Richter et al.

The EPMA Journal (2016) 7:16

DOI 10.1186/s13167-016-0064-4

REVIEW Open Access

Prevention of fatigue and insomnia in shift

workers—a review of non-pharmacological
measures
Kneginja Richter1,2,3*, Jens Acker4, Sophia Adam5 and Guenter Niklewski1,3

Abstract
Background: Excessive fatigue and insomnia are common among shift workers and can lead to negative effects
such as reduced work performance, processing errors, accidents at work, absenteeism, reduced quality of life, and
symptoms of depression. Moreover, work in rotating shifts can be a risk factor for different somatic and psychiatric
diseases and may contribute to poor health, especially in elder adults and women. This review aims to show
non-pharmacological preventive measures against fatigue and insomnia in shift workers.
Method: Computerized literature searches in MedLine and in the Cochrane Library were performed with the
following key words: shift work disorder, fatigue, insomnia, shift work, measures, treatment, therapy, strategies and
coping. The search was limited to non-pharmacological studies that were conducted on human subjects and
published as English-language articles in peer-reviewed journals since 1970. Additional studies were identified
through the reference sections of relevant articles. Eighteen articles on fatigue in shift workers, including six original
research articles with a total sample size of 3504 probands consisting of industrial workers, office employees, aircraft
maintenance engineers, and non-shift workers working in simulated shifts, were analyzed, as well as seven articles
on insomnia, including an original research article with a sample size of 26 media workers. Also, 4 reviews on shift
work disorder were analyzed.
Main: The occurrence of fatigue and insomnia in shift workers associated with a working period is described as
shift work disorder. Estimations on the prevalence of shift work disorder in shift workers vary between 5 % and
about 20 %; about one in three shift workers is affected by insomnia and up to 90 % of shift workers report regular
fatigue and sleepiness at the workplace. We concluded that there is a necessity for treatments to improve the sleep
quality of the shift working population. The most common non-pharmacological recommendations to improve
sleep quality and to reduce insomnia and fatigue were scheduling, bright light exposure, napping, psychoeducation
for sleep hygiene, and cognitive-behavioral measures.
Conclusion: Some important preventive coping strategies for fatigue associated with shift work such as napping and
exposure to bright light have already been investigated and are generally approved. A few studies also provide good
evidence for the efficacy of cognitive-behavioral techniques in the treatment of chronic primary and comorbid
insomnia. These coping strategies summarized in this paper should be considered in the workplace health promotion
programs of each work environment to improve working conditions for shift workers and to save money.
Keywords: Predictive preventive personalized medicine, Shift work, Socioeconomic factors, Mood disorders, Innovative
strategies, Risk factors, Chronic fatigue, Comorbid insomnia, Health promotion, Work environment

* Correspondence: Kneginja.Richter@gmx.de
1
Center for Sleep Medicine, University Clinic for Psychiatry and
Psychotherapy, Paracelsus Medical University Nuremberg,
Prof.-Ernst-Nathan-Straße 1, D-90419 Nuremberg, Germany
2
Faculty for Social Sciences, Georg Simon Ohm University for Applied
Sciences, Nuremberg, Germany
Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Richter et al. The EPMA Journal (2016) 7:16 Page 2 of 11

