Neuroscience and Biobehavioral Reviews 96 (2019) 272–289

Contents lists available at ScienceDirect

Neuroscience and Biobehavioral Reviews

journal homepage: www.elsevier.com/locate/neubiorev

Fatigue and its management in the workplace T

a b c c,⁎
John A. Caldwell , J. Lynn Caldwell , Lauren A. Thompson , Harris R. Lieberman
a
Oak Ridge Associated Universities, Oak Ridge, TN, United States
b
Naval Medical Research Unit Dayton, Dayton, OH, United States
c
Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Fatigue and workplace sleepiness are consequences of modern industrial society. Fatigue is a complex biological
Sleep phenomenon that occurs as a function of time awake, time-of-day, workload, health, and off-duty lifestyle.
Circadian Fatigue is a function of two major biological factors – the homeostatic drive for sleep and circadian rhythm of
Alertness sleepiness. The greatest cause of fatigue is insufficient or disrupted sleep. Excessive sleepiness in the workplace
Workload
and on highways is a serious safety hazard, and insufficient or disrupted sleep results in numerous accidents and
Naps
Safety
adverse mental and physical health outcomes. Evidence-based strategies that promote better sleep and optimize
Transportation work/rest schedules can mitigate the impact of fatigue and sleep loss. Proper nap and sleep scheduling, work
Workplace breaks, modeling and monitoring tools, fatigue detection technologies, and pharmacological countermeasures
Shift work can be implemented at home and/or in the workplace to reduce performance and safety hazards. Education
about obtaining adequate sleep, the dangers of fatigue in terms of both health and cognitive consequences, and
the availability of scientifically-proven sleep-enhancement and alertness-management strategies is essential.

1. Statement of the problem performance, safety, and health.

Fatigue is a significant problem in modern society, largely because 2. Definition of fatigue

of high workplace demands, long duty periods, disrupted circadian
rhythms, social and societal demands, and insufficient sleep
(Sadeghniiat-Haghighi and Yazdi, 2015; Luckhaupt, 2012). It is a
complex phenomenon that occurs as a function of time awake, time-of-
day, workload extremes, health, and on-the-job and off-duty responsi-
bilities and lifestyle. Fatigue is an inevitable consequence of modern
industrial society for a variety of reasons. Around-the-clock operations,
inconsistent work schedules, and rapid/frequent time-zone transitions
often adversely affect internal circadian rhythms. Short and variable
off-duty periods, lengthy commutes, and less-than optimal sleep en-
vironments frequently degrade the quantity and quality of sleep. In
addition, there are substantial individual differences in both sleep re-
quirements and fatigue tolerance that generally place some individuals
at greater risk than others. Fatigue and excessive daytime sleepiness are
also consequences of disorders of the central or peripheral nervous
systems and/or other disease states including common illnesses such as
infections, asthma, gastrointestinal disorders, and metabolic abnorm-
alities (Guilleminault and Brooks, 2001; National Sleep Foundation,
2018). However, fatigue can be managed by the application of evi-
dence-based fatigue risk management approaches which improve
“Fatigue is the state of feeling very tired, weary or sleepy resulting
from insufficient sleep, prolonged mental or physical work, or extended
periods of stress or anxiety. Boring or repetitive tasks can intensify
feelings of fatigue. Fatigue can be described as either acute or chronic.”
(Canadian Centre for Occupational Health and Safety, 2017). Fatigue
from lack of sleep will be the focus of this review. Fatigue can also
result from intense or monotonous cognitive activities or physical de-
mands, however, these issues will not be addressed here. Krausman
et al. (2002) provide a detailed account of the effects of physical fatigue
on cognition. Mental and physical fatigue result from different condi-
tions and have different symptoms, and it is important to distinguish
between the two (Lieberman, 2011). The common signs and symptoms
of fatigue from insufficient sleep and/or circadian disruptions/mis-
alignments and its effects are summarized in Table 1.
3. Fatigue from inadequate sleep
Sleep is a biological necessity like food, water, and oxygen, but like
consuming food and water, and unlike breathing, obtaining sufficient

⁎
Corresponding author at: Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine, General Greene Avenue, Building 42, Natick, MA,
01760, United States.
E-mail address: harris.r.lieberman.civ@mail.mil (H.R. Lieberman).

https://doi.org/10.1016/j.neubiorev.2018.10.024
Received 19 July 2018; Received in revised form 4 October 2018; Accepted 31 October 2018
Available online 02 November 2018
0149-7634/ Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
J.A. Caldwell et al. Neuroscience and Biobehavioral Reviews 96 (2019) 272–289

Table 1 3.2. Endogenous biological mechanisms responsible for sleepiness/fatigue

Signs, Symptoms, and Effects of Fatigue.
Signs and Symptoms of Fatigue Sleepiness is a function of two major biological factors – the
homeostatic drive for sleep and the circadian rhythm or “body clock” of
Rubbing the eyes sleepiness (Goel, 2017). In individuals who work consistent daytime
Head nodding
schedules, these two factors operate together to maintain consolidated
Forgetting instructions
Long eye blinks
sleep at night and stable alertness during the day. However, in in-
Yawning dividuals engaged in rotating work/rest schedules and those who fail to
Fidgeting and squirming in the seat obtain adequate sleep, the interaction between homeostatic and circa-
Not talking to co-workers dian factors can cause significant problems.
Inability to solve routine work problems
The homeostatic drive for sleep is primarily a function of the
Irritability
Sleepiness (including involuntary sleep onset) amount of sleep recently obtained as well as the amount of time that
Inability to concentrate or memorize has elapsed between the end of the last sleep period and the beginning
Lack of motivation of the next sleep period. Failure to obtain the required 7–9 h of sleep per
Depression
day rapidly impairs both alertness and performance. Furthermore, re-
Giddiness
Headaches
maining awake for longer than 16 continuous hours significantly de-
grades performance (Williamson and Feyer, 2000), especially when the
Effects of Fatigue latter hours coincide with the late-night/early-morning period, leading
Reduced decision making ability to an adverse combination of the homeostatic and circadian drives for
Reduced ability to do complex planning sleep. Remaining awake on any single occasion for more than 24 con-
Reduced communication skills
tinuous hours produces a variety of acute adverse effects such as de-
Reduced productivity or performance
Reduced attention and vigilance graded vigilance, reaction time, attention, memory, and decision-
Reduced ability to handle stress on the job making (Lim and Dinges, 2010).
Increased reaction time –in speed and thought The circadian clock, or “time of day according to the body’s clock,”
Loss of memory or the ability to recall details
is the second key factor that defines alertness. As diurnal animals, hu-
Failure to respond to changes in surroundings or information provided
Inability to stay awake (e.g. falling asleep while operating machinery or driving
mans evolved to be awake and active during the day and asleep at
vehicles) night. Whenever this innate schedule for waking and sleep is disrupted,
Increased tendency for risk-taking problems arise. People who work at night or travel across multiple time
Increased forgetfulness zones are required to be alert at a time when the body is physiologically
Increased errors in judgement
programmed for a sleep cycle. During the circadian trough, the low-
Increased sick time, absenteeism, rate of turnover
Increased medical costs point in the body’s circadian rhythm that generally occurs between
Increased rates of adverse incidents 0200 h and 0600 h, alertness is lower, reaction time is slower, and ac-
curacy is poorer than during the circadian peak (i.e., during daytime
hours) (Folkard and Tucker, 2003).
sleep requires individuals to engage in volitional behaviors affected not
When considering the impact of the homeostatic and circadian
only by personal choices, but also by societal demands. Factors that
drives on alertness and performance, it is important to note these two
influence sleep behaviors include individual genetics, knowledge, be-
drives interact with one another. Thus, cognitive performance during
liefs, and attitudes about sleep, health and disease, and many other
the circadian trough after many hours of continuous wakefulness will
variables. These are embedded in a societal context that includes home,
be substantially more impaired than cognitive performance when the
family, the sleep environment, neighborhood, occupation, socio-
trough occurs immediately after awakening from a recent sleep period.
economic status, and many other factors. In the modern industrial age,
This is because, in the former case, there would be sleep pressure due to
these factors often prevent individuals from obtaining sufficient sleep
both high circadian and high homeostatic sources, whereas in the latter
(Grandner, 2017). Furthermore, several common illnesses disrupt sleep
case, the sleep pressure would largely be a function of only the circa-
and increase fatigue.
dian factor.

3.1. Prevalence of the problem 3.3. Acute versus chronic sleep deprivation

Sleep experts recommend 7–9 h of sleep per night for most adults
(Hirshkowitz et al., 2015), but many fail to obtain adequate sleep. The
Centers for Disease Control (CDC) surveyed adults in 29 US states be-
tween 2013 and 2014 and found that 36.7% of employed adults re-
ported sleeping less than 7 h per night (Shockey and Wheaton, 2017).
The authors stated that several work factors influence sleep duration
and that insufficient sleep is especially a problem for workers in the
production, health care, protective service, transportation, and food
service fields in part because of the high levels of shift work in these
occupations.
In the recent past there has been a downward trend in the amount of
sleep obtained by Americans. Whereas the average sleep duration in
1985 was 7.4 h, it declined to 7.18 h in 2012 (Ford et al., 2015). In
addition, only 22.3% of adults reported sleeping less than 6 h per night
in 1985, but that number increased to 29.2% in 2012 (Ford et al.,
2015). Recent statistics suggest this trend has diminished, but in-
adequate sleep and the resulting on-the-job sleepiness nevertheless re-
main prevalent among adults, and chronic sleep loss continues to ne-
gatively impact mood, performance, and health.
Both acute episodes of total sleep deprivation (i.e., remaining awake
for an extended periods) and repeated episodes of partial sleep depri-
vation (i.e., chronically getting less than 7 h of sleep per night across
several days) impair cognitive performance and health (Lo et al., 2012).
It is not possible to adapt to reduced sleep even after repeated exposure
to it (Simpson et al., 2016).
3.4. Recovery from acute versus chronic sleep loss
Generally, recovery from acute, total sleep deprivation is faster than
recovery from chronic sleep restriction. Most acute sleep-deprivation
studies indicate performance returns to baseline levels within 2 nights
when recovery sleep of at least 8 h per night is obtained (Balkin et al.,
2008). However, this is not the case with chronic sleep restriction. Full
recovery from several (i.e., 7–14) days of progressive sleep debt takes
longer than 3 consecutive days despite 8 h of sleep per night throughout
the post-sleep-restriction period (Belenky et al., 2003; Van Dongen
et al., 2003). In general, restoration of baseline performance can take
several days – as long as a week – following chronic sleep loss (Axelsson

