Employee Sleep Promotion Programs in Workplace Settings: An Exciting,Viable Area for Lifestyle Medicine

Abstract

In the past several decades, our population sleep health has fallen short of recommendations. Moreover, there has been an increase in sleep difficulties amidst COVID-19. Work consumes a huge proportion of our waking lives, and the nature of our work can impact the quantity and quality of employee sleep. Conversely, employee sleep also matters for work-related outcomes as evidence demonstrates poor employee sleep health is associated with increased presenteeism, absenteeism, and health care costs. Given the prevalence of poor sleep health in our population, the changing nature of work and increasing demands on capped time, the worksite represents a promising and potentially underexplored venue for lifestyle medicine practitioners to consider employee sleep health and, where possible, novel employee sleep health promotion programs. This article outlines the impact of work on sleep and reviews the potential for incorporating sleep into lifestyle interventions in workplace settings.

“Insufficient sleep and untreated sleep disorders present significant work-related consequences, including lower productivity, presenteeism, and health care costs.”

Introduction

Insufficient sleep duration, poor-quality sleep, and untreated sleep disorders are increasingly common across the population, particularly among employed populations.^1-3 Unfortunately, sleep difficulties are associated with poor mental health,^4,5 obesity, ⁶ cardiovascular disease,^7,8 and workplace-related outcomes, such as workplace productivity. ⁹ The workplace is increasingly recognized as a viable location for lifestyle medicine approaches ¹⁰ ; yet, most of the published studies have focused on other domains than sleep. ¹¹ This article reviews the problem of poor sleep health in our society, the role of work in understanding sleep difficulties, and the opportunities for worksites to better promote employee sleep health.

The Problem of Poor Sleep Health in the Population

Insufficient and poor sleep are increasingly pervasive in the population. Over the past several decades, beginning in 1985 sleep duration at the population level in the United States (US) began a steep decline. ¹² Approximately 75% of adults in the US report insufficient sleep in the prior 30 days, ² and recent analyses of data collected among working adults in Asia show that average reported sleep duration in an employed population was 6.4 hours, ¹³ falling short of the recommended 7 to 9 hours for adults.^14,15

While sleep duration is important, sleep health is a multidimensional construct, and additional dimensions of sleep such as timing and satisfaction are important considerations and consequential for daytime alertness. ¹⁶ According to data collected form a nationally representative sample, 7 in 10 Americans reported that their sleep is not restorative. ¹⁷ Unfortunately, these issues are increasing in prevalence amidst the COVID-19 pandemic, which showed that nearly 40% of Americans reported insomnia symptoms. ¹⁸

Moreover, it is estimated that between 50 and 70 million Americans suffer from one or more of the over 90 differentially diagnosable sleep disorders; yet, many of those impacted remain untreated, leading the National Academies to term insufficient sleep and sleep disorders an unmet public health problem. ¹⁹

The Nature of Work Impacts Employee Sleep Health

While there are diverse, nuanced influences on our sleep, work is one contextual factor that presents important implications for employee sleep, health, and workplace productivity.^1,20,21 In a large study of adults in the general population, research found that those who report being employed were at greater risk for sleep difficulties than those that were not employed. ¹ Moreover, in the same study, work-related characteristics were significant predictors of sleep difficulties, including work content and work-related stressors. ¹

In addition to the content and stress associated with a job, additional aspects of work have been shown to impact employee sleep, such as work-to-family conflict, which refers to instances where work demands interfere with an employee’s personal life and ability to achieve work-life-balance. In a study of nearly 800 information technology workers, researchers found that each additional unit of work-to-family conflict was associated with 8 fewer minutes of nighttime sleep, and work-to-family conflict explained 16% of variance in insomnia symptoms. ²² In addition to workload, stressors within the work environment have been shown to relate to employee sleep, such as discrimination. Job discrimination refers to unequal treatment in the workplace based on race, sex, sexual orientation, or other factors. In a study of more than 25,000 employees, among those with insomnia symptoms, race-specific job discrimination was associated with a 37% increased odds of new onset insomnia. ²³

The work characteristic that has been shown to be particularly disruptive to employee sleep is shift work, or work that takes place outside the hours of 6 a.m. to 6 p.m. According to data collected from the Nurses Study II, nurses with 20 or more years of cumulative shift work was associated with a 40% increased risk of breast cancer. ²⁰ In addition, research has shown that men with a history of shift or night work faced an approximately 2-fold increased risk of prostate cancer. ²⁴ Given this and other strong evidence, the International Agency for Research on Cancer, part of the World Health Organization, declared shift work a probable cause of cancer. ²⁵

Employee Sleep is Consequential for Workplace Productivity and Other Work-Related Outcomes

Work and employee sleep have a bi-directional relationship such that work impacts employee sleep, but sleep also impacts an employee and their work-related productivity, among other domains. Research has demonstrated a u-shaped relationship between employee sleep duration and adverse work and health care outcomes. Specifically, presenteeism, absenteeism, and health care costs are significantly higher among employees who report sleeping less than the recommended 7 to 9 hours and among employees who report sleeping longer than the recommended duration (9 hours or more), as compared to those obtaining sufficient sleep.^26,27

Workplace safety is also jeopardized when employees are not obtaining sufficient sleep. According to a meta-analysis of published research, the risk of a workplace injury is 60% higher among employees who report sleep difficulties, compared to those without such difficulties, and 13% of all workplace injuries were attributed to sleep difficulties. ²⁸