Background Vallieres and colleagues investigated the sleep pattern

The desynchronization of the biological clock caused by of 418 adults, including 51 night workers, 158 rotating
shift work can lead to physical and psychiatric diseases. shift workers, and 209 day workers, reported night and
Fatigue and insomnia resulting from a disturbed sleep- rotating shift workers with insomnia to have a sleep pro-
wake cycle occur frequently in shift workers and may file similar to that of day workers with insomnia [20].
manifest as the so-called shift work disorder (SWD, Moreover, a positive association between shift work, in-
2016 ICD-10-CM: G47.26) [1–8]. somnia, and fatigue has been shown [21]. Insomnia (2016
According to the ICSD 2 classification, essential symp- ICD-10-CM: F51.0) is one of the core symptoms of SWD.
toms of shift work sleep disorder are insomnia or exces- The prevalence is about 6 % in the total population [22]
sive sleepiness that occurs as transient phenomena in and affects between 29 and 38 % of the shift workers [23].
relation to work schedules. Different schedules belong to Symptoms include difficulties falling asleep, a disturbed
the term “shift work”-occasional overnight duty, rotating sleep duration, frequent awakening, and an intense focus
shifts, permanent night shifts, or early morning work on the sleeping behavior itself [10, 24, 25]. The socioeco-
(starting between 4 and 7 a.m.) [4]. nomic and health-related consequences of insomnia in
The condition usually persists for the duration of the shift workers such as absenteeism and mood disorders
work-shift period. Shift work is common in protective [26, 27] should likewise not be underestimated.
services, transportation, healthcare, and other services The same applies to fatigue (2016 ICD-10-CM: R53).
that directly affect the health and safety of other [9]. The Core symptoms of fatigue are exhaustion, tiredness, and
consequences of shift work disorder can negative affect lethargy. The effects of fatigue are also undesirable and
the physical and mental health, quality of life, productiv- cause a loss of efficiency, concentration difficulties, as well
ity, and work performance as well [7, 10–15]. Shift as decreased productivity and safety at work [28]. Up to
workers diagnosed with SWD usually have a primary 90 % of the shift workers report sleepiness and fatigue at
complaint of insomnia or excessive sleepiness; the pri- work [29]. Long and erratic working hours can lead to
mary complaint is temporally associated with a work acute and chronic sleep deprivation as well as a poor sleep
period that occurs during the habitual sleep phase. A quality and thus result in impairments in several domains,
loss of the normal sleep-wake pattern usually appearing including attention, cognition, and motor skills [30]. Also,
in SWD patients can be shown with polysomnographics rotating and night shifts can be a risk factor for chronic
or the Multiple Sleep Latency Test [4]. Drake, Roehrs, and cardiovascular diseases [31, 32], digestive diseases
Richardson, Walsh, and Roth investigated 2570 shift [33], metabolic diseases [34], and diabetes [35].
working individuals and reported differences in the Many authors have researched the risks that result from
prevalence of SWD in night shift workers and rotating shift work, long working hours [36], and a short sleep dur-
shift workers. Fourteen percent of the night workers and ation [37, 38]; they found that shift work increases the risk
8 % of the workers on rotating shifts met criteria for for attention deficits [39] and accidents at work [40–42].
SWD [5]. Among workers on an oil rig, for example, the The risk potential of night (28 %) and evening shifts
prevalence of SWD was estimated at about 23 % [16]. (15 %) is here higher than that of day shifts [43].
The American Academy of Sleep Medicine estimates the For women, there is a high risk of negative health con-
prevalence of SWD, depending on which country is con- sequences from shift work - especially women over 50
sidered, between 5 and 8 %, with night shift workers be- often suffer from fatigue, and female night shift workers
ing affected particularly frequently [4]. Thus, not every have a 28 % risk for breast cancer [44, 45]. Women who
shift worker will develop physical or psychiatric diseases have been working night shifts for more than 20 years
but the prevalence is quite high. SWD is assumed to be have an even further increased risk for breast cancer [46,
caused by a misalignment of the circadian rhythm and 47]. There are some references providing evidence that
environmental stimuli and may have potentially harmful night and shift work increase the risk of ovarian [48],
consequences on an individual's health status and quality colorectal [49], prostate [50], and endometrial cancer
of life [1, 4, 17]. Waage and colleagues showed in a lon- [51]. The health risks presented here are well-known
gitudinal study including 1533 nurses important risk fac- health risks encountered by shift workers. Since approxi-
tors for SWD: the numbers of night shifts worked in the mately 15 to 26 % of the US labor force work night,
previous year, composite score on the Epworth Sleepi- evening, or rotating shifts [52], there is an urgent need
ness Scale, use of melatonin, use of bright light therapy, for coping strategies in the workplace.
and symptoms of depression [18]. Another risk factor
pointed out by Kalmbach and colleagues is working in Review
rotating shifts. In the sample, odds were over five times Methods
greater for highly sleep-reactive individuals to develop We conducted three separate computerized literature
SWD after transitioning to rotating shifts [19]. searches in MedLine and in the Cochrane Library. The
Richter et al. The EPMA Journal (2016) 7:16 Page 3 of 11

