III. EXPLORATORY RESEARCH TARGETING SHIFT WORKERS

This section details the findings of Phase II of this project. In Phase I, qualitative research was conducted with two groups of drivers at risk for drowsy driving, (1) shift workers and (2) young men. This research revealed that shift workers appeared to be more motivated and ready to change their behavior related to sleep and the conditions that contribute to drowsiness and fatigue compared with young men. Therefore, shift workers were judged to be more likely to respond to an intervention.

The aim of Phase II research was to gather detailed qualitative information on (1) the nature of drowsy driving among shift workers, (2) the conditions that may contribute to drowsy driving, and (3) to explore potential interventions that may decrease the risk of drowsy driving. Shift work supervisors and upper-level human resource and safety managers were identified in Phase I as people who may exert some influence over the behavior of shift workers and these groups were included in the Phase II research discussions.

Potentially successful interventions with shift workers were identified through a search of the existing literature. The acceptance and utility of the proposed interventions were explored with each group. Group participants were asked to identify which intervention or combination of interventions might prove to have the most impact in reducing drowsy driving among shift workers and to anticipate potential barriers to successful implementation of each intervention in their workplace.

METHODOLOGY

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Shift workers and Shift work Supervisors

We conducted focus group research in Boston, MA on February 2 and 3, 1998 and in Atlanta, GA on February 4 and 5, 1998. The sites were selected according to the following criteria:

1. Geographic diversity.
2. High concentration of workers scheduled to be working at night (e.g., health care industry, manufacturing, hospitality industry, airlines, shipping).
3. High reliance on the automobile for transportation.
4. Urban, suburban, rural mix.
5. Existence of quality focus group facilities.

Participants

Two groups of targets were interviewed using focus group research techniques, (1) shift workers and (2) shift work supervisors. We conducted two groups on each night, one each of shift workers and shift work supervisors, for a total of eight groups. Each consisted of eight to twelve participants, recruited by field houses at each site. Each participant was a licensed driver. Most important, each participant has a history of driving while drowsy as evidenced by responding "Yes" to at least two of the following statements:

1. Have you ever fallen asleep or nodded off while driving?
2. Have you started to drive or continued driving an automobile when you felt very fatigued, drowsy or sleepy three or more times during the past year?
3. Have you driven an automobile after being awake for a period of eighteen hours or longer three or more times during the past year?

A copy of the telephone screener appears in Appendix D.

Most of the group participants were employed in blue collar labor, service (24 hour customer service), and health care positions.

In addition to the focus group interviews conducted with shift workers and shift work supervisors, one-on-one telephone interviews were conducted with upper-level managers. Previous focus groups identified the company management as one of the barriers to implementing potential intervention strategies.

Procedures

A moderator's guide was prepared to focus discussion on the topic areas to be covered. The guide included a warm-up and introduction, and in-depth discussion of various potential interventions to reduce the risk of drowsiness and drowsy driving.

Each discussion group lasted approximately ninety to one-hundred twenty minutes.

Subject areas discussed were:

• Problem Recognition
• Sleep Behavior
• Potential Intervention Strategies
• Communication Channels

The moderator's guide differed slightly for shift workers and shift work supervisors. Generally the discussion with shift workers focused on what the workers could do to make changes in their own lifestyle. The opinion of shift workers was also solicited about the type of interventions and support their employers could provide that would improve their working conditions. The discussions with supervisors were more focused on the opportunities for intervention or changes in the workplace environment or the effect of policies. A copy of the moderator's guide appears in Appendix E.

Upper-level Managers

Focus group interviews were not judged to be a feasible interview strategy for reaching upper-level managers. One-on-one telephone interviews were conducted with upper-level managers. Results from these telephone interviews are detailed in a separate section in this report due to the differing methodology.

One-on-one telephone interviews

One-on-one telephone interviews were conducted with upper level management during the month of April 1998. The purpose of the interviews was to determine (1) current levels of awareness of fatigue as an employee safety issue, (2) how that awareness could be most effectively raised, (3) the current state of safety-related policies and practices, and (4) what changes in the shift work environment could be made to prevent fatigue among workers and enable shift workers to get better quality sleep.

