The Perceptions and Effects of Sleep Deprivation in a Department of Anesthesiology

Abstract

Background and Objective Sleep deprivation has multiple pathophysiological, psychological and cognitive effects. The effects of sleep deprivation on anesthetists have been recognized both within and outside of the workplace. This study investigated the perceived effects of sleep deprivation on anesthetists. To document the longest time spent without sleep due to work schedule, to describe the perceptions of the effects of sleep deprivation and the degree of sleepiness and daytime fatigue symptoms using the Epworth Sleepiness Scale (ESS) and to describe measures taken by anesthetists to overcome sleepiness. Methods A prospective, contextual, descriptive research design was followed for the study. A convenience sample of anesthetists completed a questionnaire regarding perceptions and effects of sleep deprivation and the ESS. Data were descriptively analyzed. Results The mean [standard deviation (SD)] longest time spent without sleep due to work schedule was 31 (9.1) hours and all anesthetists felt that they had insufficient sleep due to work schedule, with 61 (57%) stating this occurred 1 to 2 nights per week. Effects of sleep deprivation included effects on academic development, feeling tired at work, difficulty in concentrating at work and feeling stressed or irritable. Dozing off in theatre both during a night call and a day shift at different frequencies were reported. Other effects on family and social life were described. The mean (SD) ESS score was 11.5 (4.4). Conclusions Anesthetists reported perceptions of inadequate sleep and the subsequent effects both at work and at home. Further research to determine the extent of sleep deprivation amongst anesthetists in South Africa is suggested.

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2018 The Korean Society of Sleep Medicine 53
pISSN 2093-9175 / eISSN 2233-8853
ORIGINAL ARTICLE
Background and ObjectiveaaSleep deprivation has multiple pathophysiological, psychological
and cognitive eects. e eects of sleep deprivation on anesthetists have been recognized both
within and outside of the workplace. is study investigated the perceived eects of sleep depriva-
tion on anesthetists. To document the longest time spent without sleep due to work schedule, to
describe the perceptions of the eects of sleep deprivation and the degree of sleepiness and daytime
fatigue symptoms using the Epworth Sleepiness Scale (ESS) and to describe measures taken by
anesthetists to overcome sleepiness.
MethodsaaA prospective, contextual, descriptive research design was followed for the study. A
convenience sample of anesthetists completed a questionnaire regarding perceptions and eects of
sleep deprivation and the ESS. Data were descriptively analyzed.
Resultsaae mean [standard deviation (SD)] longest time spent without sleep due to work sched-
ule was 31 (9.1) hours and all anesthetists felt that they had insucient sleep due to work schedule,
with 61 (57%) stating this occurred 1 to 2 nights per week. Eects of sleep deprivation included ef-
fects on academic development, feeling tired at work, diculty in concentrating at work and feeling
stressed or irritable. Dozing o in theatre both during a night call and a day shi at dierent frequen-
cies were reported. Other eects on family and social life were described. e mean (SD) ESS score
was 11.5 (4.4).
ConclusionsaaAnesthetists reported perceptions of inadequate sleep and the subsequent eects
both at work and at home. Further research to determine the extent of sleep deprivation amongst
anesthetists in South Africa is suggested. Sleep Med Res 2018;9(1):53-57
Key WordsaaEpworth Sleepiness Scale, Anesthetist, Sleep deprivation.
INTRODUCTION
In June 2016, South African newspapers reported on a tragic accident in which a fatigued
medical intern fell asleep whilst driving home resulting in both her and another’s death [1].
Similarly in the United Kingdom (UK), newspaper articles reported on the death of a fatigued
anesthetist aer falling asleep at the wheel [2], and other motor vehicle accidents caused by
tired doctors [3]. In a forum article Erasmus [4] highlighted excessive working hours of junior
doctors in South Africa [4]. A 2016/2017 national survey on the eects of fatigue amongst anes-
thetists training in the UK showed that 84.2% of respondents felt too tired to drive home and
57% reported a motor vehicle accident or near miss when driving home aer a night shi [5].
