Episode 6: Impact of Fatigue on Healthcare

Cara Lunsford (00:40.164)
It's Lois James, right Lois? I have a real affinity for the name Lois. My very first cabbage patch was named Lois. Yes.

Lois James (00:42.268)
Yep, like Lois Lane.

Lois James (00:50.978)
No way. That's funny. It's become kind of an old person's name. Like most people that I hear that are Lois now are like grandmothers.

Cara Lunsford (00:59.28)
Yeah, but you know what? A friend of mine, named his daughter Mabel.

Lois James (01:05.287)
is also another older name. Yeah, super cute though.

Cara Lunsford (01:08.41)
Yes, yes. I know, so cute, right? So I love the name Lois, Lois James, such an easy name also, thank you. It's not always easy.

Lois James (01:17.984)
Of course. Growing up in Ireland, people did not really know how to pronounce it, so it was interesting. But here in America, I think because of Lois Lane and Family Guy and a couple of other things, everybody's more familiar with it.

Cara Lunsford (01:24.922)
Okay, so you're.

Cara Lunsford (01:32.686)
So you're from Ireland.

Lois James (01:34.562)
Yes, yeah, moved to the States about, coming up on 18 years ago. Crazy.

Cara Lunsford (01:41.213)
Wow. I live right next to an Irish pub. Yeah, literally, I mean literally next to it. I could throw a rock over my fence and hit the pub. And so, and it's been there since 1963.

Lois James (01:44.952)
Let's do the one.

Lois James (01:58.946)
So how's your sleep? Disturbed, imagine.

Cara Lunsford (02:01.966)
You know, it's not too bad. It's not too bad. But what holidays coming up, Lois?

Lois James (02:08.011)
No, exactly. You won't get much sleep that night.

Cara Lunsford (02:11.334)
St. Patrick's Day, St. Patrick's Day is coming up and it is a madhouse. It's a real madhouse. So.

Lois James (02:20.942)
You know, I actually think that St. Patrick's Day is a bigger thing in America than it is in Ireland. It's pretty funny. I mean, people here just absolutely love it.

Cara Lunsford (02:30.62)
It's just an excuse for people to get trashed. Yeah.

Lois James (02:34.958)
In Irish people we don't need nixies.

Cara Lunsford (02:37.884)
Right? Well, so this is this topic that we're going to talk about, which is really disordered sleep. I was a night shift nurse for the first two and a half years when I had to do my tour of duty, right? Because you come out of nursing school,

Lois James (02:50.327)
Yeah.

Lois James (02:59.48)
so you know.

Cara Lunsford (03:05.722)
You oftentimes don't get to go right into, right, you know, right into day shift. And so, you know, I had to do my, my two ish years of, of night shift. Fortunately at the time I was, you know, I didn't have children. I was, you know, in my mid twenties. So I was able to.

Lois James (03:28.782)
you

Cara Lunsford (03:36.039)
come home, sleep. You I had this structure where I would drink a lot of water during the night. I didn't drink a lot of coffee. I would come home and I'd, you know, go into my bathroom and I'd keep the lights out and I would be like telling myself, it's nighttime, it's nighttime. And I'd brush my teeth and try to like keep my eyes closed and.

Lois James (03:38.958)
you

Lois James (03:53.006)
Mm-hmm.

Cara Lunsford (04:04.164)
I didn't want any lights to be on and then I would try to get into bed and sleep through the trash truck coming at 10 a.m.

Lois James (04:06.456)
you

Lois James (04:13.762)
Sounds like you were doing a lot of things right. That's a lot more than most will do. that's pretty good.

Cara Lunsford (04:15.92)
Yeah.

I was trying, I was trying because I did not like the way it made me feel. So Lois, tell us a little bit about how, first of all, a little bit of your background. How did you get into this? How did you get passionate about sleep?

Lois James (04:37.39)
Absolutely. So when I first came over to the States, I came over to do a PhD in criminal justice. So that's actually my background. My undergrad is in psychology and I came over to do a master's and a PhD in criminal justice at Washington State University. And as part of that, I met this professor called Brian Vila, who became like my favorite professor and he became my mentor and kind of my academic dad. And he...

had co-founded or started this center that we have at Washington State University called the Sleeping Performance Research Center, or the SPRC, which is this world-class facility where essentially we study sleep from the molecular level up through different animal models to humans in the lab to humans in the fields. And he was one of the of the founding people, and I started taking classes from him and started to become really interested in what he was doing.

And so I started like as a research assistant in the SPRC back in, goodness, I want to say maybe 2008. Like I have grown up in that space and this past fall I was elected as the new director for the SPRC. So it's really kind of come like massively full circle for me since like a little baby research assistant and now, you know, to being the director.

Essentially that's how I got really interested in it. As you can imagine with my criminal justice background, a lot of the early work that I did was with first responders, know, also shift working, a lot of the similar, a lot of the similar kind of shift related concerns that we see in healthcare. And my kind of involvement then with the College of Nursing came a little bit later, but I've been with them for well over a decade at this point.

And now obviously a lot of my work is with nurses and other medical professionals to try and help them overcome some of these issues that we just see that's inherent with shift work and inherent in professional groups that are stressful, know? they, know, stress and fatigue can lead to some pretty catastrophic mistakes.