Participants

The interviewees were 15 managers whose organizations represented different types of environments, including hospitals, hotels, newspapers, airlines, factories, and a physical plant.

SUMMARY OF FINDINGS

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1. As noted in previous qualitative research, shift workers report less quality and quantity sleep (approximately 4 to 5 hours per night) compared with recommended amounts of sleep (approximately 7 to 8 hours per night). They also report difficulty in sleeping. Shift work supervisors report sleeping patterns and difficulty in sleeping consistent with those of shift workers.
2. Shift workers and supervisors recognize the potential for problems as a result of sleep deprivation. These problems include fall-asleep motor vehicle crashes. This recognition may be a general perception of the problem rather than something that they are actively thinking about or acting upon. However, awareness of the problem creates an opportunity for promoting a change in behavior.
3. Several potential interventions show promise to be acceptable to shift workers and supervisors and may have an impact on the drowsiness of the workers. These include:
   • Educating shift workers and employers about the importance of good sleep hygiene
   • Emphasizing the priority that needs to be placed on sleep Educating family members about the importance of sleep and providing tips on how to help the shift worker in their family get better sleep
   • Educating the shift worker about how to make changes in their life to improve sleep quality and get more sleep (e.g., sleeping prior to going to work, using strategies to reduce distractions during sleep)
   • Involving the worker in setting schedules so they can feel more control and flexibility to make changes in their behavior
   • Encouraging employers to provide the same services to night shift workers that are provided to day shift workers (e.g., open cafeteria, gym) and to schedule training and seminars during night shifts
   • Educating shift workers and supervisors on the importance of good environmental conditions such as Increasing the lighting and regulating the temperature in the workplace
   • Educating workers on the effects of a poor diet on fatigue and drowsiness and improving diet and food choices at the workplace
   • Educating shift workers on the benefits of physical activity for promoting quality sleep and maintaining alertness during wakeful hours and providing opportunities for workers to get regular physical activity, either on the worksite during breaks or apart from work and encouraging workers to take advantage of those opportunities
   • Changing policy regarding napping during breaks and providing areas to nap during breaks and encouraging workers to use their breaks
   • Offering courses in parenting skills, stress management, time management and conflict resolution.
4. Upper-level managers felt that education on the nature of the drowsy driving problem and tips to promote better adaptation would be the most effective intervention. They are supportive of promoting changes in the lifestyle of their workers, such as diet, exercise and increased sleep.
5. Shift work supervisors appear to have the flexibility to implement some of the interventions. They also appear to be motivated to intervene to keep their workers safe.
6. Night shift workers and night shift supervisors reported difficulty in receiving communications from management and often felt "out of the loop." Some reported that extra effort was required to stay informed, such as coming into work early to attend staff meetings.
7. Shift workers and supervisors had several excellent suggestions for methods of communicating messages about sleep hygiene, drowsiness and fatigue, and drowsy driving. These include:
   • Electronic mail
   • In-services or worker training
   • Updates or reminders during briefing at beginning of shift
   • Newsletters
   • In-house video monitors
   • Posters in the break room or next worksite exits
8. Family members represent an important point of influence in the sleep behavior of shift workers. They have the ability to make sleep during daylight hours go smoothly or create problems for the shift worker. They can also motivate shift workers to improve their sleep habits.

SHIFTWORKERS AND SUPERVISORS: DETAILED FINDINGS

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Problem Identification

Shift workers appear to be very aware of the problems of excessive sleepiness or drowsiness related to their shift work. They were ready to acknowledge that fatigue affected their personal life and their ability to drive. However, they were not ready to admit that their job performance suffered. Many participants had anecdotes of extreme drowsiness or tiredness while on the job or traveling home from their job. Most participants acknowledged having some personal experience with drowsy driving, such as falling asleep while waiting at a red light, head bobbing while driving, weaving in their lane while driving, and missing a freeway exit.

"My eyes are open but I'm not there."

