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Review
. 2016 Aug 23;2016(8):CD010641.
doi: 10.1002/14651858.CD010641.pub2.

Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work

Tracy E Slanger  1 , J Valérie Gross, Andreas Pinger, Peter Morfeld, Miriam Bellinger, Anna-Lena Duhme, Rosalinde Amancay Reichardt Ortega, Giovanni Costa, Tim R Driscoll, Russell G Foster, Lin Fritschi, Mikael Sallinen, Juha Liira, Thomas C Erren
Affiliations
Review

Person-directed, non-pharmacological interventions for sleepiness at work and sleep disturbances caused by shift work

Tracy E Slanger et al. Cochrane Database Syst Rev. .

Abstract

Background: Shift work is often associated with sleepiness and sleep disorders. Person-directed, non-pharmacological interventions may positively influence the impact of shift work on sleep, thereby improving workers' well-being, safety, and health.

Objectives: To assess the effects of person-directed, non-pharmacological interventions for reducing sleepiness at work and improving the length and quality of sleep between shifts for shift workers.

Search methods: We searched CENTRAL, MEDLINE Ovid, Embase, Web of Knowledge, ProQuest, PsycINFO, OpenGrey, and OSH-UPDATE from inception to August 2015. We also screened reference lists and conference proceedings and searched the World Health Organization (WHO) Trial register. We contacted experts to obtain unpublished data.

Selection criteria: Randomised controlled trials (RCTs) (including cross-over designs) that investigated the effect of any person-directed, non-pharmacological intervention on sleepiness on-shift or sleep length and sleep quality off-shift in shift workers who also work nights.

Data collection and analysis: At least two authors screened titles and abstracts for relevant studies, extracted data, and assessed risk of bias. We contacted authors to obtain missing information. We conducted meta-analyses when pooling of studies was possible.

Main results: We included 17 relevant trials (with 556 review-relevant participants) which we categorised into three types of interventions: (1) various exposures to bright light (n = 10); (2) various opportunities for napping (n = 4); and (3) other interventions, such as physical exercise or sleep education (n = 3). In most instances, the studies were too heterogeneous to pool. Most of the comparisons yielded low to very low quality evidence. Only one comparison provided moderate quality evidence. Overall, the included studies' results were inconclusive. We present the results regarding sleepiness below. Bright light Combining two comparable studies (with 184 participants altogether) that investigated the effect of bright light during the night on sleepiness during a shift, revealed a mean reduction 0.83 score points of sleepiness (measured via the Stanford Sleepiness Scale (SSS) (95% confidence interval (CI) -1.3 to -0.36, very low quality evidence). Another trial did not find a significant difference in overall sleepiness on another sleepiness scale (16 participants, low quality evidence).Bright light during the night plus sunglasses at dawn did not significantly influence sleepiness compared to normal light (1 study, 17 participants, assessment via reaction time, very low quality evidence).Bright light during the day shift did not significantly reduce sleepiness during the day compared to normal light (1 trial, 61 participants, subjective assessment, low quality evidence) or compared to normal light plus placebo capsule (1 trial, 12 participants, assessment via reaction time, very low quality evidence). Napping during the night shiftA meta-analysis on a single nap opportunity and the effect on the mean reaction time as a surrogate for sleepiness, resulted in a 11.87 ms reduction (95% CI 31.94 to -8.2, very low quality evidence). Two other studies also reported statistically non-significant decreases in reaction time (1 study seven participants; 1 study 49 participants, very low quality evidence).A two-nap opportunity resulted in a statistically non-significant increase of sleepiness (subjective assessment) in one study (mean difference (MD) 2.32, 95% CI -24.74 to 29.38, 1 study, 15 participants, low quality evidence). Other interventionsPhysical exercise and sleep education interventions showed promise, but sufficient data to draw conclusions are lacking.

Authors' conclusions: Given the methodological diversity of the included studies, in terms of interventions, settings, and assessment tools, their limited reporting and the very low to low quality of the evidence they present, it is not possible to determine whether shift workers' sleepiness can be reduced or if their sleep length or quality can be improved with these interventions.We need better and adequately powered RCTs of the effect of bright light, and naps, either on their own or together and other non-pharmacological interventions that also consider shift workers' chronobiology on the investigated sleep parameters.