Cara Lunsford (06:50.652)
Yeah, yeah, absolutely. You don't want to really be in charge of people's lives and be sleep deprived. And you're not making great decisions, right? Cognitively, if you're suffering, and physically, if you're suffering. So what have been some of the...

Lois James (06:58.947)
session.

Lois James (07:11.471)
Yeah, excellent.

Cara Lunsford (07:17.376)
major takeaways for you, like throughout the time that you've done research around this. What are kind of some of the most profound things that you've taken away or things that surprised you in your research?

Lois James (07:22.702)
you

Lois James (07:32.014)
One of the big things, and we did it, we did a large study that looked at the impact of fatigue and different shift schedules on nursing performance in our simulation lab that we have at WSU. And, you know, so we looked at the impact of these things on patient care, on interactions with patients. And then because we have driving simulators, we also push our nurse participants in a driving simulator to kind of simulate the drive home post shift.

And I would say the big findings that we had from that study were the thing that is affected the most in terms of patient care is the therapeutic communication or the formation of bonds with patients. So certain things like, know, I mean, we're always, of course, we're always concerned about things like medical error and, you know, kind of miscalculating medication dosage, that kind of thing.

And although those certainly can be affected by fatigue, they're often so automated with nurses and with healthcare professionals that they're a little bit more resilient or resistant, whereas kind of how a nurse interacts with a patient. I mean, that was hugely impacted by their level of fatigue. And that is really, really a critical component of the job, because if a patient doesn't feel kind of heard and supported,

and cared for and advocated for, that does have a consequent follow-up effect on their outcomes, because they're going to be less likely to come back to the hospital, they're going to be less likely to comply with instructions, they're going to be less likely to want to be involved in the healthcare system. And we see that, you know, that's a driving contributor of disparities around health outcomes as well. So that was one of the big ones. And then the other huge one that we saw was

the nurse themselves, their own safety. So we saw that our night shift nurses, much higher risk for collision in the simulator, in the driving simulator. So, you know, it's a patient care problem, but it is also a safety problem. And we know from decades of research and also decades of anecdotal evidence that the drive home post shift is one of the most dangerous points in a shift workers life.

Cara Lunsford (09:53.565)
I am so glad that you said that because many, many years ago, I reached out to Lyft and I said, I would love to do a partnership with you. And they were so thrilled at the idea of being able to do something.

This was with my previous company, which was Holly Blue, and it was the first social network for nurses and nursing students, which I then brought over to nurse.com through acquisition. But that was something that Lyft was really interested in. When I reached out to them, I said, this is a major problem for a lot of shift workers. I know when I was driving home,

There was times when I didn't even remember the drive home. I was like, I know I got from point A to point B. There was times when I would be stopped and I'd actually start to nod off. And it was scary, really scary because I thought, you know, I'm spending my life trying to take care of patients and be a healer.

Cara Lunsford (11:14.224)
be a healthcare provider? What if I killed somebody on the way home? Like, how devastating? I wouldn't be able to live with myself. that's how it felt. And that's a stress in and of itself.

Lois James (11:25.966)
Yeah.

Lois James (11:30.292)
absolutely. you know, mean, the drowsy driving is such a not me, not just specific to health care, but it's such a massive issue. And it doesn't yet have I mean, it doesn't have the same stigma as as drunk driving, for example, despite the research showing very conclusively that it has the same, you know, the same risks. Right. And I mean, drunk driving in one sense is, you know, it's more predictable. You have a certain number of units of alcohol and your performance is impaired by this amount.

and so on and so forth. When you're really tired, it's not quite the same. It's not quite linear or predictable like that. And what I mean by that is you're fine, you're fine, you're fine, you're asleep. And we have these kind of micro sleeps or these lapses when we're drowsy driving and maybe we'll notice and maybe we'll think, my goodness, I'm nodding off or you hit the bumps on the side of the road and that jolts you awake. But so often, most of the time we get away with it.

Right? Because nothing happens in our commute home. You know, I mean, we have one of these micro lapses or these micro sleeps when there's no like turn in the road or there's, you know, there's no kind of external factor. So it's almost kind of self-reinforcing and we think to ourselves, it's not that big of a deal. I just need to make it home. But you know, that one time, and there have been plenty of stories in the news of that one time where, you know, you have one of those micro sleeps at the same time that a dog or a kid runs across the road.

and nothing is worth it. So I'd really kind of urge anybody who feels like they're nodding off at the wheel, just to find a safe spot, pull over and just sleep for 10 minutes.

Cara Lunsford (13:11.888)
Yeah, yeah, absolutely. It's just, it's not worth it. And I used to think I had all of these, I was very, what's the word I wanna use? I had a very predictable.

pattern or you know that I would do every time. So I also tried to stack my day in my nights. So I tried to I tried not to have like a Monday, Thursday, Saturday shift because it's very hard to go back and forth between working at night and then you're trying to be off during the day but you have to sleep for some of it but you don't want to sleep all of it because you need to sleep that next night and it's it really has a lot of

Lois James (13:38.606)
Mm-hmm.

Lois James (13:44.896)
Okay.

Cara Lunsford (14:01.106)
effects on your relationships too. My friends were not available when I was available and it has that impact on your social life, outside of work. Even when I would be driving home.

Lois James (14:10.958)
Yeah.