Most of the participants readily admitted that drowsy driving could be a major potential problem for themselves and their co-workers. The supervisors also readily recognized the problem and seem to be very concerned about it. However, they felt powerless to address it. Some described situations where they had to violate company policy (i.e., no sleeping while at work) in order to keep their employees safe and functioning. Most had encountered employees sleeping on the job.

"Guy's snoring standing straight up."

Health care professionals, particularly nurses, represented a large number of the research participants and these people recognized the irony of the situation and conditions under which they were working.

"Here we are saving people's lives and we're putting our own people in danger."

Sleep Behavior

Shift workers reported that they tend to sleep on an irregular schedule and their sleep was dictated by other time demands. Sleep did not appear to be a high priority for most shift workers.

"Priorities keep you awake."

Very few shift workers or supervisors working the night shift among the participants of our

groups reported getting more than four to six hours of sleep on a regular basis during the work week. Many did not realize how much sleep they were actually getting until they were asked to think about it. At that point, they realized how little sleep they got and that it was typically poor quality sleep.

A common sleep pattern during the work week was falling asleep within an hour or two after returning home from work, sleeping for four hours and waking up in the early afternoon. Occasionally this sleep was supplemented with a 1 to 2 hour nap in the evening just prior to going back to work.

Many shift workers reported having a difficult time falling asleep. Various distractions such as daylight, increased temperature and usual environmental noises (e.g., traffic, birds singing) contributed to their difficulty in falling asleep. Some reported using alcohol to help them fall asleep, to varying degrees of success.

Shift workers also suggested that their younger co-workers were among the worst offenders of sleep deprivation.

"The younger people need sleep and they are the ones out being social."

A general observation by the researchers was that the participants who reported sleeping the late afternoon and early evening (prior to going to work) appeared to be better adapted to the shift work schedule. However, these workers also tended to have fewer family responsibilities.

Group participants appeared to fall into two categories with regard to their sleep behavior. One

group of people historically had difficulty sleeping (i.e., prior to starting shift work) or considered themselves to be light sleepers who require very little sleep.

"I sleep whenever I feel like I have to, to function well. I've never really had set sleeping hours. Four hours is the most I got anyways."

"I'm a night owl. That's why I prefer that particular shift."

"I think I've always been a night owl. It's hard to get to sleep and I don't sleep for long periods."

"I've always been a night person."

"The night staff are hard core night people."

The people that fit into this first group seem to have gravitated toward the night shift and appear to prefer the conditions of night shift work. This group seemed to get less than the average amount of sleep during the night shift and also encountered difficulties associated with sleep deprivation. Many of these people continue to face responsibilities that require their attention during the day (e.g., families).

A second group of people appear to have more difficulty adjusting to the night shift and did not appear to enjoy it . They work the night shift because of external motivating factors. Some are working on their education during the day, while others were creating more flexible time to take care of their children while their spouse worked during the day. Others were working nights for job advancement.

"I know it (working nights) is temporary. I have to climb the ladder within the company."

"I don't want to leave my kids during the day."

Many of the shift workers reported that they were good sleepers because they could "fall asleep right away" at any time. They did not recognize that this is a sign of sleep deprivation.

Motivations for Working Shifts

The participants readily offered reasons for why they like working night shifts. These reasons include:

• Pay differential
• Less traffic, ease in finding parking
• Greater ease in taking care of small children

  "I like to be there when my kids get home from school."

• No supervisors or upper level management on the night shift- less politics
• More flexibility with daylight hours
• Workload is less (in some work situations)
• Time goes fast
• More relaxed pace of work
• Quiet

  "You have the world to yourself."

Although these reasons are compelling and logical, it was not clear from the discussion whether these were conscious choices made by the workers to obtain this type of work situation or arguments to bolster or rationalize to themselves their current circumstance. Many of the shift workers seemed to be under the impression that night work gives them more time. They did not seem to recognize or directly link that extra time with overall less sleep or their own sleep deprivation.

The participants reported that the main reasons they disliked working the night shift were "staying awake," "being up all night," "being chronically tired" and "sleeping out of sync with the rest of the world."