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J.A. Caldwell et al.
et al., 2008).
The rate of recovery is a function of both the duration of post-sleep-
restriction sleep as well as the duration of pre-sleep-restriction sleep.
With regard to the former, Banks et al. (2010) found that prolonging the
post-deprivation sleep periods can speed recovery, but even so, in-
dividuals who experience 5 nights of severe sleep restriction will not
fully recover after a single night of 10 h in bed. With regard to the
latter, reducing the extent of sleep debt prior to chronic sleep restriction
exerts a beneficial effect on the speed of recovery (Rupp et al., 2009,
2010).
4. Fatigue from long work hours and boredom
In addition to the negative impacts of sleep loss and disrupted cir-
cadian rhythms, fatigue that degrades cognitive performance also can
result from participating in long boring tasks such as highway driving,
monitoring equipment, and flying highly-automated aircraft (Ting
et al., 2008; Guo et al., 2016; Krueger, 1989; Goode, 2003). In la-
boratory studies conducted using monotonous, boring tasks, decre-
ments in cognitive performance occur in 10 min or less and increase
over time (Bonnefond et al., 2010; Boksem et al., 2005; Fine et al.,
1994; Guo et al., 2016; Kato et al., 2009; Lieberman et al., 1998). In
driving simulator studies, decrements in reaction time and other aspects
of driving performance are present in as little as 10 min as well when
the simulation is monotonous (Ting et al., 2008). In an industrial set-
ting, prolonged work shifts (greater than 8 h) also lead to decrements in
alertness and performance (Rosa and Bonnett, 1993). Dembe et al.
(2005) reported there is a higher risk of injuries after an increase in the
number of hours worked per day and per week; Morisseau and
Persensky (1994) found working overtime in the nuclear industry is
associated with an increase in adverse incidents. Hamelin (1987) de-
monstrated a relationship between longer work hours and increased
risk of truck accidents, particularly at night. Folkard and Lombardi
(2006) concluded that the risk of errors and incidents increased 13% for
10 h shifts and 28% for 12 h shifts in comparison to 8 h shifts. Within
the aviation environment, Samel et al. (1997) found pilot fatigue in-
creases progressively as a function of flight length, and Rosekind et al.
(1994) determined for some pilots performance lapses increased during
the latter portion of long-haul flights. Furthermore, after examining
commercial flights (conducted under Federal Aviation Regulations, Part
121) and human-factor aviation accidents in the U.S. between 1978 and
1999, Goode (2003, p. 312) concluded there was an “increased risk of
accidents with increased duty time and cumulative duty time.” Ac-
cording to Akerstedt (1995), long work hours can be associated with
increased sleepiness, in part because long hours on the job reduce op-
portunities for adequate off-duty sleep.
5. Origins of the 8 h workday
In 1890, many full time industrial employees in the U.S. worked an
average of 100 h per week (Ward, 2017). However, with the formation
of labor organizations and other entities focused on workers’ protec-
tions and rights, the work week evolved into the standard 8 h day/40 h
work week (Derickson, 2013). The first attempt to establish an 8 h work
day in the U.S. was a failed petition by the National Labor Union to
Congress in 1866. However, in 1867 the Illinois State Legislature passed
a law limiting the work day to 8 h, with a caveat: employers could
contract more than the 8 h of work with their employees. This led to a
turning point in the labor movement, a multi-city strike across the U.S.
and Europe on May 1, 1867 (Ward, 2017). Government workers were
granted an 8 h day in an 1869 proclamation by President Grant, and in
1898, the United Mine Workers union successfully petitioned for a
mandated 8 h day (Ward, 2017). However, the major breakthrough
came in 1926 when Henry Ford, President of the Ford Motor Company,
mandated an 8 h per day/40 h work week. As a consequence, in 1937
General Motors workers went on strike demanding shorter work hours.
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Finally, a national standard was established in 1938 when Congress
passed the Fair Labor Standards Act (FLSA) limiting the U.S. employee
work week to 8.8 h per day and 44 h per week which was amended in
1940 to 8 h per day and 40 h per week (Ward, 2017).
6. Current work regulations
As discussed above, the FLSA, enacted in 1938, sets the minimum
wage and defines overtime work but does not directly regulate many
aspects of employee work hours. Individual states also have laws reg-
ulating the minimum wage. The FLSA does not regulate employee rest
periods for purposes of alleviation of fatigue, but the Act does include
language on rest periods and employee compensation (Fair Labor
Standards Act, 2008). The FLSA states that short periods of rest –
20 min or less – are recommended and should generally be paid as
working time, while any mandated meal periods of 30 min or more are
not compensated as working time, and the employee should be com-
pletely relieved of duty during that time. Employees exempt from the
FLSA law includes railway workers and commercial truck drivers who
are covered, respectively, by the Railway Labor Act and Motor Carriers
Act. Other workers such as air transportation workers and merchant
mariners are governed by their own industry-specific regulations. Su-
pervisory employees and those earning over $100,000 per year are
exempt from FLSA, but those making less than $23,600 are not.
In contrast to the U.S., The European Union (EU) limits working
hours across all professions – including the medical field – to no more
than 48 duty hours per week (Temple, 2014). The Working Time Di-
rective, enacted in 2003, mandates a minimum of 4 weeks of paid va-
cation per year, rest breaks of at least 11 h during each 24 h period, and
a mandatory day off each 7 days (European Union, 2003). Exceptions to
this regulation in the United Kingdom (UK) include those employed in
the armed forces, emergency and police personnel, and domestic ser-
vants in private households (United Kingdom Government, 2017). Also,
unique to the UK, some groups of employees are allowed to “opt out” of
this regulation, but certain workers including airline workers, ship or
boat workers, and delivery/road transport drivers cannot (United
Kingdom Government, 2017). France and Germany also maintain cer-
tain unique labor laws including a new law establishing employees’
“right to disconnect” which bans companies from emailing their staff
after work hours (Morris, 2017).
Although federal regulations do not exist for most workers re-
garding work and rest periods within the U.S., most states do have laws
in place. For example, Massachusetts has a “day of rest” state law
(Commonwealth of Massachusetts, 2018). Also, unions often negotiate
employees’ hours, rest, mealtime breaks, etc., and collective bargaining
can supersede regulations that govern other workforces.
The U.S. Occupational Safety and Health Administration (OSHA)
provides guidance on extended hours and shift work, however, there is
no specific OSHA Standard for extended/unusual shifts (Occupational
Safety and Health Administration, 2017). OSHA defines a normal work
shift as generally consisting of an 8 consecutive-hour work period,
during the daytime hours, occurring 5 days per week, and with at least
an 8 h rest period each day. Work during longer consecutive hours,
more days per week, or during nighttime hours is considered by OSHA
to be “extended or unusual”. As part of their guidance for employers,
OSHA recommends reducing the length of a shift in favor of increasing
the number of days worked. They also suggest increasing the number of
break periods and meal times, and that more physically intensive work
be performed at the beginning of a shift if possible (Occupational Safety
and Health Administration, 2017).
6.1. Flight crews
The Federal Aviation Administration (FAA) published a final rule for
flight crew (i.e. pilots and co-pilots) duty and rest requirements effec-
tive January, 2014 (Department of Transportation. Federal Aviation
J.A. Caldwell et al.
Administration, 2012). The FAA formulated the regulation based on
sound scientific principles including research on sleep and circadian
rhythms. This rule applies to all types of part 121 passenger operations;
there are no separate rules for domestic, flag or supplemental passenger
operations. All pilots must now sign an official document stating they
are “fit for duty” before each flight, and airlines must remove a pilot
from duty if he or she reports fatigue. Previous FAA rules mandated a
9 h rest period which could be reduced to 8 h in certain circumstances;
however, the new rule requires 10 h rest periods with the opportunity
for at least 8 h of uninterrupted sleep. Maximum flight times have also
been updated: maximum daytime flight time is 9 h and maximum
nighttime flight time is 8 h. The new rule also limits a pilot’s flight duty
period to 9–14 h, depending on the start time and number of flight
segments. Finally, the FAA proposed that airlines implement a Fatigue
Risk Management System to assist pilots with meeting the new re-
quirements (Department of Transportation. Federal Aviation
Administration, 2012).
Air traffic controllers must have 24 h of consecutive rest time in
each consecutive 7-day period. Except in emergency situations, con-
trollers may not be on duty for more than 10 consecutive hours or more
than 10 h during a 24 h period unless they have had a rest period of 8 h
at or by the end of the 10 h period (14 CFR 65.47 - Maximum hours).
6.2. Nurses
Currently there are no federal regulations regarding work/rest cy-
cles for nurses in the U.S. However, 16 individual states currently have
regulatory tools to prevent nurses from working extreme overtime
hours without adequate rest periods (American Nurses Association,
2012a, b; Bae and Yoon, 2014). The first of these is a mandatory
overtime policy which allows nurses to refuse mandatory overtime re-
quests by employers unless an “unforeseeable emergency situation”
occurs. A second tool, the consecutive work hour policy, aims at re-
stricting the number of consecutive hours nurses are allowed to work.
In most circumstances, nurses are restricted to working 12 h within a
24 h period (Bae et al., 2012). There are also restrictions that include
mandatory breaks, such as a 10 h rest period, between shift periods
(American Nurses Association, 2012a, b). The American Nurses
Association (2012a, b) has pursued federal legislation for protection of
nurses and supports individual state regulations in place. Additionally,
the Institute of Medicine has made recommendations that nurses not be
allowed to work “…in any combination of scheduled shifts, mandatory
overtime, or voluntary overtime in excess of 12 h in any given 24 h
period and in excess of 60 h per 7-day period.” (Institute of Medicine,
2004, p. 13).
6.3. Medical residents
In July 2011, the Accreditation Council for Graduate Medical
Education (ACGME) published duty hour regulations for medical re-
sidents in the U.S. (Accreditation Council for Graduate Medical
Education, 2011). The regulations set an 80 h work week as the max-
imum permitted and set forth guidelines for increased oversight by
senior physicians. In 2017, the regulations were updated to eliminate
extended duration (16 h) shifts by first year residents. By comparison,
medical residents in other countries work significantly fewer hours per
week.
6.4. Truck drivers
The Federal Motor Carrier Safety Administration (FMCSA) set new
regulations on hours of service for U.S. truck drivers in July, 2013
(Federal Motor Carrier Safety Administration, 2014). This final rule
decreased the maximum average work week for drivers from 82 h to
70 h. The regulation does allow drivers who have reached their 70 h
maximum to resume driving if they rest for 34 consecutive hours.
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However, these 34 h must include at least two nights between the hours