Cara Lunsford (14:21.816)
after a night shift, I had this thing where I would always, there was a donut shop right down the street. I would pull in, I would get a donut, I would get a glass of milk. I would roll my windows down so that there was a lot of air in my car and I would eat.

while I was driving because somehow the the sugar and everything kind of would like keep me awake for a little while enough to get home but somehow the milk would also help me sleep or at least in my mind it did. Yeah.

Lois James (14:44.462)
Yeah.

Lois James (14:53.048)
There you go.

Cara Lunsford (14:54.392)
So then I would get home and then like I was saying to you earlier, I would walk in and I'm like, don't, nobody talk to me. I have to like go straight into my bedroom. I had blackout curtains. I would make sure that like the room was already dark so that by the time I got home, I was walking in, it's dark, I walk into my.

Lois James (15:07.587)
Yeah.

Cara Lunsford (15:19.202)
my bathroom, do my whole like teeth brushing thing, I would take melatonin and I would get into bed, put on an eye mask and put in earplugs.

Lois James (15:30.712)
Yeah, yeah, exactly.

Cara Lunsford (15:31.581)
And that was it. That was my, and I would do that. And I always drank a lot of water at night. Somehow drinking water all night actually helped me stay awake as opposed to some of my colleagues who would try to drink caffeine, but they ended up with all kinds of like gastrointestinal issues and all kinds of other things. What have you seen physically in people who are trying to stay awake?

Cara Lunsford (15:59.921)
What kinds of like co-morbidities are they ending up with?

Lois James (16:03.192)
Yeah, sure. Well, it's so interesting that you say that because hydration is in fact, alerting, right? So water is a great tool for as a counter fatigue measure. But yeah, I mean, we see all sorts of, so basically shift work, know, kind of at its core, if you're working nights is circadian misalignment, right? So your...

You're out of sync with your circadian rhythms and our circadian rhythms because we're not nocturnal animals. We're diurnal, know, we're biologically designed to be awake during the day and asleep at night. So anything we do that counters that results in circadian misalignment. And that is unfortunately associated with the development of a multitude of different diseases or certainly, you know, can work as a catalyst.

for them, the big one that we see is gastrointestinal. Like you said, know, I mean, the body is not designed to consume and digest food at night. It just isn't. So what we see now and what we recommend is when you're working nights, try and minimize your calorie consumption during the hours of 10 p.m. and 6 a.m. to 250 calories, which I know a lot people don't necessarily want to do because they're like, okay, well,

that kind of takes away my main shift meal. And yes, it does, but it is much, much better for the body. It's better for the body to try and keep to a fairly normal, quote unquote, diet system, right? In terms of your meal times, right? So that's kind of one of the main things that we do. Another major one that we do is we really advocate for what we call split sleep for night shift workers.

So as you say, know, mean, the garbage truck comes at 10 a.m. and that's, you you done because the way our circadian rhythms work is like, you know, about 10 a.m. is when, you know, we're at our, kind of peak, our highest in our, in our alertness and, you know, in our dips. So the body is basically saying, okay, well, sun's up. It's time to be up and about. So we're fighting that even if we're really tired.

Lois James (18:18.432)
So for night shift workers, it's a lot easier for them to get home and let's say get three, four hours sleep and then sleep again for three, four hours later in the day before they go back on shift, right? Versus trying to sleep for six or seven hours when you get off work. Very few of us are gonna be able to do that. So they're definite, I don't want it to seem like it's all doom and gloom. There are definite ways that we can help mitigate these disease risks.

Cara Lunsford (18:38.491)
Yeah.

Lois James (18:47.362)
but it is important to know that these disease risks are there. You people need to take it seriously. They need to take fatigue, sleep restriction, and shift work seriously.

Cara Lunsford (18:57.862)
Yeah, so another, like I always imagine what the listeners are thinking, right? As they're hearing all this and they're thinking, yeah, well, when I come home, I have a child, but my child's with a nanny and the nanny's in the house. And.

Sometimes they're coming and they're going and I'm there and so I hear them. I hear my child crying. you know, so also like mom guilt is such a real thing. mean I think sometimes we think we can go to work at night.

And because I've talked to some of my colleagues before who say, I work the night shift because it allows me to be available for my kids things during the day. I'm like, now, wait a minute. When are you sleeping? So and because I think sometimes.

Lois James (19:54.998)
Right. When are you sleeping? Yeah.

Cara Lunsford (20:04.026)
You know, in nursing, we are still a very female forward industry. We tend to split ourselves or feel a sense of guilt, like, OK, well, I'm going to go to work and I'm to be there all night. But that allows me to be at your soccer game tomorrow morning, which is at 10 a.m. And so I'm going to just stay up and I'm going to kind of.

rally. I know I have to work that night, but I'll come home and after the soccer game I'll sleep a few hours and this happens a lot.

Lois James (20:38.754)
Yeah, yeah.

No, absolutely. I, you know, and it's a really important point is that sometimes life happens and we can give all of the recommendations for best practices. We can give all of the tools of, know, this is how you improve your sleep and get more and so on and so forth. But at the end of the day, I mean, people have to make it work with their, with their living situation. So I think a really important consideration if a listener is in that position, right? Where they're like, okay, well, I can only get two hours here and two hours there.

or whatever that looks like is just, if that is the case, you really have to make sure that you take opportunities to catch up on sleep. Because if you are sleeping that little, for whatever reason, you're building up sleep debt, right? And you're gonna have to pay it back. you cannot, you can't discount that, right? Because otherwise you could be in the situation where you're driving your kids to that soccer game and you go off the road.