Influence of the Family on Sleep Hygiene

Family members appear to have a great deal of influence over the sleep of shift workers. Many of the shift workers said that family was important to them and were motivated to work shifts to accommodate the needs of their family. Therefore, family members are well positioned to motivate shift workers change their sleep behavior.

"You don't want to let your family down."

However, in many cases the influence of the family has negative effects on the sleep of shift workers. They believed that working the night shift was more difficult for people with families. Many of the shift workers complained that family members often disrupted their sleep.

"My daughter hinders my sleep."

Disruptions to sleep ranged from people calling on the telephone or stopping by during regular daylight sleep time to children playing loudly or entering the sleeping room to ask questions.

"It's like if you get a call at 3am. They don't understand it if they don't live it."

In the groups there were a few examples of how family members can ease the difficulty of working night shifts. Good communication among family members appeared to facilitate adaptation to a night shift schedule.

"At my house we have rules. It makes it easier. They don't bug me and stay out of my room."

The shift workers who reported the best cooperation from family members were proactive in getting their help. Some said they enlisted their family members to help around the house with things like the cooking, cleaning and laundry.

"The most important thing (to getting sleep) is family and friends looking out, understanding the situation."

Reliance on Shift Work/Overtime to Maintain Lifestyle

As noted in earlier focus groups, many shift workers rely on the increased pay from working shifts and the availability of overtime hours to maintain a certain standard of living. It was also clear that many of the shift workers who did volunteer for overtime regularly were not eager to give up one of the few opportunities to make more money.

"It's always the same people volunteering for overtime."

A change in priorities (e.g., the importance of sleep, good health) prompted by education may be necessary before these workers begin to choose sleep over opportunities to make money. However, the supervisors indicated that the company actively encourages people to pickup extra hours and this seems to be an effective method for making sure the night hours are covered. Similarly, shift workers were motivated by the pay differential offered for working the night shift. The group participants were very quick to point out that although they knew that the extra money encouraged them to forego sleep, they did not want to lose the pay differential. Shift workers and supervisors were aware that their employees were working another job. They recognized that this can be a problem among night shift workers.

Interventions to Improve Sleep/Reduce Risky Driving

Education and Awareness

Many of the participants felt grateful for the opportunity to discuss the problem of fatigue and drowsiness related to shift work in the focus groups. In many ways discussing drowsiness and fatigue was cathartic. They were relieved that they were not alone in their experiences. They recognized drowsy driving and fatigue as a major problem for themselves and their co-workers, yet they perceived that few other people had interest in discussing the issue.

The shift workers and supervisors felt that educational interventions would be very beneficial. They suggested that in particular, class offerings on parenting, stress management, and time management would help to reduce the risks from fatigue and drowsiness.

Although both the shift workers and the supervisors had extensive experience with working shifts and sleep deprivation, they seemed to have a limited understanding of the effect of sleep deprivation on their health and the risks associated with chronic sleep deprivation. When discussing drowsy driving in the group, they admitted that they felt like they were on a dangerous course and if it continued they would have a problem.

"I know if I keep going I am going to crash."

Some talked about it with co-workers and felt that they were the only people who understood the problem. Most felt that their employer was not very concerned about the personal aspects of working the night shift to their workers. Even family members did not seem to be able to understand their predicament.

"(A big problem is) getting the rest of the world to respect that my day is your night."

The perception of the researchers was that the shift workers wanted others to recognize the special difficulties they have and try to empathize with them. They indicated that the process of other important people in their lives trying to understand would be an important first step in improving conditions and helping them to get more sleep. The participants suggested that if the company showed an initiative and demonstrated that it cares about its employees, the interventions would be more acceptable to the employees.

"They need to show that they care about us, not just the bottom line."

Many of the shift workers felt that management was in a position to promote positive changes for their sleep and it appeared that the initiative for a program may have to come from the company. Most of the group participants agreed, however that the motivation to change behavior had to come from themselves. The participants recognized that they were responsible for their personal behavior and lifestyle and conceded that things they did contributed to drowsiness. They seemed to push themselves to the limit of sleep deprivation and that sometimes they needed to regain perspective on their life.