Untreated sleep disorders impact employee sleep, health, and workplace productivity; yet, many of those with sleep disorders remain undiagnosed or untreated. According to a telephone survey, researchers found between 4% and 40% of a sample of reported symptoms of sleep apnea, but only 2% reported a sleep apnea diagnosis. ²⁹ In another analysis of Medicare beneficiaries, among those with diagnosed insomnia, only 22% received treatment for their condition, and treatment was associated with reduced risk of psychiatric comorbidities, including Alzheimer’s disease, anxiety, and depression. ³⁰ Research among employees in a health care system found that nearly 20% of participants received one or more positive scores on a rapid workplace-based sleep disorders screener, most were undiagnosed (>90%), and a positive sleep disorder screening result was associated with a 3.6-times increased risk of burnout. ³¹

Research has explored the economic impact of insufficient sleep and untreated sleep disorders. Research among employed adults with severe insomnia demonstrate significantly lower productivity and worse performance than those without such symptoms, costing an additional $1967 annually in terms of accidents, illness, and presenteeism (showing up at work but underperforming). ³² In the aggregate, insomnia symptoms and insufficient sleep duration among employees in the US extracts a 411 billion dollar toll on the US economy due to productivity losses, accidents, and injuries. ³³

The Promise of Worksites for Lifestyle Medicine Approaches to Employee Sleep Health Promotion

Worksites are promising avenues for lifestyle medicine interventions for several reasons. First, most employed adults spend a large portion of their waking hours working. ³⁴ During the time spent at work, there is tremendous potential for reaching employed adults with sleep health programming in this context. Second, work impacts employee sleep, particularly work that requires shift work (i.e., working outside the hours from 6 a.m. to 6 p.m.), presenting a moral and ethical imperative to support employee sleep health with resources, education, and sleep/circadian science-informed policies and practices (e.g., avoiding rotating shift schedules). ³⁵

Workplace-based interventions that include lifestyle medicine principles and behavioral targets are increasingly common. Research reveals that 46% of a nationally representative sample of worksites in the US reported some type of workplace health promotion programming for their employees. ³⁶ Unfortunately, fewer than 10% of these worksite health programs focused on sleep, and the employers that did focus on sleep were typically successful companies with a large number of employees and budgets for employee health programming. ¹¹ In a review of the published literature on workplace-based sleep health promotion programs, authors found that the types of programs were heterogenous, some focusing on napping while others on sleep hygiene, yet half of the programs identified achieved an increase in employee sleep duration among those enrolled in the employee sleep health promotion program. ³⁷

Several recent studies describe new and novel approaches to employee sleep health promotion. Researchers evaluated a sleep health promotion worksite-based program, specifically, an expert-led hour-long sleep health education program followed by access to a personalized sleep health coach delivered via a smartphone application (app) in a randomized controlled trial with 1355 daytime employees in a large health care system, finding that employees who received the sleep program reported longer sleep duration on work (intervention: 7.2 hours v. Control: 6.99 hours, P = .01) and free (intervention: 8.26 hours v. Control: 8.04 hours, P = .03), healthy sleep behavioral changes (e.g., less feelings of fatigue or sleepiness: OR = 1.30, P = .005; increased sleep consistency: OR = 1.40, P = .003; longer sleep duration: OR = 1.44, P = .001), lower health care utilization (RR = .81, P = .03), and fewer dollars lost due to absenteeism in the intervention compared to the control (dollars lost in the control: $478 v. dollars lost in the intervention: $475, P = .001). ³⁸ In another workplace health program, experts aided in the design of a curriculum to be deployed in a train-the-trainer model that included a half-day educational session with a workbook and goal setting exercises increased employee reports of longer sleep duration and higher sleep quality and reduced reports of anxiety, depression, and insomnia symptoms in a small within-subject pilot study with 55 employees. ³⁹

Taken together, employee sleep health promotion programs are far less frequent than programs addressing other lifestyle medicine domains, such as exercise or nutrition; yet, sleep health promotion is a promising approach for increasing sleep, mental health, and workplace productivity.

Conclusions

Work, including the nature of work, schedules, social support, and work-related stressors, impact employee sleep health.^1,3 Moreover, sleep disorders are common (∼20% of employed adults in a study of a large health care system in the US) and commonly undiagnosed or treated, but present a nearly 4-fold increased risk of burnout. ³¹ Insufficient sleep and untreated sleep disorders present significant work-related consequences, including lower productivity, presenteeism, and health care costs.

Sleep difficulties became more common among both employed and unemployed populations during the COVID-19 pandemic. ¹⁸ In addition, the nature of work is also shifting, presenting interesting implications for employee sleep. Before COVID-19, 24% of employees reported working from home, which has increased to 38% of workers in the US reporting working from home. ³⁴ On one hand, this transition might cut down on commuting time, but it also results in more work taking place in the home environment, which could result in difficulties drawing lines between work and personal time, such as time for sleep and rest.

Given the changing nature of work and increased prevalence of sleep difficulties in working populations and given that untreated sleep issues and disorders are associated with increased risk of poor health and reduced workplace productivity, there is an exciting opportunity for lifestyle medicine practitioners to focus on worksites as an ideal avenue for employee sleep health promotion programs. Recent evidence provides support for new and novel strategies, such as smartphone apps and train-the-trainer models for delivering sleep health education in worksites. ³⁹ There are also exciting evidence that these approaches not only improve sleep, but also improve mental health and workplace productivity. ³⁹

In addition to these published programs, there are additional opportunities for lifestyle medicine practitioners to explore that hold promise for sleep health promotion in workplace settings, such as the use of cognitive behavioral therapy, an evidence-based behavioral treatment with favorable outcomes for aiding in insomnia treatment. ⁴⁰ There has also been an explosion in the use of commercially available sleep trackers in recent years. In 2019, approximately 28% of adults in the U.S. reported using a smartphone app or device to track their sleep. ⁴¹ These technologies could be incorporated into employee sleep health promotion programs for initiatives, such as employee sleep challenges.