Sleep and its importance have long been speculated upon and studied. Research has estab-
lished that the average adult has 6.8 to 7.4 hours of sleep a night [6]. In today’s society many
shi-workers do not achieve this [6]. Less than normal sleep achieved on consecutive nights
results in chronic sleep deprivation while acute sleep deprivation results from a period of
complete sleep loss [6]. Sleep deprivation aects many physiological systems, as well as having
https://doi.org/10.17241/smr.2018.00220
e Perceptions and Eects of Sleep Deprivation
in a Department of Anesthesiology
Megan Sanders, MBChB, DipPec, DA, MMed, FCA1, Helen Perrie, MSc2, Juan Scribante, MCur2
1Department of Anesthesiology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
2Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Received: June 10, 2018
Revised: June 21, 2018
Accepted: June 25, 2018
Correspondence
Megan Sanders, MBChB, DipPec, DA, MMed,
FCA
Department of Anaesthesiology,
Chris Hani Baragwanath Academic Hospital,
26 Chris Hani Road, Diepkloof 319-Iq,
Johannesburg 1860, South Africa
Tel +27119331843
Fax +27119331843
E-mail nutmeg.m@gmail.com
ORCID
Megan Sanders
https://orcid.org/0000-0002-1094-190X
Helen Perrie
https://orcid.org/0000-0002-9890-7887
Juan Scribante
https://orcid.org/0000-0002-2221-5024

54 Sleep Med Res 2018;9(1):53-57
How Sleepy are Our Junior Anesthetists?
a wide range of other eects [6]. is leads to symptoms of ‘day-
time sleepiness,’ as well as psychological and emotional conse-
quences [7,8]. Sleep deprivation also has an inuence on neuro-
cognitive functioning and can result in short lapses of attention
which is oen termed ‘microsleep’ [7,9]. Dawson and Reid [10]
found that after 17 hours of sleep deprivation the decline in
cognitive psychomotor ability is equivalent to alcohol intoxica-
tion. Although it is dicult to test, executive functioning in the
form of decision making and simulated tasks has been shown
to be aected by sleep loss [11,12].
Within the medical environment sleep deprivation is known
to increase the risk of medical errors and have an impact on
academic development of training doctors [13-15]. ere are
also increased risks of percutaneous injuries amongst doctors
who are fatigued [16]. It has been demonstrated that sleep de-
privation has an inuence on the social lives and daily activities
of doctors and has been linked to a negative impact on mood
and personal relationships [15].
In South Africa it is known that doctors have long working
hours and are sleep deprived [4]. According to the South Afri-
can Society of Anesthesiologists (SASA): ‘continuous on call
duty of less than 12.5 hours is suggested, more than 17 hours is
to be discouraged, and excess of 24 hours to be condemned’
[17]. Within a Department of Anesthesiologyanesthetists are
exposed to prolonged working hours and night calls. Hence the
perceptions of sleep insufficiency and the longest time spent
without sleep due to work schedule, as well as the effects of
sleep deprivation on the work and social life of anesthetists
needed to be assessed. In addition, the study aimed to describe
the degree of sleepiness and daytime fatigue symptoms through
the use of the Epworth Sleepiness Scale (ESS) [18] and to de-
scribe measures taken by anesthetists to overcome sleepiness.
METHODS
Approval to conduct this study was obtained from the Hu-
man Research Ethics Committee (Medical M150106) and oth-
er relevant authorities.
A prospective, contextual, descriptive research design was
followed. e study population consisted of anesthetists work-
ing in a Department of Anesthesiology, Convenience sampling
was used. At the time of the study there were 131 eligible anes-
thetists (interns, medical officers and registrars). The sample
size was determined by the number of responses and a re-
sponse rate of 79 (60%) completed questionnaires was regard-
ed as an appropriate sample size [19].
Following an in-depth review of the literature a dra ques-
tionnaire was developed. e questionnaire included questions
from a sleep questionnaire by Kim et al. [20] and the ESS [18].
Two senior anesthesiologists and a doctor specializing in sleep
medicine reviewed the questionnaire and added ve questions
to the sleep questionnaire. Content and face validity was there-
fore ensured.