"If you are falling asleep at the wheel, it's a wake-up call."

The challenge of a program is to catch the people before they reach this point.

Alcohol-Impaired Driving Comparison

One way to draw attention to the problem of drowsy driving is to compare the effects of driving while drowsy to driving performance under the influence of alcohol. The group participants recognized drunk driving as a serious traffic safety and health problem. Most of the participants responded very favorably to this comparison and in many cases felt that drowsy driving was worse or a bigger problem than drunk driving. The thought of having lots of other drivers on the road at the same levels of drowsiness they experience was frightening to the participants.

One participant reported that he had been pulled over by the police, who suspected him of driving under the influence of alcohol, when in fact he was simply very drowsy.

Comparing Chronic Sleep Loss to Staying Awake All night

Most of the shift workers and supervisors had extensive experience with chronic sleep loss and staying awake for periods greater than 24 hours. This comparison did not appear to be very meaningful or motivating to them or give them any information about the risks of driving.

Worker Involvement in Setting Schedules

Shift workers felt that there would be important advantages to their own lifestyle if they were able to participate with management and supervisors in the scheduling. This suggestion received very positive response from the shift workers. The shift work group participants felt that letting workers be involved in setting schedules would leave the impression that the company cares and makes the initiative. They thought it would make schedules more acceptable to employees and improve attendance.

"If they ask me, I'll probably give them twice as much as they expect."

However, many of the group participants recognized that total flexibility would be difficult to achieve from the perspective of the employer. Most doubted whether employers would be willing or able to allow flexibility. Others pointed out that union rules and seniority were important barriers to implementation.

Supervisors indicated that they were typically the person in charge of setting the schedule. Some of the supervisors said they took the initiative and involved workers in schedule setting on an informal basis and it seemed to work well. Many supervisors indicated that they were willing to consider personal requests when creating the schedule.

"You get better results when you do that."

In some instances, however, worker involvement was not practical. They said they felt uncomfortable doing it without the support of upper management. They also doubted that a formal system would work. This intervention may have to rely on the judgment of the supervisors.

Environmental Conditions in the Workplace

The participants were specifically asked about the effect of environmental lighting and temperature. Many participants reported that the lighting in their workplace was turned down during the night. This was especially true in health care settings where patients were asleep during the night. The health care workers reported that the lights were dimmed in non-patient areas (e.g., nursing station) as well.

The temperature in the workplace varied widely. Participants complained about extreme conditions (either too hot or too cold). These widely ranging temperatures may also contribute to general fatigue.

Many of the participants felt that regulating the temperature and increasing the lighting in their workplace would be helpful in managing their drowsiness. Others indicated that their workplace already used bright lights during the night shift and it seemed to help them to stay alert.

"Bright lights and cold temperature help you to stay awake."

Shift workers felt their employers needed to be educated on the importance of keeping the work area well lit and cool in order to ward off drowsiness. It was apparent that the night shift supervisors have some control over the lighting and temperature and they may be a good target for an educational effort. However many felt that they would need to discuss it with upper-level management before implementing it.

In addition, social support was viewed as an important part of the work environment. Many night shifts operate with a "skeleton crew" and workers who are on the job at night with no one else said they tended to get tired and drowsy. They suggested that another co-worker would help to keep them awake and alert.

Sleep Aids

The participants were asked what kinds of things they used to help get better sleep. Some of the participants reported that they already used some sort of sleep aid. Examples included darkening shades, fans or white noise machines, ear plugs and sleep masks. Others indicated that they had tried a few things on their own or through the recommendation of a co-worker. Among the participants who reported that they had tried "something and it did not work" it appeared that they did not persist in their efforts to make the intervention work. The participants reported that they had to experiment on their own with various things to keep themselves awake, each to varying degrees of effectiveness. However, many said they had not tried anything to get quality sleep.

"I didn't try anything. But I'm willing to try."

