic. Burned out individuals also often complain about attentional problems. However, it is currently not clear whether such complaints are based on true cognitive deficits or whether they merely reflect the way burned out individuals rate their own cognitive performance. To confirm the cognitive complaints we used a cognitive failure questionnaire (CFQ) to assess the level of self-reported attentional difficulties in daily life. We also measured performance on tasks of sustained attention and response inhibition (the SART and the Bourdon-Wiersma Test). We compared three groups: (1) a group of 'burned out' individuals (n=13) who stopped working due to their symptoms and sought professional treatment; (2) teachers at a vocational training institute (n=16) who reported high levels of burnout symptoms but continued to work; and (3) teachers from the same institute (n=14) who reported no burnout symptoms. The level of burnout symptoms was found to be significantly related to the number of cognitive failures in daily life, and to inhibition errors and performance variability in the attentional tasks. To our knowledge, explicit tests of objective cognitive deficits in burned out individuals have not been conducted before. Consequently, this is the first study to indicate that burnout is associated with difficulties in voluntary control over attention and that the level of such difficulties varies with the severity of burnout symptoms.     

Perceived physical work capacity, stress, sleep disturbance and occupational accidents among firefighters working during a strike

Fire-fighting and rescue work are arranged in such a way that various kinds of accidents and catastrophes can be handled. In an understaffed situation, such as a strike, this goal may not be met. The objective of this study was to investigate factors associated with perceived physical work capacity, stress, sleep disturbance, and occupational accidents among firefighters who remained at work during an extended strike. A cross-sectional questionnaire study was carried out among 543 firefighters (83% of the target group) in 71 fire brigades in Finland. After the strike had lasted for 9 to 11 weeks, most of the firefighters perceived their physical work capacity to be rather good or very good. Stress increased along with a decreasing number of personnel in a crew (OR= 2.3, CI= 1.0-5.3, for less than 75% of a normal crew vs. normal crew) and with decreasing number of personnel in a shift (OR= 2.4, CI= 1.1-5.4, for less than 25% of normal shift vs. normal shift). Sleep disturbance was reported to occur as soon as the total working time exceeded 50 h/week. Working more than 70 h/week increased the risk of occupational accidents almost 4-fold compared with working no more than 50 h/week. These results suggest that exceptional situations, such as a strike, are a challenge to human capacity. With time, increased stress and sleep disturbance may lead to serious consequences.     

Perceived physical work capacity,stress, sleep disturbance and occupational accidents among firefighters working during a strike

Fire-fighting and rescue work are arranged in such a way that various kinds of accidents and catastrophes can be handled. In an understaffed situation, such as a strike, this goal may not be met. The objective of this study was to investigate factors associated with perceived physical work capacity, stress, sleep disturbance, and occupational accidents among firefighters who remained at work during an extended strike. A cross-sectional questionnaire study was carried out among 543 firefighters (83% of the target group) in 71 fire brigades in Finland. After the strike had lasted for 9 to 11 weeks, most of the firefighters perceived their physical work capacity to be rather good or very good. Stress increased along with a decreasing number of personnel in a crew (OR= 2.3, CI= 1.0-5.3, for less than 75% of a normal crew vs. normal crew) and with decreasing number of personnel in a shift (OR= 2.4, CI= 1.1-5.4, for less than 25% of normal shift vs. normal shift). Sleep disturbance was reported to occur as soon as the total working time exceeded 50 h/week. Working more than 70 h/week increased the risk of occupational accidents almost 4-fold compared with working no more than 50 h/week. These results suggest that exceptional situations, such as a strike, are a challenge to human capacity. With time, increased stress and sleep disturbance may lead to serious consequences.     

Appropriate use of bright light promotes a durable adaptation to night-shifts and accelerates readjustment during recovery after a period of night-shifts