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Conflict of interest statement

Tracy Slanger: **

J. Valérie Gross: **

Andreas Pinger: **

Peter Morfeld: **

Miriam Bellinger: **

Anna Duhme: **

Rosalinde Reichardt: **

Mikael Sallinen: I have received a total of EUR 12,000 for five lectures on well‐being at work from the insurance company Ilmarinen. I have also received a total of EUR 2,000 for a review of applications submitted to the Petromaks Research Programme from the Research Council of Norway.

Lin Fritschi: none known.

Giovanni Costa: none known.

Tim Driscoll: none known.

Russell Foster: none known.

Juha Liira: none known.

Thomas Erren: **

** Shift work is regularly conducted at Evonik Industries and at the University Hospital of Cologne University. Since 1988, the University of Cologne and Evonik Industries (and their corporate predecessor, RAG) have had a public‐private partnership regarding research. The contributing research institutes, The Institute and Policlinic for Occupational and Environmental Medicine and Prevention Research (IPOEP) in Cologne and The Institute for Occupational Epidemiology and Risk Assessment (IERA) in Essen, select and conduct their research independently of one another. In Germany, scientific freedom in research, teaching and instruction, and study is constitutionally guaranteed. The right to the Freedom of Research and protection thereof are inseparably coupled with responsibility. The public‐private partnership contract between the University of Cologne and Evonik Industries explicitly emphasises the freedom in research and scientific publication of collaborating institutions.