following key words in different combinations were used adjustments, behavioral interventions, and pharmaco-
to search for the theme of fatigue: fatigue and shift work, logical interventions. These findings indicate that there
measures, treatment, therapy, strategies, and coping. For is no unrestrictedly useful treatment since individuals re-
insomnia, we searched for insomnia and shift work, spond differently to each intervention. Rather, tailored
measures, treatment, therapy, strategies, and coping. and combined interventions and holistic approaches
The following key words in different combinations were should be targeted [70].
used to search for articles regarding shift work disorder: In some cases, medical treatment should be recom-
measures, treatment, therapy, strategies and coping. We mended in addition to non-pharmacological interven-
ordered the articles from these searches into the categor- tions. Hajak and Zulley analyzed SWD in a systematic
ies fatigue and insomnia. In the process, we focused on review and recommended optimizing the shift plan, en-
articles that were based on research on human subjects hancing concentration through light exposure, observing
and published in peer-reviewed journals between 1970 sleep hygiene, and, in some cases, medical treatment. It
and 2015. Pharmacological studies were excluded, i.e., should be noted that only people with the full spectrum
any study that involved treatment with drugs was not in- of shift work disorder should get medical treatment and
cluded in the analysis; in other words, only interventions that medication does not alleviate the underlying cause,
with the intent to improve health and well-being that i.e., the disturbance of the circadian rhythm [54].
did not involve the use of any drug or medicine, e.g.,
psychoeducation on sleep hygiene, cognitive-behavioral Napping
techniques, or changes in light exposure, were included. Short naps which minimize sleep inertia can generally be
In addition to the results of these searches, reference regarded as helpful [72, 75]. Purnell and colleagues exam-
sections of relevant articles were used to identify further ined 24 engineers working for an airline company in a
studies that had not come up in the database searches. crossover-designed study. During 2 weeks, they examined
On the topic of insomnia in shift work, the electronic da- the influence of a 20-min nap in the workplace between 1
tabases cited 60 articles. After excluding papers that did not and 3 a.m. In the first week, employees took naps during
meet the criteria, eight papers that strictly focused on the their shifts; whereas in the second week, no nap was taken.
relevant topics were left and included in our study. On the They found that during the week with naps, employees
topic of fatigue in shift work, 79 papers were found and performed better in a vigilance test (reported p < 0.01),
reviewed, of which 19 papers met the inclusion criteria. suggesting that they were more alert in the workplace and
that they could sleep well at home [53]. Morgenthaler
Results et al. recommend a 20-min nap during working hours and
In the following, some generally acknowledged coping exposure to light for 4 × 20 min immediately after the be-
strategies against fatigue and insomnia in shift workers ginning of the shift or, at the latest, before half of the work
are presented: napping, nutrition, light, scheduling, life- period is over [13]. According to some more consistent
style training, and cognitive and behavioral interven- findings in several laboratory simulations and field investi-
tions. We were able to find that these measures are gations, short naps improve alertness, vigilance, reaction
common practice and scientifically sound. While there is times, and performance and decrease the risk of accidents
plenty of research on fatigue, there are evidently fewer [76]. Rajaratnam, Howard, and Grunstein give the general
studies dealing with measures against insomnia in shift advice that a 20–30-min nap during the night shift or nap-
workers. For an overview of measures against fatigue, ping for periods between 30 min and 2 h before evening
see Table 1 [13–15, 53–67], and against insomnia, see or night shifts can help to maintain alertness and wakeful-
Table 2 [15, 59, 68–72]. For an overview of measures ness [72]. However, napping itself leads to sleep inertia
against SWD, see Table 3 [9, 46, 73, 74]. and may even impair vigilance. Hence, the efficacy of nap-
Neil-Sztramko, Pahwa, Demers, and Gotay provided ping depends mostly on the timing and duration as well as
an extensive review on health-related interventions on the stage of sleep and the particular circadian phase.
among shift workers. All studies were conducted with
participants working night shifts. Because of the hetero- Nutrition
geneity regarding study samples, jobs, types of interven- Some studies also recommend the use of caffeine, espe-
tion, outcomes, results, and study quality, no estimation cially at the start of a night shift [62, 77]. Beaumont and
of effect sizes could be made. Moreover, different chron- colleagues provided evidence for the positive effects of
otypes were not taken into consideration and there were caffeine on vigilance (reported p < 0.01) and cognitive
few age-specific analyses. Besides that, due to the setting performance (reported p < 0.05) during a long wakeful-
at the workplace, studies were often neither randomized ness period [65]. Nutrition is also an important factor
nor blinded. Still, four types of interventions could be for employees working shifts. Paz and Berry investigated
identified: controlled light exposure, shift schedule the beneficiary influence of certain meal compositions
 Richter et al. The EPMA Journal (2016) 7:16
Table 1 Recommendations for measures to prevent fatigue in shift workers
Authors Citation Title Type of paper Recommendations Sample size Sample occupation Population
background
Purnell, Feyer, and [53] The impact of a nap opportunity Original Nap 24 Aircraft maintenance Age 21–59, all
Herbison during the night shift on the engineers working in male, at least
performance and alertness of 12-h rotating shifts 4 months of
12-h shift workers experience
Morgenthaler et al. [13] Practice parameters for the clinical Systematic Nap
evaluation and treatment of review
circadian rhythm sleep disorders.
An American Academy of Sleep
Medicine report
Hajak [54] Sleepless in a 24-h society. When Systematic Scheduling, light exposure,
inner and external rhythms collide review consideration of suitability
for shift work
Juda, Vetter, and [55] Chronotype modulates sleep Original Scheduling 238 Full-time workers in 83 women, 155
Roenneberg duration, sleep quality, and rotating shifts men; average age
social jet lag in shift workers 38.8 ± 9.6 years
Härmä, Tenkanen, [56] Combined effects of shift work Original Regular exercises, but 3020 Employees of postal and All male, 45–60
Sjoblom, Alikoski, and lifestyle on the prevalence not right before an telecommunication agencies, years
and Heinsalmi of insomnia, sleep deprivation evening shift the railway company, and 5
and daytime sleepiness industrial companies, workers
in the forest industry and
heavy workers
Roth [57] Appropriate therapeutic selection Guideline Timed light exposure
for patients with shift work disorder
Kolla and Auger [58] Jet lag and shift work sleep disorders: Systematic Exposure to bright light
how to help reset the internal clock review
Thorpy [14] Understanding and diagnosing shift Systematic Exposure to light
work disorder review
Thorpy [15] Managing the patient with shift Overview Behavioral measures
work disorder (exercise and improved
sleep hygiene)
Barion and Zee [59] A clinical approach to circadian Review Combination of sleep
rhythm sleep disorders hygiene education and
timed exposure to
bright light
Zisapel [60] Circadian rhythm sleep disorders: Review Bright light/avoidance
pathophysiology and potential of light at different times
approaches to management
Aelfers, Bosma, [61] Effectiveness of a minimal Two-armed- MPI (minimal 124 Workers suffering from 115 men and 9
Houkes, and psychological intervention to randomized psychological intervention) (chronic) mental fatigue women