Data were collected at departmental academic meetings dur-
ing October and November of 2015. Participation was volun-
tary and consent was implied by completion of the self-admin-
istered questionnaire. This was stipulated on the information
sheet on the questionnaire. ere was no identifying informa-
tion on the questionnaires, which were folded and returned to
a sealed box thereby ensuring anonymity. Condentiality was
ensured as only the authors had access to the raw data. One au-
thor (MS) was present at all meetings to answer any queries.
Descriptive statistics were used to analyze data. Categorical
variables were described using frequencies and percentages.
Likert Scale data were reported as ordinal data. e ESS scores
were reported as interval data as ESS scores were presented as
such in the initial study [18] and subsequently in other studies
[15,20]. ESS total scores were normally distributed and the
mean and standard deviation (SD) were used to describe the
results.
RESULTS
Of the 131 distributed questionnaires, 107 (81.7%) were re-
turned. Not all questions were answered by all anesthetists and
the number of anesthetists who answered the question is indi-
cated where appropriate. e professional designation of anes-
thetists was 22 (60%) interns, 15 (14%) medical ocers and 70
(66.4%) registrars.
e mean (SD) longest time spent without sleep due to work
schedule was 31 (9.1) hours. Eighty-three (88.8%) of the 107
anesthetists answered this question. Perceptions regarding in-
sucient sleep due to work schedule and diculty in awaken-
ing are shown in Table 1.
Table 2 illustrates the frequency at which anesthetists felt
sleepiness aected their lives at work. e majority of anesthe-
tists responded in the 1 to 2 days per week category for all four
questions.
Fig. 1 shows the number of anesthetists who doze o in the-
atre both during the day and on a night call. One anesthetist
Table 1. Insufcient sleep and difculty in awakening
Response
Insucient
sleep due
to work schedule
n (%)
Diculty
in awakening
in the morning
n (%)
Never 03 (2.8)
1 to 2 nights per month 13 (12.1) 20 (18.7)
1 to 2 nights per week 61 (57) 30 (28)
3 to 4 nights per week 26 (24.3) 30 (28)
Almost always every day 7 (6.5) 24 (22.4)

Sanders M, et al.
www.sleepmedres.org 55
reported dozing o in theatre every day and more than once
per night call.
Other eects of sleep deprivation on work are shown in Fig. 2.
e majority, 99 (92.5%) anesthetists, have missed social and
family activities, 44 (41.1%) a percutaneous injury on duty and
101 (94.4%) felt at risk of having a motor vehicle accident be-
cause of sleepiness.
The mean (SD) ESS score was 11.5 (4.4) indicating mild
sleepiness. Forty-six (43.4%) anesthetists had a normal score (0
–10), 32 (30.2%) had mild sleepiness (11–14), 19 (17.9%) had
moderate sleepiness (15–17) and 9 (8.5%) had severe sleepi-
ness (18 or higher). One anesthetist did not complete the ESS.
irty-two (29.9%) anesthetists reported that they drink caf-
feinated beverages 1 to 2 times per day. Table 3 illustrates the use
of caeinated beverages during a night call. One unit is 250 mL
or one cup.
Other strategies used by anesthetists to resist sleepiness are
represented in Fig. 3. Some anesthetists used more than one
strategy.
DISCUSSION
Sleep deprivation and the eects thereof are well described
in the literature, however no South African study on the eects
of sleep deprivation on anesthetists could be identied. Exten-
sive research on sleep deprivation amongst health care workers
has been conducted and a wide variety of methods have been
used to describe the phenomena. Where standardized scales or
questionnaires where used the results were not always reported
in a standardized manner. is makes direct comparison with
other studies dicult.