Cara Lunsford (21:39.27)
Exactly.

Lois James (21:39.394)
Right? So, you know, I mean, it's really, really hard. And I know I'm a mother as well. It's really hard to feel like, God, but I don't want them to miss out. I don't want to miss out on anything. I want to be able to do it all. I feel like I can do it all. I feel like I'll be okay. But we can't, right? We have to take those moments to recharge, refuel, right? And essentially that's what sleep is. So recovery and repair, right? You know, we need it.

Cara Lunsford (22:05.392)
Yes.

Lois James (22:06.734)
It is a fundamental biological need. So, you know, making sure that you have those opportunities to sleep for as long as you can to catch up.

Cara Lunsford (22:18.588)
Yeah, and sometimes it is about saying, you know what, I'm not going to drive myself to work. I'm going to take a Lyft or I'm gonna take an Uber or a taxi or whatever your ride share option is. And maybe you doze off while you're in the car. I don't know how, you know, depends on how long your commute is, but sometimes people have to drive in 45 minutes or an hour.

Cara Lunsford (22:43.99)
that could be a time when you could take a nap. I know I have taken a nap in an Uber or a Lyft while I'm driving to work or being driven to work. Similarly, when you're coming back, you'll have another opportunity to probably doze off for a little bit as you're being driven home. It's worth it to spend the extra money.

Lois James (22:47.918)
Yes.

Lois James (23:08.398)
Well, especially coming home, it's such a great option because, you know, we find this this little bit of a catch-22, right? Where, you know, I mean, we we advise people when you get off night shift, you want to try and just like you were saying, minimize light exposure. You want to stay really relaxed so that you can get home and you can fall asleep. Right.

But that is problematic if you're driving because you obviously don't want to increase your risk of falling asleep while you're driving. So a of a ride share option is so great because you know could leave the hospital before you leave the hospital you put on sunglasses, right? You you try and minimize all external stimulus you get in your ride share, you get home your glasses on the whole time until you're into your room and you you know

hopefully have a fairly sound and light proof environment. Light proof anyway is a lot easier because you can just get blackout blinds and I recommend that every single shift worker has a pair of good quality blackout blinds because they're not very expensive and they could literally change your life. So, you know, that is an ideal. Obviously that is not a good strategy to take if you're increasing your risk of drowsy driving.

So there's that balance that can be mitigated if you're not driving home.

Cara Lunsford (24:30.844)
Yes, totally. And I think these are really good options because I do think it's important to give people best practice, right? And to say, ideally, in a perfect scenario, this is what it looks like for you. But...

How much, so we know that like gastrointestinally, like that's kind of one of the number one things that most shift workers or night shift workers are experiencing. I know that I had plenty of coworkers who had.

ulcers and acid reflux. And we know that acid reflux continually, if you have it, can lead to things like Barrett's esophagus. It can lead to esophageal cancer. So these are all things that are really important for people to understand that it's not just, I have a little acid reflux. That over time is damaging to the esophagus and can lead to other things. So I think that was a really important

Lois James (25:17.55)
Yeah.

Lois James (25:29.784)
Mm-hmm.

Cara Lunsford (25:35.592)
call out. Is there anything else that you feel nurses should be like taking away from this? what?

Lois James (25:46.606)
Yeah, I mean, so in addition to the gastrointestinal risks, there are also, of course, some pretty significant risks around sleep disorders, developing sleep disorders from night shift work. So that can be, you know, it could be insomnia, it could be sleep apnea, it could be what's literally just called shift work disorder, which is kind of low level insomnia characterized by, you know, constantly feeling tired when you are awake.

So I think being kind of mindful of those and if you feel like even if you had the opportunity to get enough sleep, you couldn't. Really important to get a referral from your family doctor to a sleep doctor. Don't go to your family doctor for this because they do not have the required specialization and training in sleep medicine. And speak to somebody about that.

that specializes in it. Most of the sleep disorders are not treated pharmacologically, know, so they're either insomnia is treated with cognitive behavioral therapy, for example, CPAP or sleep apnea is treated with a CPAP or a mandibular device. So most of them, you know, so don't kind of worry about, my, well, I don't want to take, you know, sleep medication. And, you know, for the most part, that doesn't happen. So I think those are really important to be mindful of.

Cara Lunsford (27:06.268)
That's good to know.

Lois James (27:08.91)
Really important to be mindful that your long-term night shift work does increase risk of certain cancers as well because light exposure during the night is a risk factor. And then also a lot of the mental health can be affected by night shift work too. And we see increases in symptoms of depression and anxiety, PTSD. So also important to kind of be mindful. I think...

The biggest take home in terms of health and shift work is that if you have to work nights, don't kind of panic and think, my goodness, I'm going to be getting cancer in 10 years. Just be mindful of like, okay, I'm at a little bit of an elevated risk, so I need to make sure that I implement as much as I can around sleep hygiene, which is, know, best possible sleep environment and, you know, creating the best circumstance for you to sleep. And then also, you know, fatigue countermeasures were feasible.