Page 4 of 11
van Eijk reduce mild to moderate controlled trial or mild to moderate
depressions and chronic fatigue depression
in a working population: the
 Richter et al. The EPMA Journal (2016) 7:16
Table 1 Recommendations for measures to prevent fatigue in shift workers (Continued)
design of a randomized
controlled trial
Schaefer, Williams, [62] Sleep and circadian misalignment Review Sleep hygiene, caffeine,
and Zee for the hospitalist: a review bright light exposure,
and planned naps
Paul, Miller, Gray, [63] Circadian phase delay induced by Original Bright light exposure 14 7 men, 7 women
Buick, Blazeski, phototherapeutic devices age: 18–51
and Arendt
Beaumont et al. [64] Slow release caffeine and Original Caffeine 17 Healthy male volunteers All male from
prolonged (64 h) continuous 19–27, mean
wakefulness: effects on vigilance age: 23 ± 2 years
and cognitive performance
Crowley, Lee, Tseng, [65] Combinations of bright light, Original Bright light and dark 67 Non-shift workers worked 35 females, 32
Fogg, and Eastman scheduled dark, sunglasses, and sunglasses in 5 consecutive simulated males between
melatonin to facilitate circadian night shifts 18 and 43
entrainment to night shift work (23.9 ± 6.2)
Eastman [66] Circadian rhythms and bright light: Review Light-work-sleep
recommendations for shift work schedules
Lowden, Moreno, [67] Eating and shift work—effects on Review Wholefood diet and
Holmbäck, Lennernäs, habits, metabolism, and performance regular food intake
and Tucker