of 0100 and 0500. While on duty, drivers must take a 30 min rest period
during their first 8 h on the road; the daily driving limit remains 11 h
with a 14 h total work day limit. Penalties for drivers and companies are
high. Companies can be fined up to $11,000 and individual drivers
fined up to $2,750 per offense for regulatory violations.
Furthermore, the FMCSA instituted a final and unique rule on
electronic logging devices (Federal Motor Carrier Safety
Administration, 2015). These devices are linked with the vehicle’s en-
gine and automatically record driving time and hours-of-service data.
Use of this system results in easier monitoring, more accurate driver
records, and greater difficulty deceiving regulators. The regulation
applies to almost all motor carriers – including commercial buses – as
well as drivers residing in Canada and Mexico but operating in the U.S.
(Federal Motor Carrier Safety Administration, 2015).
6.5. Railway industry
The U.S. Federal Railroad Administration (FRA) “Hours of Service”
laws were most recently amended in 2008. These laws govern train
employees’ (to include operators, dispatch and signal employees) on-
duty and off-duty hour requirements, including consecutive work day
and total monthly limitations (Rail Safety Improvement Act, 2008).
Employees are limited to 276 h worked per calendar month, 12 con-
secutive hours worked per day, a minimum of 10 consecutive hours of
rest per 24 h period, and no more than 6 consecutive days of work
(although 7 days may be worked if the employee is given 72 con-
secutive hours off duty at their home terminal) (Rail Safety
Improvement Act, 2008). While the 2008 Hours of Service laws are
Congressionally mandated, the FRA has received authority to imple-
ment regulations on work hours for train employees working in com-
muter and intercity passenger transportation; in August, 2011, the FRA
published a final rule on these limitations (Federal Railway
Administration (FRA), 2011). While many FRA regulations are similar
or identical to the 2008 laws, the FRA has included mandated use of
“fatigue science modeling”. All passenger train employees’ work sche-
dules must be analyzed by a validated biomathematical fatigue model
(e.g. Fatigue Avoidance Scheduling Tool™) and approved as presenting
an acceptable level of fatigue risk. Schedules that are entirely within the
hours of 0400 h and 2000 h or those which have previously been
modeled and have an acceptable level of risk can be exempt; however,
all nighttime schedules between 2000 and 0400 must be analyzed by a
fatigue science program. If a schedule is deemed to result in excess risk
of fatigue, it must either be mitigated or have supporting documenta-
tion on its necessity and approval by the FRA (Federal Railway
Administration (FRA), 2011; Hursh et al., 2004, 2006).
6.6. Nuclear power
The worst nuclear accident in the U.S. began at 0400 h at the Three
Mile Island plant in Pennsylvania and was attributed in part to work-
place fatigue (Mitler et al., 1988). The U.S. Nuclear Regulatory Com-
mission regulates work hours for workers at nuclear reactor facilities
including operators, members of the fire brigade, maintenance per-
sonnel and security officers (Nuclear Regulatory Commission (NRC),
2008). These employees are limited to 16 work hours per 24 h period,
26 h per 48 h period, and 72 work hours per 7-day period. Employees
must have a minimum 10 h break between successive work periods and
a minimum 34 h break in any 9-day period. The Commission also reg-
ulates days off. Employees working 8 h shifts have 1 day off per week,
and those working 10 h shifts have 2 days off per week. Those working
12 h shifts as operators or fire brigade are given 2.5 days off; main-
tenance personnel working 12 h shifts have 2 days off; and security
personnel working 12 h shifts are given 3 days off per week (as aver-
aged over each shift cycle) (Nuclear Regulatory Commission (NRC),
2008).
J.A. Caldwell et al.
6.7. Summary
There are some general work-hour regulations imposed by Federal
and State statutes, but the issue of workplace fatigue is usually not
addressed. Exceptions include pilots, truckers, and nurses, but for most
other occupations, workplace fairness, work/non-work-time balance,
physical exhaustion, and worker health are the concerns, not the impact
of work hours on cognitive or physical fatigue and on-the-job perfor-
mance or judgement. The National Institute for Occupational Safety and
Health (NIOSH) provides guidance on strategies for fatigue mitigation
including guidance promoting workplace health and safety in relation
to fatigue and sleep (Centers for Disease Control and Prevention (CDC)
NIOSH, 2017). NIOSH provides fact sheets (https://www.cdc.gov/
niosh/topics/workschedules/education.html) on strategies to make
shiftwork easier for the employee (i.e. get on a schedule, go to bed at
consistent times, etc.), as does the Canadian Centre for Occupational
Health and Safety (https://www.ccohs.ca/oshanswers/psychosocial/
fatigue.html). However, there are no general regulations in the U.S.
for mitigating the effects of shiftwork on cognitive performance or
physical and mental fatigue.
7. Causes of inadequate sleep
Sleep loss in the U.S. population is often associated with sleep dis-
orders, and lifestyle and occupational factors are also significant con-
tributors to the problem (Institute of Medicine, 2006). The average
American is sleeping only about 7.18 h per night, less than most need
(Ford et al., 2015), and this is at least in part due to work-related fac-
tors.
7.1. Shift work
Approximately 18–26%, or between 26 and 38 million, of the U.S.
workforce are considered to be shift workers (Drake and Wright, 2011),
and most members of the working population are on some type of ir-
regular or non-standard schedule to include weekend work, split shifts,
on-call work, compressed weeks, telework, part-time work, variable/
flexible working time, and prolonged duty periods (Costa, 2010).
Workers on non-standard and/or variable schedules suffer from sleep
loss and disruption of circadian rhythms (Harma et al., 1998; Drake
et al., 2004). Chronic alterations, disruptions, or misalignment of the
circadian clock in relation to environmental cues and the terrestrial
light-dark cycle (such as that associated with shift work) can contribute
to circadian rhythm sleep disorders including delayed sleep phase,
advanced sleep phase, non-entrained sleep-wake cycle, irregular sleep-
wake cycle, shift work sleepiness disorder, and jet lag (American
Academy of Sleep Medicine, 2014).
The combination of sleep restriction and circadian disruptions can
be especially devastating from an alertness and performance stand-
point. Van Dongen and Dinges (2005) point out circadian rhythms in-
fluence almost every aspect of alertness and performance. In general,
performance quality follows the pattern of internal body temperature (a
standard marker of the biological clock) as low body temperature –
which is physiologically programmed to occur during nighttime sleep –
is associated with less alertness, slower reaction time, and poorer ac-
curacy. Thus, it is not surprising that night shift workers often perform
more poorly than their daytime counterparts (Folkard and Tucker,
2003). There is substantial evidence that night work is associated with
increased accidents. Folkard and Tucker (2003) estimate that the re-
lative risk of workplace incidents on the afternoon shift (generally
starting between 1400 h and 1800 h) increases approximately 18%
compared to day shift, whereas the risk of incidents on the evening/
night shift (generally starting between 1800 h and 0400 h) increases to
about 30%.
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7.2. Sleep disorders
Another contributor to sleepiness and performance impairment is
untreated sleep disorders. As many as 70 million Americans are affected
by a sleep disorder, and many remain undiagnosed and untreated. The
most common disorders are sleep apnea (periods of cessation of
breathing or shallow breathing during sleep), insomnia (the inability to
initiate and/or maintain sleep), and periodic limb movement syndrome
(the involuntary movement of arms and/or legs during sleep) (Colten
and Altevogt, 2006). The prevalence of sleep apnea ranges from 6 to
13%, depending on sex and age (Peppard et al., 2013). Depending on
diagnostic criteria, the incidence of insomnia in the general population
ranges from 10 to 48% (Chung et al., 2015). The incidence of periodic
limb movement syndrome has not been studied extensively in the
general population, but the estimated prevalence is between 0.1 to 13%
(Scofield et al., 2008). These disorders, when untreated, are associated
with poor sleep quality and quantity which lead to daytime sleepiness
and increased mortality, morbidity, work absences, and reduced pro-
ductivity (Yazdi et al., 2014).
7.3. Poor sleep hygiene
Sleep habits including poor sleep environments, inconsistent sleep/
wake timing, sleep-disrupting associations between the bedroom and
non-sleep behaviors, as well as engagement in arousal-producing ac-
tivities in close proximity to bedtime often create sleep initiation and
maintenance difficulties. Left unaddressed, the resultant insomnia ad-
versely impacts performance and health; however, treatment with be-
havioral therapies, provided by a professional, often can resolve the
problem (Morin, 2011; Stepanski and Wyatt, 2003).
7.4. Medications
Medical disorders and medications used to treat them can cause
daytime sleepiness and/or poor sleep at night. Sometimes, it is difficult
to separate the effects of the disorder itself from the effects of the
treatment, with both potentially affecting sleep and daytime alertness.
While it is beyond the scope of this paper to describe the effects of these
disorders and medications on sleep and daytime sleepiness, a brief
summary of the major classes of medications used to treat various
disorders and their effects on sleep and somnolence follows
(Schweitzer, 2011).
Several antidepressants can affect sleep and daytime alertness.
Some tricyclic antidepressants and monoamine oxidase (MAO) in-
hibitors initially may be sedating during the day, but this effect may
lessen with time. The selective serotonin reuptake inhibitors (SSRIs)
and serotonin and norepinephrine reuptake inhibitors often disturb
sleep and produce daytime sedation as a side effect. Serotonin an-
tagonist/reuptake inhibitors can improve nighttime sleep quality, but
may induce daytime sedation. Antipsychotic, anxiolytic, and anti-
epileptic drugs also can be sedating, as are first generation Type 1 (H1)
receptor antagonists (antihistamines). One first generation anti-
histamine, diphenhydramine, is widely-available as an FDA-approved
over-the-counter sleep aid and is also approved for treating allergies.
Pain medications also often produce daytime sleepiness as a side effect,
particularly opioids and triptans (serotonin receptor agonists generally
used to treat migraine headaches). Other drugs can have stimulating
effects which tend to disrupt nighttime sleep. These include corticos-
teroids, pseudoephedrine, phenylpropanolamine, and theophylline.
Caffeine, if consumed later in the day in moderate and high doses, also
can interfere with sleep (Drake et al., 2013). Any medication that dis-
rupts sleep is likely to produce subsequent daytime drowsiness (fatigue)
since restless or short sleep is not adequately restorative.
J.A. Caldwell et al.
7.5. Light exposure
Exposure to light can have positive or negative effects on sleep and
alertness as a function of its timing, wavelength, and brightness (Dijk
and Archer, 2009). Light typically synchronizes circadian rhythms to
the external environment via modulation of autonomic and neu-
roendocrine systems, especially melatonin (Fisk et al., 2018). Suffi-
ciently bright light increases arousal and often has positive effects on
cognition, especially in tasks requiring sustained attention. Intermittent
light exposure can affect sleep in either a positive or negative fashion
depending on the timing of exposure. Blue-enriched light is particularly