These observations suggest that a need exists for a systematic education about sleep aides among shift workers. Sleep aides appears to be one area that has promise for promoting better quality sleep in shift workers. Educating them about the various types of sleep aides, possibly using testimonials from co-workers who use the different aides or strategies, may increase the use of the aides and promote better quality sleep.

Diet

A poor diet was recognized as a common fact of shift work. However, the shift workers and supervisors did not consciously recognize the impact a poor diet may have on fatigue level. However, when prompted to think about it by the moderator, they did believe that it could have an effect on drowsiness on the job. After some thought, the participants recognized that the type of foods they eat during the night shift and the way they eat tend to promote drowsiness. High fat, greasy foods and a high volume of food were common, as was frequent snacking to "stay awake."

"Nurses eat a lot of junk food."

An educational program highlighting the drowsiness risks of a poor diet and support in the workplace with healthy food offerings, plus social support from co-workers may have a positive effect on drowsiness.

Another problem shift workers face is a decreased range of choices for food. Late night fast food and pizza places are among the few selections available during the night. Work sites that have a cafeteria open during daylight hours are closed during the evening.

"All we have are vending machines."

Physical Activity

Many of the participants recognized that physical activity is an excellent way to promote regular sleep. They thought it would make them feel better, help them get better sleep and give them more energy when they were awake.

Some participants said their workplace either had a gym on the premises or provided incentives or discounts to use local gyms. Several shift workers said they knew people who take advantage of the services either before or after work. Many also knew of co-workers who used their break time to go for a brisk walk. However, they did recognize that most employees do not take advantage of the opportunity to get some exercise. Few people seemed to do any exercise during the shift. Others said that the gym at work was closed during the night.

Walking during break times may provide an easy and inexpensive way to promote physical activity in the workplace. One important barrier to physical activity in the work area is having a safe place to do it. People are able to get outside and walk during the daylight, but few are willing to go out at night.

Napping

The topic of naps appeared to be somewhat sensitive to both the shift workers and their supervisors. They reported that it was sometimes necessary to stay awake and be productive at the job. However, they had to be secretive about doing it. Many of the participants reported that their company has a policy against taking naps during scheduled work times. This was especially true for health care workers (e.g., nurses and nursing aides).

"Naps are frowned upon."

Breaks and "lunch" periods were frequently used for napping, however, even in companies that had policies against napping. Both shift workers and supervisors reported that their co-workers napped in break rooms or other available spaces. Some even reported going out to their car in the parking lot to get some sleep.

Shift supervisors seemed to recognize that napping occurred among their employees and most seemed to understand the need for it to happen. For the supervisors that did not have a policy against napping, they accepted the employees who did it as long as the employee was responsible and got his or her work done. The group participants reported that they watch out for each other on the night shift and were willing to wake each other up after a nap during a break.

Several members of different groups suggested that the company provide a special room that was quiet where people could take naps. They also suggested that a sleep room would be good for people who want an opportunity to stay at work and take a quick nap before driving home.

READINESS TO CHANGE SLEEP BEHAVIOR

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In previous qualitative research we discovered that the shift worker target appeared to be highly motivated to change their behavior to get better quality and quantity of regular sleep. Many of the shift workers believed that drowsy driving was a problem caused by their chronic sleep deprivation. However, they seemed to be somewhat ingrained in their routine and did not stop to really consider the effects of their schedule or consider alternatives to improve their life. The process of engaging them in a discussion about the risks of drowsiness appeared to really get them to think about the issue of drowsiness and the risks it posed to their health.

After discussing the problem it became clear that in many cases the shift workers still offered many reasons why they stay awake and these reasons kept them from changing. A change in personal behavior will first require a careful consideration of the benefits they are getting from staying awake and a change in priorities.

It also appeared that shift workers were not ready to begin changing their sleep behavior on their own. Several potential motives were suggested, including family members, a tragic outcome to a co-worker or close friend due to drowsiness or fatigue, and the initiative of employers to promote systematic changes.

"Management needs to show the workers they know about the problem and that they understand and care."