Page 5 of 11
Richter et al. The EPMA Journal (2016) 7:16 Page 6 of 11

Table 2 Recommendations for measures against insomnia among shift workers

Authors Citation Title Type of Recommendations Sample Sample Population
paper size occupation background
Penn and [68] Behavioral Systematic Work-related factors: rest
Bootzin techniques for review periods, variation, complexity
enhancing and interest value of work,
alertness and self-pacing of work, feedback/
performance knowledge of results, incentives.
in shift work Sensory and kinesthetic stimulation,
physiological regulation, cognitive
skills. Interventions to affect
sleep, stress, and family life
Kerin and [69] Improving Overview On-the-job training, scheduling,
Aguirre health safety, and involvement of the family
and profits in
extended hours
operations
(shift work)
Neil- [70] Health-related Systematic Controlled light exposure,
Sztramko, interventions review shift schedule, behavioral
Pahwa, among night and pharmacological
Demers, shift workers: interventions
Gotay a critical review
of the literature
Järnefelt, [71] Cognitive- Non- Cognitive-behavioral 26 (19 included Media workers 13 males and
Lagerstedt, behavioral randomized therapy in analysis) from a broadcasting 13 females,
Kajaste, therapy for intervention company diagnosed age 43.5 ± 8.4
Sallinen, shift workers with insomnia
Savolainen, with chronic
and Hublin insomnia
Thorpy [15] Managing the Overview Behavioral measures
patient with (exercise and improved
shift work sleep hygiene)
disorder
Barion and [59] A clinical Review Combination of sleep hygiene
Zee approach to education and timed exposure
circadian rhythm to bright light
sleep disorders
Rajaratnam, [72] Sleep loss and Systematic Nap
Howard, and circadian disruption review
Grunstein in shift work:
health burden
and management

on the performance of shift workers. They showed that regular normal day and night eating patterns should be
the ratio of protein and carbohydrates should be 1/3 to maintained.
provide an optimal diet for shift workers. Differences in
psychometric performance were correlated with glucose Light
(reported p = 0.05) and insulin concentrations (reported Shift workers experience a circadian misalignment since
p = 0.04), and a large neutral amino acid ratio was corre- they have to work when their bodies are actually pre-
lated with alertness (reported p = 0.05) [78]. Lowden and pared to sleep. Melatonin is suppressed by (indoor) light.
colleagues [67] reviewed the influence of nutrition and As a result, suppressed endogenous levels of melatonin
specific meal patterns on shift workers’ performance. were found in employees working night shifts [79].
They provided some useful nutrition guidelines for shift However, the exposure to bright artificial light can coun-
workers, yet individual metabolic differences and the teract this suppression and may lead to the circadian
willingness to adapt eating habits to the shift schedule adaptation to night or shift work [80].
should be taken into consideration. A wholefood diet As Eastman mentions in his review, the efficacy of
consisting of vegetables, fruit, wholegrain, and low-carb treatments with bright light depends on many variables
food such as cottage cheese and eggs, and the avoidance such as the intensity, scheduling, and surrounding of the
of sugar-rich products with a high glycemic load and procedure. Moreover, he points out aspects of feasibility
convenience foods, is advised. Despite the night work, since individual light-work-sleep schedules need to be
Richter et al. The EPMA Journal (2016) 7:16 Page 7 of 11

Table 3 Recommendations for measures against insomnia among shift workers

Authors Citation Title Type of Recommendations Sample Sample Population
paper size occupation background
Wright, Bogan [9] Shift work and the assessment Review Approaches to promote sleep,
and Wyatt and management of shift wakefulness, and adaptation of
work disorder the circadian clock to the
imposed work schedule.
Zee and Goldstein [73] Treatment of shift work Review Temporary bright light exposure
disorder and jet lag during the shift, avoidance of
bright light toward the latter portion
of the work period, adequate
opportunity for sleep
Bajraktarov, Novotni, [46] Main effects of sleep disorders Review Physical fitness, sleep hygiene, timed
Manusheva, Nikovska, related to shift work-opportunities exposure to light
Miceva-Velickovska, for preventive programs
Zdraveska, et al.
Eastman, Boulos, [74] Light treatment for sleep Review Timed exposure to light
Terman, Campbell, disorders: consensus report.
Dijk, Lewy VI. Shift work