potent (Brainard et al., 2001). Daytime blue light exposure tends to
exert positive effects on nighttime sleep whereas evening exposure
exerts negative effects. Boubekri et al. (2014) found that day workers
employed in offices devoid of windows received less daytime light ex-
posure during the week (thus, less daytime blue light exposure) and
consistent with the previously-noted general expectation, tended to
sleep less than workers in offices with windows. They attributed this
effect to lowered physical activity and quality of life for those workers
with low daytime light levels, ultimately affecting sleep quality. Viola
et al. (2008) found that blue-enriched office light led to increased
workplace performance, reduced daytime sleepiness, and improved
reported night-time sleep quality. Conversely, Chang et al. (2015)
found evening light exposure from reading certain light-emitting e-
books (which emitted short-wavelength–enriched light peaking at
452 nm – in the blue light range) reduced sleepiness, prolonged sleep
latency, delayed the circadian clock, and impaired next-morning
alertness when compared to those who read a printed book. Adults as
well as children and adolescents who use electronic media (e.g., tele-
visions, computers, electronic games, phones, and MP3 players) in the
evening have consistently later bedtimes and a reduction in total sleep
time (Cain and Gradisar, 2010; Fossum et al., 2014). This may be at-
tributed to the fact that many of these devices emit high levels of blue
light. In any case, use of electronic media at bedtime may displace
sleep, increase arousal levels and delay sleep initiation (Fossum et al.,
2014).
8. Health impact of insufficient sleep
Sleep is a vital physiological function, and insufficient sleep due to
sleep deprivation, sleep restriction, and/or sleep disruption has been
linked to numerous adverse mental and physical health outcomes. In
the absence of adequate sleep, significant declines in overall whole
brain activation occur, with the greatest deactivation in regions re-
sponsible for higher-order cognitive processing, general arousal, and
emotional/affective regulation (Mullins et al., 2014). Sleep loss and
sleep disorders are among the most common overlooked and readily
treatable health problems. From 50 to 70 million Americans chronically
suffer from a disorder of sleep and wakefulness, hindering daily func-
tioning and adversely affecting health and longevity (National Heart,
Lung, and Blood Institute, 2003). Restricting sleep to less than 7 h per
night has wide-ranging effects on the cardiovascular, endocrine, im-
mune, and nervous systems, and is associated with adverse con-
sequences including obesity in adults and children, impaired glucose
tolerance, and cardiovascular disease including hypertension (Institute
of Medicine, 2006). In addition, sleep disorders are known to be asso-
ciated with an increased risk of depression, anxiety, substance abuse,
and suicide (Johnson et al., 2006; Wallander et al., 2007; Wong et al.,
2009; Bernert et al., 2005; Troxel et al., 2015). Insufficient sleep
duration contributes to 7 of the 15 leading causes of death in the U.S.,
including cardiovascular disease, hypertension, accidents, diabetes, and
septicemia (Kochanek et al., 2014).
8.1. Effects of sleep loss on health
Sleep disturbances increase the risk of infectious and inflammatory
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diseases and contribute to all-cause mortality (Erwin, 2015). The
greater the sleep disturbance, the greater the extent of adverse effects.
Shortened sleep duration has been associated with increased coronary
artery calcification, a predictor of future coronary heart disease
(Gangwisch, 2009), and reduced insulin sensitivity which may increase
the risk of diabetes (Touma and Pannain, 2011). Sleep loss likely plays a
role in the Nation’s obesity epidemic in part because of impaired ap-
petite control and reduced physical activity resulting from increased
feelings of sleepiness and fatigue (Patel, 2009). Sleep problems also
appear to impair the stress response and energy balance because of, in
part, disrupted hormonal regulation including dysregulation of cortisol
and thyroid stimulating hormone (TSH) (Van Cauter et al., 2007).
Furthermore, it appears that sleep restriction increases susceptibility to
colds, influenza, herpes zoster (shingles), and potentially, HIV-related
complications (Erwin, 2015).
8.2. Effects of sleep loss in combination with circadian disruption on health
Epidemiological research on the impact of shift work and night
work suggests these work schedules and the associated chronic sleep
loss increase the risk of a variety of adverse long-term effects on health,
including effects on mental health, gastrointestinal, and metabolic
function (Costa, 2010). Females are additionally at increased risk of
pre-menstrual syndrome, pregnancy-related problems such as greater
frequency of miscarriages, impaired fetal development, and decreased
fertility (Mahoney, 2010).
Although controversial, in 2007 the International Agency for
Research on Cancer concluded that shift work involving circadian dis-
ruption is probably carcinogenic to humans (Costa et al., 2010; Straif
et al., 2007). This conclusion was largely based on findings that female
shift workers are at greater risk of developing breast cancer, and evi-
dence that shift work may be associated with an increase in en-
dometrial, prostate, and colorectal cancer as well as non-Hodgkin
lymphoma (Costa, 2010; Straif et al., 2007; Kolstad, 2008). Further-
more, shift work has been associated with an increased risk of devel-
oping diabetes, especially among male shift workers and other em-
ployees working rotating shifts (Gan et al., 2015). Among women
working rotating night shifts for several years, increased all-cause and
cardiovascular-disease mortality as well as lung cancer mortality has
been reported (Gu et al., 2015). Medic et al. (2017) reported that nurses
working rotating night shifts also are more likely to be diagnosed with
colorectal cancer while Ferri et al. (2016) reported that nurses working
rotating night shifts suffer more frequently from chronic fatigue, psy-
chological, and cardiovascular symptoms than their day-shift-worker
counterparts.
9. Sleep loss and cognitive error/performance
The impact of poor or insufficient sleep on cognitive function, and
as a result increased accident risk, has long been recognized. Focusing
on sleep is the most important factor from a fatigue-management per-
spective, and recent updates to critically important hours-of-service and
duty-and-rest regulations now reflect this (see for example Federal
Motor Carrier Safety Administration, 2011; Federal Aviation
Administration (FAA), 2012a,b). Sleep quality, sleep quantity, sleep
timing, the amount of wake time since the last sleep period, and re-
covery from long stints of duty are critical determinants of waking
performance and associated safety.
9.1. Effects of sleep loss on performance in general
Reduced sleep exerts cumulative adverse effects on cognitive per-
formance and the brain including reduced vigilance, increased lapses of
attention, short term memory degradation, and deficits in frontal lobe
functions; rapid and involuntary onsets of sleep can also occur (Banks
and Dinges, 2007; Bonnet, 1994; Dinges, 1992; Horne, 1988, 1993;
J.A. Caldwell et al.
Koslowsky and Babkoff, 1992; Naitoh, 1975; Thomas et al., 1993).
Dinges et al. (1997) reported 4–6 h of sleep per day creates a “sleep
debt” which seriously and rapidly impairs waking performance.
Belenky et al. (2003) and Van Dongen et al. (2003) confirmed these
results in similar studies during which subjects were restricted to 3–7 h
of sleep per night for several days. Many other studies have found 5 h or
less sleep per night degrades cognitive performance, reduces sleep la-
tency values, increases subjective sleepiness, increases behavioral,
mood, and physical complaints, and produces polysomnographic in-
dications of elevated sleep pressure (Blagrove et al., 1995; Carskadon
and Dement, 1981, 1982; Frazier et al., 1971; Gillberg and Akerstedt,
1994; Hamilton et al., 1972; Herscovitch and Broughton, 1981;
Herscovitch et al., 1980; Rosenthal et al., 1993; Taub and Berger, 1973;
Tilley and Wilkinson, 1984; Webb and Agnew, 1965; Wilkinson, 1969).
These negative effects adversely affect performance and safety in the
real world. Sleepiness behind the wheel or on the flight deck, for in-
stance, seriously increases the risk of having an accident (Drake et al.,
2010; Caldwell and Caldwell, 2017). Studies comparing the effects of
increased blood alcohol concentrations (BAC) to the effects of sleep loss
illustrate the seriousness of the problem. Sustained wakefulness of
20–24 h produces decrements equal to those observed with BAC levels
of between 0.08%-0.10% (levels legally defined as drunk in many jur-
isdictions) on tests of psychomotor performance, grammatical rea-
soning, vigilance, and simulated driving performance (Arnedt et al.,
2000, 2001; Dawson and Reid, 1997; Lamond and Dawson, 1999). In
one study, 24 h of sustained wakefulness was associated with perfor-
mance impairments equal to those associated with 0.05% BAC on tasks
of continuous attention, memory and learning (Falleti et al., 2003). The
combined effects of fatigue and alcohol are more detrimental than the
effects of either alcohol or fatigue alone (Arnedt et al., 2000).
Chronic reductions in total sleep per night degrades alertness, cog-
nition, and vigilance (Balkin et al., 2000; Carskadon and Roth, 1991),
and recovery from these deficits is slow (Belenky et al., 2003; Van
Dongen et al., 2003). There is growing evidence that even when periods
of chronic sleep restriction are interspersed with seemingly adequate
periods of recovery (many workers curtail their sleep during the week
and then “catch up” on the weekends), objectively-measurable pro-
blems persist and physiological adaptation to sleep restriction fails to
occur (Simpson et al., 2016).
9.2. Effects of sleep loss in combination with circadian misalignment on
performance
Circadian disruptions, especially the requirement for night work,
substantially degrade cognitive performance. The innate physiological
tendency of humans to sleep at night and be awake during the day is
powerful, and thus it is no surprise difficulties occur when this is not
possible. Altering the normal sleep/wake cycle, either through night
work or time zone changes, affects the ability to remain alert and the
ability to sleep. Shift-lag results when non-traditional work hours (night
or early morning hours) are required either on a permanent night shift
or a rotating schedule, because this creates a misalignment between the
internal clock and the normal activity and sleep schedule. Jet-lag results
when individuals change time zones of at least 3 h, because this causes a
notable misalignment of the body’s internal clock and the external
environment. For time-zone changes, the new environment’s time cues
such as light and the social environment lead to faster realignment of
biological rhythms than shift work. When personnel switch work
schedules from day to night, adaptation to night work and day sleep
occurs slowly and may only be partial. Regardless of the source of the
circadian rhythm disruption, until rhythm resynchronization occurs,
sleep will be impaired, a cumulative sleep debt will occur, and alertness
and performance will be compromised. Several studies of night shift
work suggest errors are more likely to be related to time-of-day than to
time-on-task, with the greatest risk occurring in the early morning
hours, coinciding with the circadian period of peak sleepiness (Lerman
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et al., 2012). Shift work in combination with long work hours have
well-documented detrimental effects on safety and can result in 50% to
100% increases in accident rates (Wagstaff and Sigstad Lie, 2011).
9.3. Effects of sleep loss on emotion
Inadequate sleep is associated with diminished emotional ex-
pressivity, impaired emotion recognition, increased emotional re-