Table 2. Sleep deprivation at work
Response Tired at work
n (%)
Diculty in concentrating
n (%)
Sleepiness on academic development
n (%)
Stressed or irritable
n (%)
Never 1 (0.9) 4 (3.7) 2 (1.9) 3 (2.8)
1 to 2 days per month 12 (11.2) 39 (36.4) 17 (15.9) 27 (25.2)
1 to 2 days per week 48 (44.9) 42 (39.3) 46 (43) 47 (43.9)
3 to 4 days per week 28 (26.2) 15 (14) 26 (24.3) 24 (22.4)
Almost always every day 18 (16.9) 7 (6.5) 16 (15) 6 (5.6)
Number of anesthetists
Frequency of dozing
Never Once per
month
Once per
week
Oen*Frequently†
50
45
40
35
30
25
20
15
10
5
0
Day shi
Night call
Fig. 1. Frequency of dozing off in theatre. *more than once per week/
almost every day. †almost every day/more than once per night call.
Missed
work
Late to
work
Eects of sleep deprivation on work
Mistake due to
sleepiness
Unrelated
mistake
Percentage of anesthetists
100
90
80
70
60
50
40
30
20
10
0
No Ye s
Fig. 2. Effects of sleep deprivation on work.
Table 3. Use of caffeinated beverages
Units Filter coee
n (%)
Instant coee
n (%)
Ceylon tea
n (%)
Herbal tea
n (%)
Cold drink
n (%)
Energy drink
n (%)
0 units 80 (74.8) 55 (51.4) 88 (82.2) 96 (89.7) 68 (63.6) 91 (85)
1 to 2 units 19 (17.8) 42 (39.2) 14 (13.1) 10 (9.3) 38 (35.5) 16 (15)
3 to 4 units 4 (3.7) 9 (8.4) 5 (4.7) 1 (0.9) 1 (0.9) 0
> 4 units 4 (3.7) 1 (0.9) 0 0 0 0

56 Sleep Med Res 2018;9(1):53-57
How Sleepy are Our Junior Anesthetists?
SASA guidelines [17] suggest that a work period in excess of
24 hours should be condemned. In this study working hours
vary from approximately 8 to 28 hours between the dierent
hospitals aliated to the department. Kim et al. [20] reported
a mean work duration of 14.9 (2.7) hours per day and the lon-
gest length of time participants had gone without sleep due to
work schedule was a mean of 38.5 (15.7) hours. Gander et al.
[21] reported mean continuous work hours of 18.6 (6.8) for
training anesthetists and 20.5 (4.96) for specialist anesthetists.
e mean longest length of time anesthetists had gone with-
out sleep due to work schedule was 31 (9.1) hours in this study.
is may be accounted for by anesthetists being awake for some
time before and aer their work period. Additional hours spent
awake may involve meetings or academic tutorials and include
travel time. Family or social activities may further prolong the
time awake. Frequent calls with resulting sleep fragmentation
as a reason for long hours of wakefulness has also been sug-
gested in the literature [20].
is study showed a mean ESS score of 11.5 which falls into
the mild sleepiness category according to the Division of Sleep
Medicine at Harvard Medical School [22]. is much higher
than the mean score of normal adults of 4.6 [23], however low-
er than the mean score of 14.6 reported for residents-physician
by Papp et al. [15] In this study all anesthetists reported insu-
cient sleep due to work schedule, and 57% of anesthetists per-
ceived insucient sleep due to work schedule 1 to 2 nights per
week which coincides with the night calls per week. McClel-
land et al. [5] reported that 81.7% of respondents had less than
30 minutes uninterrupted sleep during a night shi and 95.1%
had disrupted sleep while o duty to varying degrees.
Screening for Obstructive Sleep apnea was not used for this
study, as it was not part of the scope for the study. However it is
noted that this may have inuenced results such as the ESS score,
and could be included in future studies.
Feeling tired at work (44.9%), having difficulty in concen-
trating at work (39.3%), eect on academic development (43%)
and feeling stressed and irritable (43.9%) also appears to corre-
spond to the weekly calls 1 to 2 nights per week. However, this
sleep deprivation perceived by anesthetists may not only be
from shi work but also from long standing chronic sleep loss.
McClelland et al. [5] reported that fatigue aected the ability of
over 50% of the respondents to do their jobs and over 80 % of
respondents felt fatigue affected management of exams and
audits.