Cara Lunsford (28:06.086)
This is for the listeners. This is, this is self love. Okay. We're not nurses are not always known for their self care. and or, or self love. And so creating an environment for yourself that is really protected, is, is a place where

you feel at peace, that you know that you can have probably minimal distractions. It's clean. You don't feel like, my gosh, I need to clean up that pile of mail or I need to look at that. Really trying to keep it a little stark, I think, and is is so important, but really like

Cara Lunsford (29:05.264)
You have to love and care about yourself enough to make this space and create this regimen for yourself. if you don't love yourself enough, you then know that like, do it for your kids, do it for your spouse, do it for the people that rely on you and care about you. Do it for them.

Lois James (29:32.226)
right? Or do it for your patients.

Cara Lunsford (29:34.353)
Do it for your patients. It's because it is so important. And I've wondered a little bit if from like a more of an administrative perspective and a hospital perspective, is it better to limit how long people actually work on night shift? Is it better to rotate them in and out every six weeks or?

you know, that you do, because most of the time we schedule ourselves for six weeks out and then, and then we do another six weeks. So is it best to kind of say that's your max, then you have to do day shift or can that be really hard?

Lois James (30:20.654)
This is a great, great question. It's a challenging question and there's a little bit of conflicting evidence, but I'll tell you the kind of, you know, the best of what we know. The hardest shift schedule in terms of rotation is what we would call kind of medium speed rotation. So the absolute worst would be like being on days for, let's say, a week or two weeks, then being on evenings, then being on nights.

or that kind of, know, well, depending on how many shifts the hospital offers, but rotating that kind of speed is really hard on the body because you just kind of starting to maybe get accustomed to it and then it's changing, right? So that we advise against. The best two options seem to be either what we would call kind of slower term rotation.

which would be about six weeks would be the minimum. So anywhere between, you know, kind of six weeks and let's say six months, I know six months can feel like a very long time to be on a particular shift, but that kind of period seems to be the best. You don't want somebody on night shifts for 10 years, right? You know, it's not gonna be good for their health. Regardless, you know, they would need to be an extreme night owl, in which case they're not necessarily going to feel the effects, but they're still going to have those

you know, those risks, those elevated disease risks, for example. The other very promising option that they do a lot more in Europe than they do here is what we call rapid forward rotation. So in other words, somebody would do, they would do a day followed by evening shift, followed by a night shift, followed by time off. Right? And repeat a day, an evening, a night, time off, a day, an evening, a night.

really important that if you do that kind of rapid rotation it has to be forward, not backwards. So it can't go like a night, an evening, a day time off, right? It has to be the opposite. It has to be like day, evening, night because it needs you need to be kind of rotating forward through it. The exception here is there's actually some police departments and some kind of first responder like if they are cross-trained for example and firefighting police and

Cara Lunsford (32:26.0)
Yeah, that makes sense.

Lois James (32:43.788)
and paramedics, some of those departments will use that system. And it seems to work pretty well. Yeah, it's a challenging one. It's one of the ones that I get asked the most often, what shift schedule will work for us? And part of it, mean, part of it does depend an awful lot on the organization. Hospitals love their 12 hours, right? Because they're easier to schedule than eights or tens. So I think within healthcare,

Cara Lunsford (32:51.836)
Okay.

Lois James (33:13.486)
12s are kind of, they're here to stay. A 12 hour day shift is perfectly manageable and not all that bad for your health. A 12 hour night shift, not so much.

Cara Lunsford (33:23.068)
Yeah. So if you were to look at it from a nurse perspective, let's say there was no evening shift, right? Let's say there was no three to 11 or something like that. I know in the ED, they have some different types of shifts in the ED. Sometimes they have that three to 11. It's not just a seven to seven and a seven to seven. So I don't know if they call that a swing shift.

Lois James (33:30.606)
Thank

Lois James (33:43.448)
Yeah. Yeah.

Lois James (33:49.774)
Yeah, swing or power or yeah.

Cara Lunsford (33:52.005)
Yeah. So if you were to do it, let's say most nurses work three to four shifts a week. But three is kind of what we consider average. Now, if they did, let's say three night shifts, okay, and

Monday, Tuesday, Wednesday. And then they take, let's say, four days off or three days off. And now they're gonna come back and they're gonna do three night shifts. But they're not gonna do their day, but there's definitely gonna be a day off or at least one or two days off between when they have to do their next set of three, maybe day shifts.

Lois James (34:47.256)
Thank

Cara Lunsford (34:48.354)
Is that something that is potentially doable or is that not recommended either?

Lois James (34:55.288)
That kind of then creeps into the realm of that mid-level, mid-speed rotation. So for the equivalent kind of example, it would be more, so let's say to balance everything out, let's say one week a nurse is gonna do a day, a day, a night. The next week they're gonna do a day, a night, a night and reset, right? That would be more that forward, that rapid forward rotation.

Cara Lunsford (35:13.755)
Mm-hmm.

Cara Lunsford (35:19.132)
Okay.

Lois James (35:24.3)
Right? And then it kind of, you know, it's for want of a better term, it's kind of spreading the misery evenly between everybody versus, know, okay, well, you got the short straw and you're going to be on nights for the next, you know, two, three months. So that is definitely an option. I know that it makes scheduling harder than if you were to rotate every three months, for example. But there is some good evidence now that it is

Cara Lunsford (35:38.34)
Yeah.

Lois James (35:54.108)
one of the more effective shift schedules.

Cara Lunsford (35:57.917)
Yeah, I think I would have really liked that. I mean, it's been almost 18 years, so was a long time ago. But funny enough, right now, I occasionally am moonlighting with a patient that I've known for like 10 years and has terrible sleep issues. And I am working all night with him. Now that means...