activity, and general emotional dysregulation, all of which can degrade
social functioning and overall mental health (Beattie et al., 2015). Sleep
deprivation leads to increased irritability, anger, and hostility; elevated
reactivity to problematic events; and reduced friendliness, happiness,
and empathy (Gordon, 2016). Lack of sleep has been associated with an
increase in mood disorders, including depression and post-traumatic
stress disorder (Wright et al., 2011; Erwin, 2015). People who suffer
from insomnia are at elevated risk for depression, anxiety disorders,
alcoholism, drug abuse, and nicotine dependence (Institute of
Medicine, 2006). Sleep-deprived individuals are less able to appreciate
humor (Killgore et al., 2006) and are worse at resolving interpersonal
conflicts (Gordon and Chen, 2014).
9.4. Effects of sleep loss on physical performance
Mental and physical fatigue or energy are separate biological
functions (Lieberman, 2011). The impact of sleep loss on physical
performance differs from the impact of inadequate sleep on cognitive
function. Sleep loss generally has limited effects on physiological
parameters such as cardiovascular and respiratory responses to exercise
of varying intensity, aerobic and anaerobic performance capability, or
muscle strength (Van Helder and Radomski, 1989). While insufficient
sleep negatively impacts systolic blood pressure, maximal work capa-
city, and physical performance reaction time (Knowles et al., 2018;
Patrick et al., 2017; Antunes et al., 2017), the direct effect of these
changes on physical performance is debatable. Most important for the
purposes of the present review, it should be noted that the expenditure
of physical energy generally has little or no impact on mental capacity
(Krausman et al., 2002), but sleep deprivation and/or circadian de-
synchronization clearly lead to mental exhaustion, impaired cognition,
and degraded alertness despite the absence of a concurrent decline in
aspects of physical performance (Plyley et al., 1987).
10. Summary of the problem
Sleep is vital for survival and optimal day-to-day cognitive func-
tioning, and insufficient sleep due to sleep deprivation, sleep restric-
tion, and/or sleep disorders is associated with several adverse mental
and physical health outcomes as well as performance decrements and
accidents. The combination of degraded attention, memory, decision-
making, vigilance, reaction time, mood, arousal, and emotional/affec-
tive regulation can seriously jeopardize workplace efficiency and safety.
Sleep loss also impairs regulation of glucose, various hormones, and
cardiovascular function which degrades health (Alhola and Plo-
Kantola, 2007; Mitler et al., 1988; Mullington et al., 2010; Mullins
et al., 2014; Nedeltcheva and Scheer, 2014; Kohansieh and Makaryus,
2015; Erwin, 2015; Grandner, 2017), and insufficient sleep has been
associated with a 13% increase in overall mortality risk and an esti-
mated U.S. economic impact of $280 billion to $411 billion annually
(Hafner et al., 2016). Given the devastating impact of sleep loss on
public health, safety, productivity, and national economic performance,
increased attention to correcting the factors responsible for chronic and
widespread sleep deprivation should be a major national priority.
11. Recommended fatigue countermeasures
Given the pace of modern society and economic realities including
work, family, and travel demands, complete elimination of fatigue is an
J.A. Caldwell et al.
unrealistic objective. Humans are diurnal organisms who are, by their
innate nature, poorly prepared for lengthy periods of continuous wa-
kefulness, nighttime work, and substantial changes in sleep/wake
schedules. However, there are a variety of strategies that can help
manage and mitigate fatigue, and these are briefly presented below.
11.1. Education for workers, management, and family
As noted previously, a number of studies have demonstrated sleep
restriction of as little as 1–2 h per day rapidly compromises vigilance
and performance in subsequent duty periods, and that following periods
of sleep restriction, individuals usually do not recover fully after only a
single night of sleep (Van Dongen et al., 2003; Belenky et al., 2003).
Also, there are several behavioral and environmental factors that can
adversely impact the quality and duration of sleep. Unfortunately, these
facts are not widely known, and thus education is important. It is cri-
tical that personnel learn about the dangers of fatigue, the importance
of obtaining adequate sleep, understanding that full recovery from fa-
tigue may take longer than anticipated, and the fact that good sleep
habits are essential for ensuring optimal sleep quality.
11.2. Optimizing sleep opportunities
The greatest cause of fatigue in the workplace is insufficient or
disrupted off-duty sleep. Of course, some sleep issues are unavoidable,
but others are amenable to modification, especially with the use of a
well-planned sleep strategy. Some general rules for optimal sleep hy-
giene are summarized below.
11.2.1. Consistency is important
Adhering to a consistent sleep/wake schedule may be impossible for
many workers because of changing duty hours and time-zone transi-
tions, but variations in bedtimes should be avoided when possible
(American Sleep Association, 2017).
11.2.2. Control stimuli in the bedroom
Using the bedroom only for sleep-compatible activities is re-
commended because keeping other behaviors out of the bedroom
avoids development of associations between the sleep environment and
potentially sleep-disrupting thoughts, actions and habits (Morgenthaler
et al., 2006).
11.2.3. Deal with worries
Resolving “worry issues” outside of the bedroom can reduce time
spent lying awake in bed. Prior to bedtime, individuals should make a
“worry list,” and write a brief action item beside each entry to minimize
thinking sleep-disrupting thoughts in the bedroom (Holmes, 2017).
11.2.4. Establish a bedtime routine
Establishing and maintaining a consistent pre-bedtime routine is an
effective strategy to promote the rapid onset of sleep (American Sleep
Association, 2017).
11.2.5. Establish an aerobic exercise routine
The importance of exercise for promoting restful sleep has been
established in the scientific literature (Uchida et al., 2012). Activities
such as running, cycling, and swimming during the day will enhance
the ability to fall asleep and stay asleep during the night. However, the
exercise period should not be too close to bedtime since physical ac-
tivity has a short-term alerting effect. It is best to exercise each day, but
not within 3–4 h of bedtime.
11.2.6. Create a comfortable sleep environment
The restorative value of sleep can be enhanced by attention to
several environmental factors. Creating a dark, quiet, cool, and com-
fortable sleep environment is important for obtaining the best sleep.
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Use of a constant masking noise can be helpful (American Sleep
Association, 2017).
11.2.7. Simulate the home sleep environment
Adverse effects due to the first-night in an unfamiliar environment
include increased wakefulness, decreased sleep, and reduced sleep ef-
ficiency (Agnew et al., 1966). Thus, when planning to sleep in a novel
context (e.g., a hotel room) consider taking familiar items such as pil-
lows, small blankets, or family pictures; sleep in the same type of
clothing as when at home; and if possible, engage in the same type of
pre-bedtime routines as those at home.
11.2.8. Properly manage dietary issues
Eating too much food or the wrong type of food immediately prior
to bedtime can create sleep difficulties; conversely, hunger can cause
awakenings during the night (Urponen et al., 1988). In general, heavy
meals should be avoided within 2 h of bedtime, and unfamiliar/overly-
spicy foods should be avoided as well since these may exacerbate gas-
trointestinal symptoms that can accompany schedule changes.
11.2.9. Manage caffeine intake
Caffeine consumption should be managed to ensure it does not
delay sleep initiation or interfere with sleep maintenance (American
Sleep Association, 2017). Individuals should avoid caffeine within 4 h
of bedtime, and longer if sleep difficulties are present. Caffeine’s effect
on sleep quality may change with aging since caffeine metabolism and
clearance can change (Nehlig, 2018).
11.2.10. Manage alcohol consumption
Alcohol has long been considered a “sleep promoter” and, although
it reduces time to fall asleep, it increases wakefulness after sleep onset
and suppresses rapid eye movement (REM) sleep (Ramakrishnan and
Scheid, 2007). The negative impact of alcohol on sleep quality makes it
a poor choice as a sleep aid. It is generally suggested that no more than
2 drinks should be consumed within 4 h of bedtime.
11.2.11. Avoid watching the clock
Watching the clock during brief wake-ups at night sets up a mala-
daptive pattern of thought that can interfere with sleep. If there is
concern about waking up on time, it can lead to constantly checking the
clock. This can be managed by setting multiple alarms, and “clock
watchers” should hide their clocks (American Sleep Association, 2017).
11.2.12. Carefully manage naps
Naps should be taken only when some factor is interfering with
normal consolidated off-duty sleep. Napping is not recommended if an
8 h sleep period is expected. The longer a period of continuous wake-
fulness, the greater the pressure to fall asleep, and since napping is a
form of sleep, it reduces sleep pressure (American Sleep Association,
2017).
11.2.13. Avoid smoking cigarettes immediately before bedtime
Nicotine is a weak stimulant, therefore its consumption in any form
should be avoided within 1 h before bedtime. Cigarette smokers are
significantly more likely than nonsmokers to report problems going to
sleep and problems staying asleep, and this is another reason to stop
smoking (Phillips and Danner, 1995).
11.2.14. Get out of bed and go to another room if sleep does not come
within 20 min
Lying in bed thinking about being unable to sleep can exacerbate
the problem. When someone is unable to fall asleep within a reasonable
time, they should get out of bed, go into another room, and engage in
something boring (or at least something that is not stimulating) until
they begin feeling sleepy, at which time they can return to the bedroom
and try to fall asleep in bed once again. While out of the bedroom
J.A. Caldwell et al.
awaiting the onset of feelings of sleepiness, activities such as reading a
book (a paper book, not a blue-light-enriched e-book), meditating and/
or listening to music are recommended since these activities are easy to
stop when sleepiness returns. Conversely, working, socializing (in-
cluding on the computer), watching TV, playing video games, or
watching an exciting movie are not recommended since they are more
engaging and may compete with returning to bed (American Sleep
Association, 2017).
11.3. Naps
A nap during long periods of continuous wakefulness can sig-
nificantly improve alertness and performance (Bonnet, 1990, 1991;
Dinges et al., 1988; Lorizio et al., 1990; Lumley et al., 1986; Matsumoto
and Harada, 1994; Rogers et al., 1989; Rosa, 1993; Webb, 1987).
However, several factors are important to consider before im-
plementing a napping regime.
11.3.1. Nap timing
One important factor is placing naps at optimal times with regard to
the amount of sleep loss. A nap taken during the day before an all-night
work shift (a prophylactic nap) will improve performance over the
night compared to not napping. Although naps taken later in the sleep-
deprivation period also are beneficial, these naps probably should be
longer than prophylactic naps to derive the same performance benefit.
11.3.2. Nap length
Another factor to consider is nap length. Most studies indicate naps
from 1 to 8 h will improve performance and alertness during long
work/wakefulness sessions. A nap before an all-night shift should be as
long as possible to produce maximum performance benefits, and pro-
phylactic naps are better than naps designed to replace sleep that al-