supported by the company [66]. Still, there is well- (reported p < 0.001) and a more intense social jet lag (re-
founded evidence underlining the benefits of a scheduled ported p < 0.001) on night shifts than the “night-owls.”
exposure to light [81]. In many cases, bright light re- Therefore, it is recommended to take the particular chron-
duces sleepiness, improves alertness, and leads to better otype into consideration when assigning the day, night, or
physical fitness, a more balanced sleep pattern, and rotating shift to individual employees [55].
higher efficiency. As Paul et al. showed, light tower use
between 00.00 and 02.00 a.m. causes melatonin suppres- Lifestyle training
sion and thus diminishes sleepiness in the work place Lifestyle training is a measure that goes one step further: it
(reported p < 0.003) [63]. Even a delayed sleep phase syn- provides a holistic approach using counseling and psychoe-
drome can be counteracted by exposure to bright light ducation [82]. Circadian Technologies, Inc. (CIRCADIAN)
in the early morning and avoidance of light in the even- is a company that helps employees to cope with the
ing. With this measure, a phase shift may be effected. challenges of shift work. Amongst other companies, CIR-
Exposure to bright light in the evening may be effective CADIAN designed the Managing a Shiftwork Lifestyle
in delaying the internal clock and can be effective program, an on-the-job training program to support em-
against advanced sleep phase syndrome [60]. For the ployees and their families with issues associated with shift
planned exposure to bright light, the recommendations work. Kerin and Aguirre [69] tested the Managing a Shift-
of the American Academy for Sleep Medicine are con- work Lifestyle intervention. Three-hundred thirty mine
sidered the gold standard. These guidelines also recom- workers attended a 4-h training workshop in groups of 10
mend planned light exposure in the work environment to 50 people. Before the training started, information about
and light restriction in the morning [13]. Another rec- the employees’ sleeping habits were assessed and collected
ommendation is reversely dealing with light. The recom- over a period of 28 days. Pre- and post-implementation
mendation here is to wear sunglasses or even blue data were compared to determine the net impact of the
blocking glasses before leaving the workplace at the end training, which included information on healthy nutrition,
of the shift or on the way back home [65]. Nonetheless, managing fatigue and alertness levels, advice on how to
this advice should be treated with caution because dark sleep better, recommendations for using naps effectively
glasses may reduce reaction times when driving and thus and on balancing work and home life. Many positive
potentially cause car accidents. changes could be noted. After the training, 77 % of the par-
ticipants described their general state of health as “good,”
Scheduling compared to 59 % before the training. Especially gastro-
In a naturalistic study by Juda, Vetter, and Roenneberg, intestinal diseases were significantly alleviated. Further-
shift workers were asked to complete the Munich Chrono- more, participants spent more time in bed. After the
Type Questionnaire for shift workers (MCTQShift) and intervention, they, on average, rested for 5.8 h compared to
the Sleep Questionnaire from the Standard Shiftwork 4.8 h before the intervention and their coffee consumption
Index (SSI). The results (length of sleep, social jet leg, and decreased. More than half of the participants recognized
sleep disturbances) were modulated by the respective changes in their sleeping environments and, in addition to
chronotype: e.g., “early-birds” had a shorter sleep duration that, the improvement of the sleep quality correlated with
Richter et al. The EPMA Journal (2016) 7:16 Page 8 of 11