Lois James (36:24.046)
Mm-hmm.

Cara Lunsford (36:27.152)
Technically I can sleep whenever he sleeps, but I get woken up. So what it feels like actually is when I had a baby and I would try to sleep when the baby sleeps. But every couple of hours I'd be up and I'd be, you know, breastfeeding or changing a diaper or something like that. And that was also so...

Lois James (36:30.488)
Sure.

Lois James (36:52.14)
Yeah.

Cara Lunsford (36:55.92)
disordered, which also we can say applies to probably a lot of nurses because we are so female heavy, like the demographic is female heavy. So there's probably quite a few moms that are sleep deprived at night, getting up, breastfeeding, then going to work and all.

Lois James (36:57.228)
Yeah.

Cara Lunsford (37:22.054)
like all of this, that complicates things as well.

How does it affect you from a sleep perspective for like a new mom?

Lois James (37:36.46)
Yeah, I mean, it's so tricky, right? Because consistency is key when it comes to developing good, healthy sleep patterns and habits. And, you know, when you have a newborn, that's not... It's kind of the equivalent experience of being on call, right? I mean, you're just on call all the time. And yes, you're going to try and sleep wherever you can, but you know that it's going to be very, very broken. The good news is from a sleep perspective,

your total sleep time that you get in a 24 hour period does not need to be in one consolidated block for it to have the same kind of benefit. So you're not asked all the time, okay, what's the recommended sleep time? How much sleep does a person need? And yes, there is individual variation for sure, but for the most part, the vast, like 99 % of us in that bell curve require between seven and nine hours sleep in a 24 hour period.

That is the norm. Now there are going to be some that are like, some listeners that are like, that's ridiculous, I'm just fine with five hours. And maybe they are, or maybe they're actually sleep deprived and they've just gotten used to it. Right? So, you know, in an ideal world between that seven and nine, that does not need to be all in one go. So don't panic and think, okay, well, if I'm being woken up every two hours, I'm going to be useless tomorrow.

Cara Lunsford (38:49.393)
Yes.

Lois James (39:03.886)
it's not the case. mean, you might feel more tired for sure, but in terms of your actual health and in terms of your disease risk down the road, for example, sleep is sleep is sleep. So whether you're getting it in a period, in a series of naps or in a consolidated amount doesn't really matter. So we absolutely take opportunities to take those naps wherever you can.

Cara Lunsford (39:17.884)
Okay.

Lois James (39:31.38)
And to that point, I just want to, because it's very important, this is something that most people don't know. There are two distinct types of nap and there you really want to try and follow them if you can. One is the kind of the power nap or the cat nap, right, which is in and around 20 minutes. And then the other is what we would call a restorative nap. That should be about 90 minutes. And there's a very specific reason for this. And that's as we sleep, we go through these cycles of sleep, right, the different phases.

And people have often heard about these, know, the alpha which is falling asleep, theta which is light sleep, delta which is deep sleep, and then REM or dream sleep, rapid eye movement sleep, which is, before you kind of rotate back up, maybe wake up, maybe don't, but go back through alpha, theta, delta, REM, and so on and so forth. That sleep cycle takes about 90 minutes, 90 to 100 minutes. And you really don't want to nap and be woken from delta.

or deep sleep because you will experience what we call sleep inertia, which every single shift worker has experienced, most people in their life have experienced, which is that feeling of being like dragged from the depths of hell and you think nothing in the world is worth waking up right at this moment for. That's that grogginess that's associated with waking from Delta. So really try when you take your nap to avoid that, either a 20 minute nap or a 90 minute nap.

Cara Lunsford (40:57.532)
That's such that that's so good to highlight because I think that that those are the things that people need to know. It's like, okay, and for me, if I'm going to try and take a 20 minute nap, I'm not I don't have narcolepsy. Okay, so I I'm not just you know, I don't just close my eyes and I'm asleep. So I have to give myself 30 or 40 minutes because I know it's going to take me some time to get to sleep.

Lois James (41:20.386)
Yes, exactly. Yeah.

Cara Lunsford (41:27.168)
especially if I know that I want to ideally sleep for 20 minutes. Similarly with like 90 minutes, like I set aside two hours because I'm like, it's gonna take me some time to relax, maybe put my headphones on, maybe listen to some hurts kind of different sound or beats or whatever it is to try and get into a place of sleep. So I...

Lois James (41:36.622)
to us.

Lois James (41:47.118)
Thank

Cara Lunsford (41:57.425)
I'm so curious, A, you said something that really stood out to me. A lot of people don't know if they're sleep deprived. They think they're powering through. They're like, I'm good. I'm good with four to five hours of sleep. I don't need any more than that. What are some signs that you are sleep deprived and you don't know it?

Lois James (42:19.092)
One of the big ones is can you sit down and do something very routine and non-stimulating and not feel like you want to fall asleep? So for example, if you sit down and watch a show, are you asleep within 10 minutes of that show? Right? I mean, that's like a key indicator that you're sleep restricted, right? Likewise, driving is a big one. If you feel like you're tired every time you drive,

Anytime you do something really kind of mundane, are you nodding off? Are you feeling sleepy? That's a big one. I mean, the big indicator, honestly, is just, I know we're not great judges of our own fatigue level. Oftentimes we think we're just fine and actually we're really sleepy, but look at the evidence. Are you falling asleep at times where you're not actually telling your body to fall asleep? That's a big one.