ready has been lost due to requirements for continuous wakefulness
(Bonnet, 1991).
11.3.3. Nap placement and the circadian phase
Another factor to consider is where the nap should be placed with
regard to circadian phase. Nap timing should take into account ease of
falling asleep, quality of sleep as a function of the body's internal clock,
and effects on performance immediately after awakening and later in
the work period. Naps placed during the circadian troughs are easiest to
obtain and show beneficial effects on later performance (Gillberg,
1984). However, a nap taken anywhere in the circadian cycle before
sleep deprivation is beneficial in maintaining performance. One caveat
to keep in mind is that there is a potential performance cost to napping
in the early morning (during the circadian trough) since post-nap
sleepiness (sleep inertia) is greater and performance is lower im-
mediately upon awakening from a nap taken during the circadian
trough compared to naps taken at other times (Dinges et al., 1985).
11.4. Sleep inertia – A negative consequence of napping
Sleep inertia refers to the transitional period from sleeping to wa-
kefulness that occurs immediately after waking and is marked by feel-
ings of grogginess and decrements in cognitive and motor performance
(Tassi and Muzet, 2000). Sleep inertia may be a serious concern when
napping is proposed as a fatigue countermeasure, especially if skilled
performance is required immediately following the nap. However, this
short-term disadvantage must be balanced against performance de-
gradation from sleep deprivation. Before implementing a napping
strategy, it is important to consider that sleep inertia will affect cog-
nitive performance and mood, especially in highly demanding situa-
tions. The duration of sleep inertia depends on many factors; however,
most sleep inertia dissipates within –35 min after awakening (Akerstedt
et al., 1989; Rosekind et al., 1995; Wilkinson and Stretton, 1971). The
intensity of sleep inertia depends on several factors, including the stage
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of sleep from which one is awakened. Awakening from slow-wave sleep
(SWS) produces more sleep inertia than from shallower stages (Bonnet,
1983; Stones, 1977; Webb and Agnew, 1965; Wilkinson and Stretton,
1971); thus it is important to: 1) minimize the amount of SWS that will
occur after a nap by avoiding high levels of pre-nap sleep deprivation;
2) place naps at clock times when SWS is known to be reduced; 3) keep
the nap period either short enough (less than 45 min) to reduce the
chances the first cycle of SWS will occur within the nap period or make
the nap long enough (at least 110–120 min.) to increase the chances
that a transition from the first cycle of SWS into a lighter stage of sleep
has occurred prior to awakening.
11.5. Rest breaks
Short breaks can increase alertness by reducing monotony of highly
automated or tedious tasks and allowing moderate levels of physical
activity. Although not as effective as other countermeasures, breaks are
at least temporarily beneficial. Allowing personnel to stand up and
move about enhances the benefit of the break (Caldwell et al., 2003;
Dijkman et al., 1997). However, even when there is no change in
posture or physical activity, alertness and performance will improve
briefly due to providing a mental break from a continuous task (Angus
et al., 1992; Galinsky et al., 2007; Heslegrave and Angus, 1985). An
increase in social interaction can enhance the benefit of short breaks,
especially in early morning hours around the circadian nadir (Dijkman
et al., 1997).
11.6. Lighting
Depending on the timing and type of exposure, light can exert either
positive or negative effects on aspects of cognition and performance
(Fisk et al., 2018). When using light as a countermeasure, its direct,
acute effects on arousal as well as its delayed indirect effects that occur
as a function of altering sleep and circadian rhythms should be con-
sidered.
11.6.1. Increasing light exposure
Properly-timed broad spectrum bright light can facilitate circadian
resynchronization after a schedule change (Daan and Lewy, 1984;
Gander et al., 1989; Kolla and Auger, 2011; Samel and Wegmann,
1997), but optimal levels of light exposure are controversial. Given the
complexities of using either light or melatonin to adjust circadian
rhythms, the recommendations from Kolla and Auger (2011) should be
consulted prior to using either strategy. Blue light appears to be espe-
cially effective at enhancing alertness (Cajochen, 2007; Chellappa et al.,
2011; Taillard et al., 2012).
11.6.2. Decreasing light exposure
Just as maximizing light exposure can be an effective fatigue
countermeasure for some situations (i.e., when providing artificial blue
light in particular within work areas at night), it is important to mini-
mize blue light exposure as a fatigue-mitigation strategy in other si-
tuations to prevent sleep disturbances and circadian misalignments
(i.e., when night workers will be attempting to sleep during the day).
For these situations, blue light-blocking glasses can be used. Wearing
these glasses in the evening significantly improves self-reported sleep
quality at night (Burkhart and Phelps, 2009), while wearing them in the
morning delays the circadian phase (Smith et al., 2009; Eastman and
Martin, 1999). Strategic use of blue-blocking glasses reduces sleep
disruption and improves performance of rotating shift workers
(Rahman et al., 2013), and these glasses appear to prevent problems
associated with the pre-bedtime use of e-readers, computers, or
smartphones (Van der Lely et al., 2015). An alternative strategy would
be to use blue-blocking phone or computer applications that are timed
to trigger in the evening for viewing of electronic screens.
J.A. Caldwell et al.
11.7. Prescription sleep/alertness aids
When scheduling, environmental, or work factors prevent proper
rest, prescription medications may be an option. Under these condi-
tions, a physician may prescribe a hypnotic to promote off-duty sleep
(when opportunities for sleep are available) or a stimulant to increase
wakefulness (when sleep-deprivation is unavoidable).
11.7.1. Medications for sleep
When sleep is difficult, prescription sleep aids may be the only way
to prevent deprivation-related performance declines. Generally, sleep
aids are intended for short-term use when other options are not ade-
quate. For example, when circadian factors such as those encountered
with shift lag/jet lag or an uncomfortable environment lead to short-
term insomnia.
Numerous prescription options are available, and the decision re-
garding which one to use should be based on the characteristics of the
hypnotic and the situation. A long-acting hypnotic such as temazepam
(half-life 3.5–18 h.) is useful for maintaining sleep for relatively long
periods during the night and/or for optimizing the daytime sleep of
night-working personnel (Caldwell et al., 2003; Rosenberg, 2006;
Simons et al., 2006). Alternatively, extended-release zolpidem (half-life
3–6 h) may be suitable if the longer-acting effect of temazepam is not
appropriate (Greenblatt et al., 2005). Another drug, eszopiclone, has a
half-life of 5–6 h with minimal residual drug effects after as little as 10 h
post dose (Leese et al., 2002). Suvorexant has an elimination half-life of
12 h (Asnis et al., 2016) and may be useful as well. For short sleep
periods or initiation of sleep at unusual times, zolpidem (mean half-life
2.5 h) and zaleplon (mean half-life 1 h) are preferred to longer-acting
hypnotics since their shorter half-lives reduce post-sleep sedation
(Caldwell and Caldwell, 1998; Dooley and Plosker, 2000; Whitmore
et al., 2004). Ramelteon (a drug that acts via melatonin pathways) also
may be appropriate when a short-acting compound is needed. However,
while ramelteon is efficacious for inducing sleep, it is not optimal for
maintaining it (Lieberman, 2007).
In general, hypnotics can minimize sleep disruptions and with
proper planning can be used without undue concern about post-sleep
hangover effects. The choice of compound depends on the timing of the
start of the sleep opportunity, the expected length of the sleep period,
and whether there is a high probability of unexpected sleep truncation.
It is important to balance the need to improve sleep with the need to
avoid residual effects. Also, it is important to consider that allowing
sleep to be shortened simply to avoid use of hypnotics may be more
detrimental (in terms of performance) than residual effects after hyp-
notic-induced sleep. Prescription hypnotics are classified by the Food
and Drug Administration (FDA) as Schedule IV compounds with low
potential for abuse or dependence (Drug Enforcement Agency, 2018).
11.7.2. Modafinil and armodafinil for alertness
Prescription stimulants generally are not prescribed except for the
treatment of a sleep disorder such as narcolepsy or idiopathic hy-
persomnia. However, modafinil and armodafinil are indicated for
treatment of excessive daytime sleepiness associated with shift work
sleepiness disorder as well as excessive sleepiness associated with nar-
colepsy or obstructive sleep apnea (Czeisler et al., 2005, 2009; Roth
et al., 2007; Schwartz, 2005). Both medications are highly effective for
alertness maintenance when sleep and circadian factors degrade per-
formance (Caldwell and Caldwell, 2017). Modafinil and amodafinil
have less abuse potential than amphetamines and are thus classified as
Schedule IV drugs as opposed to Schedule II drugs (Drug Enforcement
Agency, 2018).
11.8. Non-prescription sleep/alertness aids
11.8.1. Over-the-counter sleep medications
Sleeping medications available without a prescription are termed
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“over-the-counter (OTC)” medications. A variety of these drugs are
available, and most of them contain antihistamines such as diphenhy-
dramine and/or doxylamine which have sedating effects (Mendelson,
2011). These medications typically produce drowsiness, but their ef-
fects are modest compared to most prescription hypnotics (Richardson
et al., 2002). Next-day carry-over effects also may be a concern for
some situations since the half-life of these substances is up to 8 h
(Katayose et al., 2012; Ringdahl et al., 2004). Nevertheless, they pro-
vide a non-prescription alternative to other hypnotic medications and
are widely used.
11.8.2. Melatonin for sleep
Melatonin is another non-prescription option for sleep promotion.
Melatonin is a hormone released at night by the pineal gland. Exposure
to bright light suppresses its release. Melatonin, even in low doses, can
increase sleepiness and impair cognitive performance (Lieberman et al.,
1984; Dollins et al., 1993). However, its use as a hypnotic is limited
since it has a very short half-life (Waldhauser et al., 1984). In the U.S., it
is regulated as a dietary supplement and is readily available, but its
availability in other countries is often restricted. In addition to its mild
hypnotic-like properties, melatonin can speed resynchronization of
circadian rhythms if administered at the appropriate time (Xie et al.,
2017; Williams et al., 2016; Liira et al., 2015) and thus may reduce shift
lag and jet lag (Arnedt and Skene, 2005; Brzezinski et al., 2005; Touitou
and Bogdan, 2007; Lewy et al., 2006; Wirz-Justice and Armstrong,
1996).
11.8.3. Herbs for sleep
Herbs with the advertised potential to promote sleep are available,
but most have not been studied thoroughly so their effectiveness has
not been established (Yeung et al., 2012a; 2012b). One herb, valerian
(Valeriana officinalis L.), appears to have some mild sedative-like
properties (Shi et al., 2014; Yi et al., 2007; Leathwood et al., 1982), but
the published literature indicates it does not have sufficient clinical
efficacy for the treatment of insomnia (Taibi et al., 2007). There is some
evidence kava-kava has soporific effects (Monti, 2004), but since its
chronic use can result in severe adverse effects (Pantano et al., 2016),
the FDA has expressed concern over its efficacy and safety.
11.8.4. Acupuncture for sleep