Figures

1
1
*Reflects search for both the current review and for the review "Adaptation of shift work schedules for preventing and treating sleepiness and sleep disturbances caused by shift work (028) (Erren 2013)"
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies; The "Applicability of design" category assesses whether, in cross‐over designs, a period effect impacted the results (based on an interaction test). If no interaction test was reported, the risk of bias was considered unclear. In cases where the trial had a parallel design, the risk of bias was judged to be low.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study; The "Applicability of design" category assesses whether, in cross‐over designs, a period effect impacted the results (based on an interaction test). If study authors reported no interaction test, we considered the risk of bias to be unclear. In cases where the trial had a parallel design, we considered the risk of bias to be low.
1.1
1.1. Analysis
Comparison 1 Bright light at night versus normal light (300 lux), Outcome 1 Sleepiness during the night shift, overall, Stanford Sleepiness Scale (Scale: 1‐7).
1.2
1.2. Analysis
Comparison 1 Bright light at night versus normal light (300 lux), Outcome 2 Sleepiness during the night shift, overall, Karolinska Sleepiness Scale (Scale: 1‐9).
1.3
1.3. Analysis
Comparison 1 Bright light at night versus normal light (300 lux), Outcome 3 Sleepiness during the night shift, postintervention only, Stanford Sleepiness Scale (Scale: 1‐7).
1.4
1.4. Analysis
Comparison 1 Bright light at night versus normal light (300 lux), Outcome 4 Sleepiness during the night shift, post‐intervention only, Karolinska Sleepiness Scale (Scale: 1‐9).
1.5
1.5. Analysis
Comparison 1 Bright light at night versus normal light (300 lux), Outcome 5 Total sleep time, next day (Actigraph ‐ hours).
1.6
1.6. Analysis
Comparison 1 Bright light at night versus normal light (300 lux), Outcome 6 Sleep efficiency, next day (Actigraph ‐ %).
2.1
2.1. Analysis
Comparison 2 Bright light alone at night versus normal light (300 lux) plus placebo capsule, Outcome 1 Sleepiness during the night shift (5‐min. Reaction Time Test ‐ milliseconds).
2.2
2.2. Analysis
Comparison 2 Bright light alone at night versus normal light (300 lux) plus placebo capsule, Outcome 2 Total sleep time, next day (Actiwatch ‐ hours).
2.3
2.3. Analysis
Comparison 2 Bright light alone at night versus normal light (300 lux) plus placebo capsule, Outcome 3 Sleep onset latency, next day (Actiwatch ‐ minutes).
2.4
2.4. Analysis
Comparison 2 Bright light alone at night versus normal light (300 lux) plus placebo capsule, Outcome 4 Sleep efficiency, next day (Actiwatch ‐ %).
3.1
3.1. Analysis
Comparison 3 Bright light during day versus normal light (530 to 648 lux), Outcome 1 Sleepiness during the day shift (Karolinska Sleepiness Scale).
3.2
3.2. Analysis
Comparison 3 Bright light during day versus normal light (530 to 648 lux), Outcome 2 Sleep quality, next night (Visual Analogue Scale ‐ 0 to 10).
4.1
4.1. Analysis
Comparison 4 Bright light during day versus dim red light, Outcome 1 Total sleep time, next night (sleep log ‐ hours).
4.2
4.2. Analysis
Comparison 4 Bright light during day versus dim red light, Outcome 2 Sleep onset latency, next night (sleep log ‐ minutes).
5.1
5.1. Analysis
Comparison 5 Bright light alone during day versus normal light (300 lux) plus placebo capsule, Outcome 1 Sleepiness during the day shift, days (5‐min. Reaction Time Test ‐ milliseconds).
5.2
5.2. Analysis
Comparison 5 Bright light alone during day versus normal light (300 lux) plus placebo capsule, Outcome 2 Total sleep time, next night (Actiwatch ‐ hours).
5.3
5.3. Analysis
Comparison 5 Bright light alone during day versus normal light (300 lux) plus placebo capsule, Outcome 3 Sleep onset latency, next night (Actiwatch ‐ minutes).
5.4
5.4. Analysis
Comparison 5 Bright light alone during day versus normal light (300 lux) plus placebo capsule, Outcome 4 Sleep efficiency, next night (Actiwatch ‐ %).
6.1
6.1. Analysis
Comparison 6 Bright light at night plus glasses at dawn versus normal light (unclear lux) and no glasses, Outcome 1 Sleepiness during the night shift (Psychomotor Vigilance Test: Median Reaction Time ‐ milliseconds).
7.1
7.1. Analysis
Comparison 7 Bright light plus glasses during day versus normal light and no glasses, Outcome 1 Total sleep time, next night (Actigraph ‐ hours).
7.2
7.2. Analysis
Comparison 7 Bright light plus glasses during day versus normal light and no glasses, Outcome 2 Sleep onset latency, next night (Actigraph ‐ minutes).
7.3
7.3. Analysis
Comparison 7 Bright light plus glasses during day versus normal light and no glasses, Outcome 3 Sleep efficiency, next night (Actiwatch ‐ %).
8.1
8.1. Analysis
Comparison 8 Nap at night (single nap opportunity) versus no‐nap, Outcome 1 Sleepiness during the night shift, postintervention (Psychomotor Vigilance Test ‐ Mean Reaction Time ‐ milliseconds).
8.2
8.2. Analysis
Comparison 8 Nap at night (single nap opportunity) versus no‐nap, Outcome 2 Sleepiness during the night shift, postintervention (Karolinska Sleepiness Scale).
8.3
8.3. Analysis
Comparison 8 Nap at night (single nap opportunity) versus no‐nap, Outcome 3 Sleepiness during the night shift, postintervention (Psychomotor Vigilance Test (Slowest 10% reciprocal reaction time ‐ milliseconds ).
8.4
8.4. Analysis
Comparison 8 Nap at night (single nap opportunity) versus no‐nap, Outcome 4 Sleepiness during the night shift, postintervention (Subjective Sleepiness Score ‐ "0 to 100").
9.1
9.1. Analysis
Comparison 9 Naps at night (two‐nap opportunities) versus no‐naps, Outcome 1 Sleepiness during the night shift, postintervention (Visual Analogue Scale ‐ 0 mm to 100 mm).
10.1
10.1. Analysis
Comparison 10 Physical exercise plus sleep education versus wait‐list, Outcome 1 Sleep quality, postintervention (PSQI ‐ score).
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