Cara Lunsford (43:18.096)
Yeah, that's such a good clue. It's a really good clue because when I'm tired or when I feel sleep deprived, I'm 100 % like that. I'll go and think I want to just sit down and binge on some Netflix or something and within 10 minutes I'm out. I'm napping and I'm like, God, I fell asleep during the middle of the day. And I also just hate that feeling of waking up or being jarred awake during.

part of the Delta when you're almost like just disoriented. You don't know what day it is, what time it is. You're not sure if you just slept until the next day. It's awful. exactly. Like, now I, you know, and I hear people say that all the time, like, I'm not going down for a nap. If I go for a nap, I'm gonna, it's gonna be worse. And so I think it was really important that you say like, look, it's...

Lois James (43:48.75)
Mm-hmm.

Lois James (43:53.386)
Yeah. Yeah. And you're like, why did I not? I feel so much worse. Yeah.

Cara Lunsford (44:13.006)
It's 20 minutes, it's 90 minutes, and then give yourself enough time to actually fall asleep for that period of time.

Lois James (44:18.504)
Exactly. And the 20 minute one, great option as a really powerful fatigue countermeasure if you're taking that 20 minute nap is have caffeine before you sleep, right? That kind of the idea of a nappuccino, right? So have like a cup of coffee, take a power nap, and then you've got the twin benefits of the boost of sleep and the caffeine.

Cara Lunsford (44:42.352)
Good point, such a good point. Now, last thing I'm gonna ask you, because I know that sleep medication, especially Ambien, you hear all these stories, right, of different types of sleep medication that are utilized and sometimes abused. So what's the thought on sleep medication? I know you said earlier a lot of times you...

you don't use medication, use these other types of like behavioral therapy and things, CBT and stuff like that. When do you see that medication is necessary and what are some things that people should be considering when they're thinking, maybe I should be taking something for this?

Lois James (45:29.676)
Yeah, and I'd love to just caveat here that I'm not a practitioner, that I'm a researcher. So please, you know, any advice, you know, do kind of consult with your healthcare team. One of the big problems with any of the sleep medication is they mess with the structure of your sleep. You know, where I was saying the kind of, know, alpha, theta, delta, rem. They can disrupt that quite a bit, which is why oftentimes people, you know, who take sleep meds,

find that they have these really awful, vivid dreams, for example. I will say that I know melatonin, although not technically a sleep med, it's a natural product, that can also have a similar effect. Like people can have some really wonky dreams with melatonin. So I would advise against using melatonin as like a routine or consistent sleep aid. It's not really designed for that. It's pretty good at shifting your...

your sleep time, like let's say you're going from nights to days and you want to reset, melatonin can be useful for that. It does take about two hours to take effect, so don't take it. And if you take it and you fall asleep right away, it's psychosomatic. It has nothing to do with the melatonin. It's going to take about two hours for it to take effect, kind of like caffeine when you have a cup of coffee and immediately you're like, woo, I'm fine. It's like, no, you're not. That's because you feel like you're fine. But yeah, in terms of the sleep meds themselves,

Cara Lunsford (46:50.108)
You're like.

Lois James (46:55.124)
really the only time, to the best of my knowledge, that sleep physicians will advocate for them is if they're essential in the short term. They're a very, very poor long-term solution for any of the sleep disorders, especially something like insomnia, which is unfortunately what people often want sleep meds for. They can't fall asleep and a sleeping pill will knock you out. I mean, it will, right? But as we all know from the countless stories of addiction,

they are highly addictive, your tolerance builds and builds and builds. So, you you've gone from taking one Ambien to help you sleep and it helps you sleep through the night to a couple of weeks later, or even a couple of days later, you're taking an Ambien and then you're awake again at 2 a.m. and then you're panicky. So the temptation is, okay, well, I'll just take another. And it's a slippery slope to then you're kind of taking them around the clock, right? So, you know, I'd be very, very cautious of any of the...

sleep meds. I also be cautious, know, oftentimes people will self-medicate using not sleep meds, but I mean like alcohol is without doubt one of the biggest sleep aids that people use, right? You know, and I mean alcohol is kind of an interesting one because it acts as a stimulant first and then it does act as a sedative, so alcohol can be fairly useful at getting somebody to fall asleep. It's horribly bad at helping them stay asleep.

right, because it starts to become a it becomes a stimulant again as it wears off in the system, right? So, you know, we've all had that experience of having maybe one too many and we fall asleep and we, you know, feel like we're sleeping really well and then at two or three a.m. we're wide awake, right? And that's often, you know, related to that. So, I mean, really the techniques that we know are the most helpful.

Cara Lunsford (48:33.808)
Yep. Yep.

Lois James (48:42.734)
for producing good quality sleep, especially if you do not have a sleep disorder, if you don't have apnea, if you don't have severe insomnia, are based around cognitive behavioral therapy, which oftentimes is around establishing routine. And I know that that can be challenging with shift work, but even within your shift periods routine, this is what I'm gonna do while I'm on nights. This is what I'm gonna do while I'm on the transition phase. This is what I'm gonna do when I'm on my time off.

this is what I'm gonna do when I'm on transition phase back to shifts, right? Having that routine, limiting technology before bed, limiting light before bed, light management, light therapy is really important, exposing yourself to light when you want to be alert, caffeine management, monitoring your intake and making sure you don't build up too much tolerance. And then the big ones for sleep hygiene, which is really temperature, sound and light.