Several systematic reviews have been published on the use of acu-
puncture for the treatment of insomnia (Lee et al., 2008; Huang et al.,
2009; Cheuk et al., 2012; Zhao, 2013; Ernst et al., 2011). Generally, the
conclusions have been less-than-positive, but the authors agree an ac-
curate assessment is difficult due to the questionable quality of avail-
able research. Higher quality studies do show at least mild efficacy
when diagnosis of the insomnia is based on Traditional Chinese Medi-
cine (TCM) principles and treatment is continued for several weeks (Fu
et al., 2017; Zhao, 2013).
11.8.5. Caffeine for alertness
For centuries, caffeine has been a popular non-prescription means to
enhance mental or cognitive functions (Snel and Lorist, 2011). Adults in
the U.S. tend to consume most of their caffeine in the form of coffee
which, depending on the preparation method and other factors, typi-
cally contains about 100 mg caffeine per cup. Caffeine is also present in
tea, cola beverages, and a few other soft drinks. Energy drinks and
energy shots (which typically contain anywhere from 50 to 316 mg of
caffeine per container) have become a popular source of caffeine over
the past decade, especially in young males, college athletes, and mili-
tary personnel (Stephens et al., 2014; Fulgoni et al., 2015; Mahoney
et al., 2018; McLellan et al., 2018). Caffeine in doses from 32 to 300 mg
when given to non-sleep deprived individuals enhances specific aspects
of cognitive performance and mood, such as attention, vigilance, re-
action time, and alertness (Lieberman et al., 1987; Lorist and Snel,
1997; Nehlig, 2010; Snel et al., 2004). Caffeine increases arousal in a
J.A. Caldwell et al.
dose-dependent manner; low doses have positive effects on moods such
as vigor, but high doses increase tension and symptoms of anxiety,
nervousness, and jitteriness (Stafford et al., 2007). Doses up to ap-
proximately 300 mg (4 mg/kg) enhance performance with minimal side
effects (Lieberman et al., 2002). Caffeine doses between 200 and
600 mg provide multiple positive performance, mood, and alertness
benefits in sleep-deprived individuals, and doses up to 300 mg are
beneficial in rested personnel engaged in monotonous activities such as
military sentry duty or lengthy periods of highway driving (Carvey
et al., 2012; Lieberman et al., 2002; Penetar et al., 1993; Smith et al.,
2005; Wesensten et al., 2002; Reyner and Horne, 1997, 2000). Caffeine
is freely and widely available and one of the most effective and safest
interventions to reduce mental fatigue – a major reason it is used reg-
ularly by 80% of the U.S. population (Fulgoni et al., 2015).
11.9. Behavioral strategies to improve sleep
For situations in which sleep opportunities are available, it is im-
portant to ensure workers take maximum advantage of them to recover
from the effects of prior wakefulness and prepare for the next duty
period. When appropriate, use of sleep medications should be con-
sidered, but when pharmacological solutions are not indicated, beha-
vioral sleep-optimization strategies can be a helpful alternative.
11.9.1. Cognitive behavioral therapy
There are numerous behavioral methods to optimize sleep, and
many are used to treat insomnia. These include stimulus control, re-
laxation, and cognitive therapies (Morin et al., 2016). Stimulus-control
therapy creates positive associations with bedtime and strengthens the
association between sleep and the bedroom. Progressive muscle re-
laxation reduces physical tension whereas imagery training focuses on
reducing intrusive thoughts and mental tension. Cognitive therapy
seeks to alter misconceptions about sleep, unhelpful beliefs, and nega-
tive thinking patterns such as worrying. While these therapies are often
successful, they may require several treatment sessions to yield the
greatest positive effects. If properly implemented, some experts suggest
cognitive therapy is more cost effective, efficacious, and safer than
pharmacological therapies, but others dispute this (Reynolds and
Ebben, 2017).
11.9.2. Meditation/mindfulness
An alternative approach to treating insomnia due to excess cognitive
arousal is mindfulness training. Mindfulness meditation can reduce
sleep-related arousal, or anxiety, by increasing positive mental and
physical states (Ong and Sholtes, 2010). Some individuals who develop
skills in mindfulness meditation sleep better, have less stress associated
with sleep, and experience other benefits including less pain, increased
calmness, and improved general daily functioning (Hubbling et al.,
2014). Mindfulness training appears worthwhile under certain cir-
cumstance, but only two controlled studies have been conducted thus
far, so further investigation into the efficacy of this technique is re-
quired (Bonnet and Arand, 2010).
11.10. Identifying and resolving sleep disorders
The identification and treatment of sleep disorders is often over-
looked as an effective counter-fatigue strategy for the workplace, but
any condition that disrupts normal restorative sleep is likely to have an
adverse effect on workplace performance unless it is recognized and
mitigated. The treatment of insomnia has been discussed above, but
there are numerous other sleep disorders that deserve attention. Sleep
apnea which is strongly associated with obesity can lead to severe
problems with daytime alertness (due to its adverse effects on nighttime
sleep), but once recognized, it can be treated a number of ways de-
pending on the severity of the problem, the physiology of the patient,
and his/her body weight. The most successful treatment option is
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continuous positive airway pressure (CPAP). Another treatment option
is a dental appliance which can be fitted by a qualified dentist. Other
treatments include surgery on the upper airway that can be as minor as
removal of tonsils and adenoids, straightening of the nasal areas, or an
uvulopalatopharyngoplasty (UPPP); or as major as reconstruction of the
jaw and tongue. Hypoglossal nerve stimulation may be an option in
patients with moderate-to-severe obstructive sleep apnea who are un-
able to tolerate CPAP (Hong et al., 2017). Additionally, some apnea
patients derive very positive benefits from weight loss alone.
Periodic limb movements in sleep (PLMS) is another disorder that
can interfere with the restorative value of sleep and impair on-the-job
performance. This disorder involves periodic contractions of the tibialis
anterior with muscle dorsiflexion of the ankle and toes, resulting in a
leg jerk or twitch lasting from one half to 5 s with a frequency of one
every 20 to 40 s. Usually these movements are associated with short
electroencephalographic (EEG) arousals. Restless legs syndrome (RLS)
sometimes accompanies PLMS and further complicates the clinical
picture. RLS is characterized by limb discomfort that prevents or delays
the onset of sleep. The symptoms of RLS vary from mild tingling in the
legs to severe discomfort and pain that becomes pronounced when
sitting or lying down. Both PLMS and RLS are generally treated with a
prescription medication that decreases limb movements.
There are other sleep disorders besides those mentioned here, but a
thorough discussion of these is beyond the scope of the present report.
Nevertheless, it is important to note that when sleep is disrupted by
sleep apnea, PLMS, RLS, or some other sleep disorder, proper diagnosis
and treatment of the problem, or any other medical condition that
adversely impacts sleep, will promote optimal on-the-job alertness and
performance.
11.11. Fatigue monitoring technologies
Real-time cognitive monitoring technologies and fitness-for-duty
testing devices have been investigated for many years with limited
success (National Academies of Sciences, Engineering, and Medicine,
2016). Vehicle-mounted systems seem to be the most feasible to im-
plement since: 1) there is usually sufficient space for such equipment; 2)
there is a readily-available power supply; and 3) the operator’s move-
ment is constrained while his/her attention is supposed to be focused
on a single primary task. However, despite almost three decades of
research on technological strategies for monitoring driver fatigue in
near real time, the usefulness of such approaches as well as the success
of their operational implementation remain questionable. This is pri-
marily due to the difficulty identifying metrics that are: (a) sensitive
and specific to fatigue and various aspects of cognitive performance
degradations; and (b) unobtrusive to collect (Lieberman et al., 2005,
2007; Mallis and James, 2012).
The assessment of sleep quality and quantity aimed at monitoring
fatigue may be a useful alternative to the approaches noted above.
While the gold standard for sleep evaluation is polysomnography, this
technique is usually impractical for home or workplace implementation
due to substantial equipment requirements and the necessity to place
electrodes on the skull. A proven alternate for evaluating basic sleep
parameters in such circumstances is wrist-worn sleep/activity mon-
itoring (Sadeh and Acebo, 2002; Morgenthaler et al., 2007). Wrist-worn
activity monitoring records the frequency and time-course of body
movements and processes this information to provide measures of sleep
quantity, sleep quality, and sleep/wake timing. This method is more
operationally feasible than polysomnography and its accuracy is better
than subjective sleep logs that rely on often inaccurate individual as-
sessments of sleep. Continuous sleep/wake measurement derived from
actigraphy can form the basis of a fitness-for-duty program since it can
determine whether or not individuals are obtaining the 7–8 h of sleep
generally required for adequate rest and restoration (Van Dongen et al.,
2003). In theory, individual actigraphy data could be examined at the
outset of work periods to exclude employees who have obtained
J.A. Caldwell et al.
significantly less than 7 h of sleep in the preceding 24 h period from
upcoming high-hazard duty periods (or at least to warn them about
their potential level of impairment).
11.12. Bio-mathematical models
Bio-mathematical models in conjunction with actigraphy are in-
creasingly being used in fatigue management programs. These models
use a set of integrated equations to predict fatigue levels based on
factors including recent sleep quantity, sleep quality, and sleep/wake
timing, the current time of day (during duty), and sometimes workload.
The effects of caffeine also have been included in some models
(Ramakrishnan et al., 2016). Prior to use in operational contexts,
models are validated (or should be validated) against various types of
performance data (such as reaction-time or accuracy measures) col-
lected in laboratory sleep-restriction or sleep-deprivation studies, or
against accident probability and/or accident severity data collected in
real-world environments (Hursh et al., 2004, 2006; Van Dongen, 2004;
Van Dongen et al., 2007; Rajdev et al., 2013). Models are typically
updated in an iterative process as new data and/or new scientific in-
formation become available. They are very useful in applied contexts
because they translate basic but often complex scientific principles es-
tablished by empirical investigations into predictions that are relevant
to operational settings.
One such model currently used by the U.S. military is the Sleep,
Activity, Fatigue, and Task-Effectiveness (SAFTE) model (Hursh et al.,
2004). The SAFTE model has been implemented in a user-friendly
software application called the Fatigue Avoidance Scheduling Tool
(FAST) (Hursh et al., 2006). SAFTE/FAST was validated in ground
transportation studies and has been modified to accept aviation-specific
input as well. SAFTE is an accurate predictor of the effects of total sleep
deprivation on the mean performance of several standard cognitive
tasks (Angus and Heslegrave, 1985; Hursh et al., 2004) and an accurate
predictor of the effects of sleep-restriction on psychomotor vigilance
(Eddy and Hursh, 2001). Its predictions compare favorably to those
produced by other models (Van Dongen, 2004). In addition, work with
