Optimal sleep health among frontline healthcare workers during the COVID-19 pandemic

To the Editor,

Since the start of the coronavirus disease (COVID-19) outbreak in December 2019 in Wuhan, China, it has been declared a pandemic and has now involved over 200 countries.^A Adverse effects on the mental health of frontline healthcare workers (HCW) has been at the forefront of concerns,1 with insomnia being one of the most commonly reported symptom.2 Because of the fundamental role that sleep plays in emotion regulation and body homeostasis, sleep disturbance can have direct consequences on both emotional functioning and wellbeing.3 As physician wellbeing and patient safety are inextricably linked,4 it is imperative that we address sleep health for the sake of physicians and their patients.

Over 1,200 HCWs from 34 hospitals in China dealing with COVID-19 were surveyed for mental health and sleep problems in a recent cross sectional, survey-based, region-stratified study.2 Frontline workers involved in direct care of patients with COVID-19 were associated with the highest risk of insomnia (odds ratio [OR], 2.97; 95% confidence interval [CI], 1.92 to 4.60), followed by depression (OR,1.52; 95% CI, 1.11 to 2.09), anxiety (OR, 1.57; 95% CI, 1.22 to 2.02), and distress (OR, 1.60; 95% CI, 1.25 to 2.04).2 These self-reported symptoms were higher among nurses, women, and frontline HCWs, and in geographical areas with higher case infection rates.

During a pandemic, concerns about personal safety, transmitting disease to family members, stigmatization from being infected, shift work, and interpersonal isolation coalesce to disrupt sleep health. This can manifest by hyper-arousal states, as well as problems with anxiety and stimulus control (e.g., beginning to associate the bed with wakefulness, rather than restful sleep); all of these can have negative effects on physician wellbeing.5 Moreover, specific lifestyle modifications such as home confinement and self-isolation can also negatively impact sleep health. Anesthesiologists may be particularly susceptible to all the aforementioned concerns given our direct involvement with high-risk aerosol-generating medical procedures, shift work, and redeployment to areas outside some practitioners’ normal scope-of-practice such as critical care units. Important biological factors also influence sleep pathophysiology including age (e.g., decreased amounts of slow wave and rapid eye movement sleep, increased incidence of sleep disorders such as obstructive sleep apnea (OSA), sex (e.g., women self-report shorter and poorer sleep compared with men; higher incidence of OSA in men and post-menopausal women), psychosocial state (e.g., presence of depression, stress, loneliness), socio-economic status, race, and ethnicity.3 Furthermore, individual sleep patterns—e.g., the hypnotype (habitual sleep duration) or chronotype (morningness/eveningness preference)—can conflict with shift work, which requires inflexible work hours and disrupts circadian rhythm.3

Optimal sleep health is essential for the wellbeing of HCW, and thus the provision of safe patient care. Physician burnout has been associated with an increased risk of patient safety incidents (OR, 1.96; 95% CI, 1.59 to 2.40), poorer quality of care due to low professionalism (OR, 2.31; 95% CI, 1.87 to 2.85), and reduced patient satisfaction (OR, 2.28; 95% CI, 1.42 to 3.68).4 Given that sleep is even more disrupted during the COVID-19 pandemic, we herein present some useful sleep habits partly adapted from cognitive behaviour therapy for insomnia, relevant information and other resources for the frontline HCW (Table; and eFigure in the Electronic Supplementary Material). We are hopeful that optimal sleep habits, stress management, cognitive strategies for sleep, relaxation techniques, increasing awareness of common sleep disorders, and behavioural interventions may compliment institutional wellness programs and aid our colleagues during this stressful time.

Table Optimal sleep health advice for frontline healthcare workers while dealing with the COVID19 pandemic

Notes

• A World Health Organization. Coronavirus disease (COVID-19). Situation Dashboard. World Health Organization. Available from URL: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (accessed May 2020).