So making sure that your sleep space is quiet. And I mean, if that's not feasible with dogs and kids and life, some kind of earplug, really essential. Light, know, blocking out light when you want to sleep. Eye mask if necessary. And then temperature, which is one that oftentimes people don't know about. You want your sleeping temperature to be about five degrees colder than you want your house to be at other times, right?

And that's because as we sleep, our body temperature drops. So it's important to try and maintain a cooler body temperature when you want to sleep. It's easy to fall asleep in a warm environment. It's not easy to stay asleep in a warm environment. So a fan or air conditioning or whatever that looks like is really important.

Cara Lunsford (50:08.656)
Yes.

Cara Lunsford (50:18.17)
Yes.

Cara Lunsford (50:28.314)
Yeah, I always found having a fan blowing at me was really helpful. I don't know if it was just even the blowing of the air, but the coolness and all of that really helped. Also, we have found that like a fan in the face helps with anxiety. helps with, you know, if anyone's ever had like a start to have a panic attack or if they've been in a car, sometimes you want to put your head out the window. You like want that feeling of the air blowing at your face that

you know, can be calming. Yeah.

Lois James (50:59.776)
Absolutely. And the sound as well, you know, I think, you know, I know I just said that it's important to be, a quiet environment, but you sometimes people find it really hard to sleep in silence, especially if you have any hypervigilance or any kind of PTSD symptomatology. So having like low level, but very monotonous or continuous noise, like a fan or like sleep sounds or whatever that might look like, that can be really helpful as well.

Cara Lunsford (51:09.99)
Yes.

Cara Lunsford (51:23.964)
Mm hmm. Yeah, that I this is not an ad for calm, but I love the calm app. I listen to it and and at Relias, we we get it as a part of our our organization. So it's something we can use. And I always listen to metamorphosis when I'm sleeping. Metamorphosis is just like a series of different sounds, but it's but it's all very nature oriented. So, you know, there's like the occasional bird.

you know, like owl or something, and there's some crickets in there. But I really feel like I'm camping, actually, when I'm listening to it.

Lois James (52:00.238)
And they have put so much research behind that in terms of, okay, making sure that it's not too much of an alerting noise, you know, because sometimes people are like, I listen to the radio when I'm asleep. And that, unfortunately, is not great because the commercials tend to be at a higher decibel and they tend to be kind of, you know, shouty, right? So you don't want a sound where something's going to pop up and like pull you out of sleep.

but like the wade sounds or the forest sounds or whatnot, despite having sometimes those little chirpy noises, they're monotonous enough that they can be really great. yeah, mean, is awesome. The sleep stories as well, listening to Idris Elba say anything is gonna make me feel relaxed, so.

Cara Lunsford (52:26.801)
Right.

Cara Lunsford (52:37.478)
Yes.

Cara Lunsford (52:46.362)
I always listen to the Harry Styles one. I love the Harry Styles sleep bedtime story. Well, is there a place, okay, because I think we gave, you gave so much information and really important information.

Lois James (52:49.09)
Yeah, funny. Yeah.

Cara Lunsford (53:07.42)
And I'm sure many of the listeners are like, oh my gosh, I'm driving in my car. I'm half falling asleep. No, I'm just kidding. And I want to go somewhere. I want to learn more about this. People can always, of course, go to the nurse.com forward slash podcast. We try to put as much information there as possible. Where can they go to get more information about sleep hygiene and shift work in that?

Lois James (53:33.186)
Yeah, mean, just reach out to me, look me up on my faculty page. I have tons of material, plenty of things that I'm more than happy to share around any of the tips on sleep hygiene, for example. And I'm very happy to get that to people.

Cara Lunsford (53:52.829)
That's amazing. So Washington State University, is that where you are? Okay, so for anyone listening... Huh?

Lois James (53:55.842)
Yes, cougar, a cougar, not a husky. A cougar, not a husky. Oftentimes people think we're UW, University of Washington. They're the huskies, we're the cougars.

Cara Lunsford (54:02.8)
Cougar not a husky.

Cara Lunsford (54:07.248)
You're the cougars. You're the cougars. if you're wanting to reach out, it's Lois James. She's at Washington State University. Find her on her faculty page. We'll make sure to have something like that also where you can find her on the nurse.com.

Lois James (54:25.206)
I believe I might be the first Lois James that pops up when you Google now, which is kind of cool. It's not a very common name now, in fairness.

Cara Lunsford (54:30.948)
That's awesome. That's amazing or Google her. But we'll make sure to have information also on the podcast landing page. So nurse.com forward slash podcast. If you want more information and I just think that this is like just such invaluable info and remember to like be safe, know, safety first, get yourself home.

Get yourself to work. You know, make sure that your family is safe. That's like first and foremost, do it for yourself, do it for your family, do it for the people that love you. Take care of yourself. Any last words, Lois?

Lois James (55:13.985)
Take care of yourself and sleep well.

Cara Lunsford (55:16.284)
Thank you so much. This has been a wonderful, wonderful interview and I'm really grateful that you spent the time with me.

Lois James (55:23.712)
Of course. Thank you so much for having me.

Cara Lunsford (55:26.18)
Absolutely. Okay, I'm gonna stop, we have to let it, hold on one second.