Abstract

The present study examines the stability of bright light circadian readjustment during two consecutive dim light night-work periods and circadian synchronization during the recovery after a night-shift period. A sample of 10 subjects was divided into 2 groups (control group: 6 subjects; experimental group: 4 subjects). All subjects worked during 5 days, between 23:00 and 07:00 h and then went to sleep. Subjects received 2500-3000 lux between 02:00 and 05:00 h during 5 days for the control group and 3 days for the experimental group. During recovery after the night-shift periods, three cycles of bright light were administered at two different times: 12:00-15:00 h for two of six subjects from the control group and 10:00-13:00 h for all subjects (4) of the experimental group. By the fifth cycle of night-work the maximum of urinary aMT6s excretion that occurs at 05:00 h in the baseline condition was shifted to 12:00 h for the control and experimental groups (delay in hours: 7±1.6 (control); 7±1 (experimental)). This result suggests that three cycles of bright light are sufficient to induce a significant phase delay and that this delay remained stable when night-work proceeded under dim light. The phase delay of the circadian aMT6s excretion by exposure to bright light was accompanied by an improvement of the quality of day sleep and level of cognitive and psychomotor performances for control and experimental groups. No significant difference was observed in the two groups for daytime sleep and nocturnal performance. The two bright light periods used during the three days of recovery induced a complete synchronization in five of six subjects. One subject showed a partial synchronization probably because he remained at the laboratory under dim light during the day and had few family and social contacts.     

Appropriate use of bright light promotes a durable adaptation to night-shifts and accelerates readjustment during recovery after a period of night-shifts

The present study examines the stability of bright light circadian readjustment during two consecutive dim light night-work periods and circadian synchronization during the recovery after a night-shift period. A sample of 10 subjects was divided into 2 groups (control group : 6 subjects; experimental group: 4 subjects). All subjects worked during 5 days, between 23:00 and 07:00 h and then went to sleep. Subjects received 2500-3000 lux between 02:00 and 05:00 h during 5 days for the control group and 3 days for the experimental group. During recovery after the night-shift periods, three cycles of bright light were administered at two different times: 12:00-15:00 h for two of six subjects from the control group and 10:00-13:00 h for all subjects (4) of the experimental group. By the fifth cycle of night-work the maximum of urinary aMT6s excretion that occurs at 05:00 h in the baseline condition was shifted to 12:00 h for the control and experimental groups (delay in hours: 7 +/- 1.6 (control); 7 +/- 1(experimental)). This result suggests that three cycles of bright light are sufficient to induce a significant phase delay and that this delay remained stable when night-work proceeded under dim light. The phase delay of the circadian aMT6s excretion by exposure to bright light was accompanied by an improvement of the quality of day sleep and level of cognitive and psychomotor performances for control and experimental groups. No significant difference was observed in the two groups for daytime sleep and nocturnal performance. The two bright light periods used during the three days of recovery induced a complete synchronization in five of six subjects. One subject showed a partial sychronization probably because he remained at the laboratory under dim light during the day and had few family and social contacts.     

A 14-h night-shift in the control room of a fire brigade

All 29 operators in the control room of a fire brigade performed test sessions during work and leisure time at 2-h intervals on a day with a 14-h night-shift, a day off and a day with a 10-h morning shift. The test sessions consisted of a visual search choice reaction time test and two Sternberg memory search tests (1 or 5 letters had to be memorized). Furthermore, the operators recorded their oral temperature and their subjective alertness before each test session. The subject also kept a diary of work and sleep times for 14 days. The circadian rhythm of body temperature was hardly changed by a single night-shift. Parallel to the body temperature, the subjective alertness fell significantly during the night-shift reaching a minimum value at 06:00 h. The mean reaction times increased non-significantly at the end of the night-shift and the results of the two Sternberg memory search tests showed no significant trends. The sleep of the operators after the night-shift was on average reduced to 5 hs 34 min. The results of subjective rating of alertness and reaction time test are interpreted as effects of the combined influences of circadian rhythmicity, sleep loss and time on professional task. Most results support the conclusion that a 14-h night-shift without extensive breaks is not acceptable.     

A 14-h night-shift in the control room of a fire brigade

All 29 operators in the control room of a fire brigade performed test sessions during work and leisure time at 2-h intervals on a day with a 14-h night-shift, a day off and a day with a 10-h morning shift. The test sessions consisted of a visual search choice reaction time test and two Sternberg memory search tests (1 or 5 letters had to be memorized). Furthermore, the operators recorded their oral temperature and their subjective alertness before each test session. The subject also kept a diary of work and sleep times for 14 days. The circadian rhythm of body temperature was hardly changed by a single night-shift. Parallel to the body temperature, the subjective alertness fell significantly during the night-shift reaching a minimum value at 06:00 h. The mean reaction times increased non-significantly at the end of the night-shift and the results of the two Sternberg memory search tests showed no significant trends. The sleep of the operators after the night-shift was on average reduced to 5 hs 34 min. The results of subjective rating of alertness and reaction time test are interpreted as effects of the combined influences of circadian rhythmicity, sleep loss and time on professional task. Most results support the conclusion that a 14-h night-shift without extensive breaks is not acceptable.