Sleep deprivation not only aects the junior doctor person-
ally but also impacts on patient safety and service delivery. In
this study, 57.9% of the anesthetists reported dozing o in the-
atre during the day and 79.4% during a night call with varying
degrees of regularity. In a study by Howard et al. [9] one third
of sleep deprived participants fell asleep during simulations.
Missing work was reported by 5.6% of anesthetists and 66.4%
had been late to work due to sleep problems in this study. Kim
et al. [20] reported a higher 37.9% of the participants admitting
to missing work and a similar 60.3% admitting to lateness be-
cause of sleep problems.
Almost half (48.6%) of the anesthetists in this study admit-
ted to making a sleepiness related mistake and 69.2% admitted
to making a mistake at work unrelated to sleepiness. Kim et al.
[20] reported 60.3% of the participants making a sleepiness re-
lated mistake and 67.2% making a non-sleepiness related mis-
take. Both studies illustrated making mistakes unrelated to
sleepiness is more common than mistakes related to sleepiness.
It could be argued that anesthetists felt mistakes are multifacto-
rial and can occur regardless of fatigue status. is is supported
by the ndings of Morris and Morris [24], who documented
factors such as haste, distraction, other stress and equipment
issues could be linked to errors. e authors further indicated
that fatigue may play a more signicant role for specic errors
such as pharmacological errors. Percutaneous injury second-
ary to sleepiness was perceived by 41.1% of anesthetists from
Fig. 3. Strategies to resist of sleepiness. *games, social media, cleaning etc.
Strategies to resist sleepiness
None Music Smoking Talking Other*
Sleep
before shi
Physical
activity
Eating/
drinking
Reading/
studying
Number of anesthetists
40
35
30
25
20
15
10
5
0

Sanders M, et al.
www.sleepmedres.org 57
this study. Ayas et al. [16] reported that 31% of interns linked fa-
tigue to percutaneous injuries. e authors also suggested other
possible causation factors such as lapse in concentration, inade-
quate lighting and patient movement, supporting the theory
that multiple factors may lead to percutaneous injuries [16].
McClelland et al’s. [5] 2017 national survey in the UK on the
effects of fatigue on trainees in anaesthesia [5] reported that
84.2% felt too tired to drive home after a night shift. The au-
thors also reported 57% had had an accident or near miss when
driving home aer a night shi. South African [1] and interna-
tional news [2,3] have reported on fatal car accidents involving
fatigued doctors. A perception of risk of accident when driving
while being sleepy was found in 94.4% anesthetists in this study.
Although anesthetists in this study indicated that they per-
ceived their sleep to be insucient to varying degrees, tradi-
tional strategies to reduce sleepiness where not always used.
Caeinated beverages were consumed by 29% of anesthetists 1
to 2 times per day. Kim et al. [20] participants seldom drank
caeinated beverages, however, 87.9% of McClelland et al’s. [5]
participants used caeine to counteract the eects of fatigue.
Only 1.9% of anesthetists in this study reported sleeping before
a shi and 21% reported eating and drinking to reduce sleepi-
ness. It was noted that no anesthetist reported the use of medi-
cation or other substances, however this could be because it is
a socially unacceptable answer.
In conclusion, this study focusses on the perceptions of sleep
deprivation of junior anesthetists in one department and gives
insight to the understanding of sleep deprivation amongst ju-
nior anesthetists. Junior doctors are the backbone of health
service delivery in South Africa. Although the working hours
and eects of fatigue were highlighted by Erasmus [4] in 2012,
further research is needed to establish the level of sleep depri-
vation and its eects on the lives of both senior junior doctors
in all specialties.
Conflicts of Interest
e authors have no nancial conicts of interest.
Authors’ Contribution
Conceptualization: Sanders M. Data curation: Sanders M, Perrie H,
Scribante J. Investigation: Sanders M. Methodology: Sanders M, Perrie H,
Scribante J. Supervision: Perrie H, Scribante J. Writing—original dra:
Sanders M. Writing—review & editing: Perrie H, Scribante J.
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