Implementation of interventions designed to promote healthy sleep and circadian rhythms in shiftworkers

ABSTRACT

Shiftwork is a significant risk factor for a host of negative health and safety outcomes, which have been at least partly attributed to disturbances of the circadian timing system. As a result, an entire sub-field of chronobiology has been devoted to developing and evaluating countermeasures for circadian misalignment, sleep disruption, fatigue, and other issues associated with shiftwork. Much of this research takes place under highly controlled laboratory conditions due to the necessity of accurately characterizing individual rhythms, both for intervention design and assessment of efficacy. Applied studies of interventions for shiftworkers are, by their nature, more complicated, often demonstrating less consistent findings. While this, in part, reflects execution under less rigorously controlled conditions, it may also stem from variability in implementation approaches. A systematic review of published studies (through May 2017) of interventions designed to enhance circadian health in shiftworkers was conducted to determine the frequency and quality of the assessment of implementation as well as barriers and enablers to implementation. A search of PubMed, PsychINFO, Web of Science, and CINAHL databases yielded a total of 5368 unique references. After a title and abstract screen, 323 proceeded to full-text review; 68 of those met final criteria for data extraction. Implementation was assessed to some degree in 60.3% of those 68 articles. Where it was assessed, the mean quality score on a scale from 1 to 5 (1 = very little, 3 = moderate, 5 = very in-depth) was 2.56. One or more enablers were identified in just 17 of the 68 studies (25.0%), and barriers in just 18 (26.5%). Implementation of these interventions is a critical but seldom-acknowledged component of their uptake and effectiveness, and we highly recommend that future shiftworker intervention research make an effort to incorporate formalized assessments of implementation and/or hybrid effectiveness-implementation approaches.

KEYWORDS:

• Shiftwork
• intervention
• implementation
• barriers
• enablers
• circadian
• sleep

Acknowledgements

The authors want to express their thanks to Aileen Chang for her assistance with database searches, and to Cora Dyslin, Ali Easterling, Jourdan Jackson, and Jianna Sode for their assistance with title and abstract screens.

Declaration of interest statement

EMH, EAS, and AMY have no conflicts of interest to disclose. GLG reports that through UCSD she has received equipment, advice or financial support and/or served as a consultant to Philips, Litebook, BIOS Lighting, flux, PennWell Corporation, LightShow West, WELL Building Institute, and that she holds two currently issued patents (USPTO #7678140 and #8366755) and two continuing patent applications (USPTO #15/085522 and #14/273971).

Disclaimer

CAPT Yablonsky and Gena Glickman are military service members or employee of the U.S. Government. This work was prepared as part of my official duties. Title 17, U.S.C. §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C. §101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.

Report No. 20-60 was supported by the Tri-Service Nursing Research Program under work unit no. N1618. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University, Department of Defense, nor the U.S. Government.