higher alertness and safety. Results were quite positive and suffer from fatigue and insomnia often have no choice but
emphasize the need for specialized training and education to work when tired. Since insomnia can lead to depression
for shift workers. The intervention was also economically and metabolic diseases, effectively coping with insomnia
successful: it led to lower levels of turnover and, as a result, can help to protect mental and physical health [84]. In-
the employer saved $952 per worker. Additionally, $940 per somnia and fatigue may also have severe consequences
worker was saved by reducing absenteeism caused by ill- such as reduced work efficiency, work accidents caused by
ness. In total, the annual savings amounted to $1892 per reduced concentration, and absenteeism [27]. These con-
employee. However, only few companies involved the fam- sequences of overfatigue are last but not least accompan-
ilies of the shift workers in the training although it can be ied by financial costs and should therefore be avoided.
very effective to give them a better understanding of how The main reasons for fatigue associated with shift work
to adjust to a shift worker’s schedule with respect to the are the disturbance of the circadian rhythm, irregular in-
need for sleep, healthy nutrition, and the organization of terruptions of the sleep-wake cycle, and sleep loss [85], ac-
family activities [1, 69]. companied by other contributing factors such as lifestyle,
anxiety, or mood disorders [86]. Both specific professional
Cognitive and behavioral interventions groups and females (typically nurses) are particularly af-
Cognitive and behavioral interventions can also be useful fected by the effects of shift work and therefore need spe-
in coping with the effects of shift work [65]. Behavioral cial attention [44, 87, 88]. Fatigue in caregivers caused by
measures beyond improved sleep hygiene, such as exer- shift work can have drastic consequences for both workers
cise, can enhance sleep quality and combat insomnia and patients. Education on the hazards and causes of fa-
and excessive sleepiness [53]. Most effective are the opti- tigue must therefore be promoted for all care providers.
mal timing of work breaks, social activities during As described above, coping strategies to prevent fa-
breaks, and sensory stimulation, but those techniques tigue and insomnia may include scheduled napping, ex-
still have to be evaluated within a shift work setting [62]. posure to light at work, and special nutrition guidelines.
The post-intervention results of a study by Järnefeld and Especially bright light has proven effective to reduce
colleagues [71] showed significant improvements in self- both fatigue and insomnia [52]. Since there are several
reported (reported p = 0.002) and actigraphic (reported possibilities for the use of light in the workplace depend-
p < 0.05) sleep onset latency, self-reported sleep effi- ing on different shift schedules, there is still a lack of
ciency (reported p = 0.006), self-reported sleep quality standardized recommendations for light therapy. It is
(reported p < 0.001), and self-reported restedness (re- taken for granted that light in the workplace mitigates
ported p < 0.05) through cognitive-behavioral strategies. sleepiness, lifts the mood, and improves the mental sta-
In addition, the perceived severity of insomnia, sleep- tus in general. Effective use of light may even lead to an
related dysfunctional cognitions, psychiatric and somatic adaptation to the extended night work period and facili-
symptoms, and the mental component of health-related tate the subsequent re-adaptation to daytime life [89].
quality of life improved significantly. The improvements The outlined benefits of bright light in industrial settings
due to the cognitive-behavioral interventions were long- should be used widely to enhance the adaptation of the
lasting and even increased over the follow-up period. In human body to night work. Future research should fu-
general, participants had a significantly better sleep qual- ture research should canvass the genetic predisposition
ity on days off than on work days, but the treatment still for maladaptive circadian phase in night shift workers.
improved their sleep quality at any point in time.
Expert recommendation
Conclusions Each company that employs shift workers should gener-
Unhealthy working conditions may cause illness in em- ally provide knowledge and support and implement cop-
ployees if they permanently have to work under harmful ing strategies against fatigue and insomnia. Since there is
conditions. Guidelines such as the “Luxembourg Declar- a wide range of different rotating shift systems, these mea-
ation on Workplace Health Promotion in the European sures must be adapted individually in every company. The
Union” contain rules of conduct for employees and em- implementation of exposure to bright light is an effective
ployers. Employers should reduce risk factors at work measure, since it can be easily put into daily practice.
and strengthen protective factors which help to improve Companies observing these recommendations for their
or maintain the health of their employees [83]. Work- shift working employees in the future would take a major
place health promotion should uncover health-related risk step towards health protection and safety in the work
factors and inform employees about the link between life- place. We state that companies employing shift workers
style and the risk of disease in detail. This in particular af- should ensure optimal environmental and basic condi-
fects shift workers who suffer from fatigue and insomnia tions: a silent dark room as an opportunity for a nap, a
as part of a shift work disorder [5], because workers who pleasant and undisturbed surrounding for a healthy meal
Richter et al. The EPMA Journal (2016) 7:16 Page 9 of 11

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