the Federal Railway Administration has shown that SAFTE-based cal-
culations accurately predict the impact of scheduling factors on human-
factors accident risk (Hursh et al., 2006). Although the accuracy of
SAFTE fatigue predictions, as well as those from other available bio-
mathematical models of fatigue and performance, is adversely affected
by individual differences and uncertain pre-duty conditions (Van
Dongen et al., 2007), model-based optimization of work schedules re-
presents an objective procedure for mitigating operational fatigue risks.
Although a detailed review of new model-development and vali-
dation efforts is beyond the scope of this paper, it should be noted the
recently-developed “Unified Model” may improve fatigue-prediction
accuracy if additional information on individual employees is available
(Rajdev et al., 2013). The Unified Model accounts for the relatively slow
recovery process that occurs following chronic sleep restriction, as well
as the enhanced performance that has been shown to result from so-
called “sleep banking.”
11.13. Shift schedules
As indicated above, working non-traditional shifts (early morning,
evening, night) either on a fixed or rotating basis adversely affects
cognitive performance. It is very difficult to manage sleep (and thus
fatigue) under these circumstances, but proper shiftwork scheduling is
quite helpful. Numerous guidelines have been published to assist
schedulers who design work rosters (e.g., Miller, 2006; Health and
Safety Authority, 2012; American College of Occupational and
Environmental Medicine and the National Center on Sleep Disorders
Research, 2011; Smith and Eastman, 2012), and they generally make
recommendations on the optimal number of consecutive night shifts to
schedule, optimal shift rotation schedules, time between shifts, and
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shift length. Other recommendations include some of the behavioral
and/or environmental interventions discussed previously.
As an example, the guide written by Miller (2006) includes 9
principles of shiftwork scheduling and explains methodologies for de-
termining optimal shift schedules for operational contexts. Briefly, the 9
basic principles suggest the following:
1 Maximize circadian stability (or schedule consistency/entrainment);
2 Keep shift length short;
3 Minimize the number of consecutive night shifts;
4 Ensure recovery time after night work;
5 Maximize the number of weekends free;
6 Provide at least 104 days off per year;
7 Ensure equity (of work schedules) for all workers;
8 Optimize scheduling predictability;
9 Provide quality time off.
Optimal use of these principles requires careful consideration of
various factors such as the type of shift (fixed or rotating), the shift
duration, the alignment of workdays and days off with weekends, the
ratio of free days to work days, shift-change times, the number of crews
available and required, etc. A shiftwork-scheduling guide should be
consulted prior to establishing work schedules, and when possible an
analysis of fatigue risk and sleep impact should be conducted using bio-
mathematical modelling and recordings of wrist actigraphy. Managing
factors which are under the control of the individual (e.g., properly
managing off-duty sleep) and devising schedules that provide adequate
time for sleep will help improve performance and alertness as well as
social relationships, morale, and health.
11.14. Fatigue risk management systems
Fatigue management is important for organizations concerned with
the health, safety, and productivity of their employees, especially for
safety-sensitive operations such as healthcare, energy, and transporta-
tion. Fatigue management efforts should be included as part of a safety
management system (SMS) including an “explicit and comprehensive
process for measuring, mitigating, and managing the fatigue risk to
which a company is exposed” (American College of Occupational and
Environmental Medicine, 2012, page 234). Integrating these cap-
abilities into a comprehensive SMS creates a Fatigue Risk Management
System (FRMS) including a number of important features. According to
Moore-Ede (2009), the key concepts required for successful FRMS im-
plementation are:
1 It must be science-based, supported by established peer-reviewed
scientific publications;
2 It should be data driven; decisions should not be based on opinions,
but rather on collection and objective analysis of data;
3 It must be cooperatively designed by all stakeholders;
4 It must be fully implemented across the entire organization to en-
sure system-wide use of tools, systems, policies, procedures;
5 It should be integrated into the corporate safety and health man-
agement systems;
6 It should not remain static, but rather should be continuously im-
proved to progressively reduce risk using feedback, evaluation, and
modification;
7 It should be proactively budgeted and justified to provide an accu-
rate return-on-investment business case;
8 It must be owned and accepted by the senior corporate leadership as
a priority responsibility.
The FRMS approach is rapidly being adopted throughout the
transportation industry, and may soon be a part of SMSs in all industrial
sectors. The Federal Aviation Administration currently encourages U.S.
airlines to establish science-based Fatigue Risk Management Programs.
J.A. Caldwell et al.
Other organizations such as mining, petroleum, and healthcare are ra-
pidly following suite.
Implementing a formal fatigue management program demonstrates
that the risks resulting from sleepy personnel are known and the or-
ganization is actively mitigating these risks – both on the job and off. In
a good FRMS, key procedures to reduce fatigue are integrated into an
overall program that ensures: employees are getting sufficient sleep; are
monitored for fatigue-related issues including sleep disorders; controls
are in place to minimize the impact of fatigue-related errors that occur;
and these procedures are periodically assessed to ensure their effec-
tiveness.
In keeping with Moore-Ede’s recommendations (2009), it is essen-
tial for any FRMS to provide multiple procedures to avoid fatigue-re-
lated incidents and accidents such as:
1 Ensuring adequate staffing levels and workload balance to reduce
fatigue-related problems associated with shiftwork;
2 Minimizing schedule-related fatigue by using bio-mathematical
models to identify the risks associated with specific work/rest
schedules, guide the implementation of fatigue countermeasures,
aid in accident investigations, and reinforce counter-fatigue educa-
tional efforts;
3 Educating employees about fatigue-related work and social/familial
hazards; the importance of sleep, circadian rhythms, and lifestyle
factors in the fatigue equation; how to obtain adequate sleep and
recognize and obtain treatment for sleep disorders; how to effec-
tively use validated alertness-management strategies. Management
must assume a key role in not only supplying information, but in
providing the motivation and, when appropriate, resources neces-
sary for employees to report to work in a well-rested state;
4 Ensuring the workplace environment promotes alertness by pro-
viding adequate and proper lighting, humidity and noise control,
and ergonomic design. In addition, the nature and duration of work,
as well as the importance of naps, rest breaks, and balanced nutri-
tion in fatigue management should be emphasized;
5 Ensuring employees and supervisors are able to rapidly recognize
signs of excess fatigue and procedures for actions to immediately
mitigate either fatigue itself or the risks due to fatigue. Actions may
include switching the employee to a less-safety-sensitive role, aug-
menting peer-based cross-checking procedures, using caffeine to
temporarily increase alertness, or changing the type or intensity of
environmental lighting;
Once an FRMS is implemented, it must be continuously evaluated
and improved based on data derived by investigation of any fatigue-
related incidents and accidents, assessment of productivity levels and
absenteeism patterns, evaluation of accident/injury rates, and health-
related costs. A corporate commitment to building and maintaining an
effective FRMS includes obtainable fatigue-management goals, strate-
gies to measure progress toward those goals, provisions for periodic gap
analyses, and workable plans to close any gaps between desired and
actual performance indicators.
12. Summary and conclusions
Fatigue and sleepiness in modern society are personal and occupa-
tional risk factors. Insufficient sleep from self- or society-imposed/
sanctioned sleep restriction, intense/lengthy work schedules, rotating
shifts, jet lag, and other factors constantly challenge individuals to
adapt. When adaptation is not complete, safety, performance, and
general wellbeing suffer. There is substantial evidence that excessive
sleepiness in the workplace and on the highways is a serious safety
hazard, and there is mounting evidence that insufficient sleep poses
significant risks to health, wellbeing, and longevity. However, as dis-
cussed in this review, there are validated strategies that can be used to
promote better sleep, optimize sleep/wake and work scheduling, and
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implement better workplace practices to mitigate the impact of fatigue
in real-world settings. Among these are attention to proper nap and
sleep scheduling with careful consideration of circadian rhythms, in-
clusion of appropriately-timed rest breaks, use of scheduling and
monitoring tools (and potentially fatigue detection technologies),
pharmacological interventions, and other fatigue countermeasures
aimed at reducing performance and safety hazards. Education to im-
prove knowledge about the importance of adequate restful sleep, the
dangers of fatigue in terms of both health and performance, and the
availability of scientifically-proven sleep-enhancement and alertness-
management strategies also is essential to safeguard the quality, pro-
ductivity, and safety of our present and future work force.
Acknowledgements
The opinions or assertions contained herein are the private views of
the author(s) and are not to be construed as official or as reflecting the
views of the Army or the Department of Defense. Citations of com-
mercial organizations and trade names in this report do not constitute
an official Department of the Army endorsement or approval of the
products or services of these organizations. This work was supported by
the US Army Medical Research and Materiel Command (USAMRMC).
Portions of this review are based on several previously published
works of two authors: Caldwell, J. A., and Caldwell, J. L. Fatigue in
Aviation: A guide to staying awake at the stick (2nd Edition). New York:
Routledge, Taylor & Francis Group, 2016; Caldwell, J. A. Aviator fa-
tigue and relevant countermeasures (Book Chapter). In D. Rainford and
D. Edwards (ed.) Ernstings’s Aviation Medicine, 5th Edition, pp. 583-
600. London, Taylor and Francis, 2015; Caldwell, J. L., and Caldwell, J.
A. Fatigue in aviation (Book Chapter), In Kennedy, C. and Kay, G.
(eds.), Aeromedical Psychology, pp. 215-238. Aldershot: Ashgate
Publishing Co., 2013; Caldwell, J. A. Understanding and managing fa-
tigue in aviation (Book Chapter), In Matthews, G., Desmond, P. A., and
Hancock, P. A. (eds.) Handbook of Operator Fatigue, pp. 379-392.
Aldershot: Ashgate Publishing Co., 2012; Caldwell, J. A., Mallis, M. M.,
Caldwell, J. L., Paul, M. A., Miller, J. C., and Neri, D. F. Fatigue
countermeasures in aviation, Aviation, Space, and Environmental
Medicine, 80:29-59, 2009; Caldwell, J. A., and Caldwell, J.L. Fatigue in
Military Aviation: An overview of U.S. military-approved pharmacolo-
gical countermeasures, Aviation, Space, and Environmental Medicine,
76(7, Suppl.):C39-C51, 2005.
J.A. Caldwell was supported by the Oak Ridge Institute for Science
and Education through an interagency agreement between the US
Department of Energy and US Army Medical Research and Materiel
Command.
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