PERCEIVED READINESS FOR EMPLOYERS TO TAKE ACTION

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Shift workers were somewhat cynical about the likelihood of employers initiating a program to help them with drowsiness and fatigue.

"If you forced senior management to work the 3rd shift, then you'd see a change."

They believed that the employer would tell them a program to improve fatigue would not be "in the budget." They also questioned the motivation of the employers.

"They just want to see you work like a horse."

"The employer is after the bottom line."

"If you don't do the work, they'll get somebody who will."

Mostly the shift workers did not feel they could rely on management to take care of their needs.

"We try to take care of ourselves at night."

A successful intervention by the employer will have to present it carefully to the workers and involve them to establish a level of trust with the workers.

Supervisors thought that the employer might respond to an economic argument for promoting sleep hygiene in their employees rather than their employees health. Supervisors felt that drowsy driving was a major potential problem for their workers, but they did not think that upper-level management had a sufficient understanding of the problem. They believed that educating them about the potential hazards would get the company to act.

Extra Hour of the Day

At the end of each group session, the participants were asked what they would do if they were given an extra hour in each day.

"I would sleep! No ifs ands or buts about it."

Many of the group members said they would use the hour to get additional sleep. However, an equal number said they would take the hour to do a variety of other activities, mostly recreational in nature (e.g., shopping, relaxing, spend with family). This finding suggests that although increasing the quantity of sleep that shift workers get may be desirable (shift workers tend to get an average of 3-4 hours less sleep than workers on other shifts), improving the quality of the sleep they do get may be more readily achieved.

COMMUNICATION CHANNELS

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Many of the group participants indicated that they would like to see an increase in the amount of time the electronic media devotes to the problem of drowsy driving. Some suggestions were news stories or news magazine programs.

"I notice that I really pick up on the stories about fatigue and drowsy driving in the media."

Most of the suggestions involved work-site communications such as posters in break rooms, brochures, tip sheets, payroll stuffers, newsletters, videos on safety monitors and safety meetings. The participants felt that meetings would probably be the most effective and they had the most enthusiasm for that method. Most reported that they had regular meetings prior to their shift with the supervisor and that would be an opportune time to discuss drowsiness and driving and ways to combat fatigue. They also suggested that special meetings during the work shift would be helpful.

Electronic mail also appears to be one very effective method for communicating brief safety messages. Many of the nurses who participated in the groups reported that e-mail was the most efficient way to reach them to deliver important messages. They recommended that the messages should be brief so they were not tedious to read in addition to all their other messages. E-mail messages should indicate where to go for further information.

MANAGEMENT: DETAILED FINDINGS

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Most of the participants stated that they had worked on a rotating or night shift at some point in the past. Two participants had noticed diminished capabilities and alertness while working on the night shift, and one was involved in a fall asleep crash.

Problem Identification

Participants were asked about the problems their company had to deal with in regard to shift worker sleepiness or fatigue. About half stated that they were not aware of any problems. The problems mentioned by the others were production errors, noticeable employee fatigue, difficulty adjusting to schedule after a day off, absenteeism, tardiness and complaints of schedule.

Current Company Policies and Practices

Participants were asked what safety or health issues their company had previously been involved with, specifically in the area of traffic safety. Five of the participants said that their company offered a defensive driving course. Other health and traffic safety issues mentioned were drunk driving, safety belt use, safety education, wellness credits, environmental concerns, motorcycle safety and ergonomics issues.

When asked about fatigue, 12 of the 15 participants stated that their company did not currently have any programs/policies in place to deal with this issue. One company does offer training in physiology, exercise programs, food, health club discounts and sleep hygiene. Another company has a fatigue countermeasure program in the airline pilot recurrent training program, which now includes flight attendants and simulator technicians. The company conducted shift worker/fatigue classes, and has started a countermeasure program that addresses what fatigue is and its symptoms; countermeasures include napping, food and exercise. Another company has a health center on site and provides sleeping tips in its wellness program.

Next, the participants were asked about the decision making process and flexibility of their company's policies. Almost every participant said that decision making starts with the safety department or human resources and then goes to senior management. One respondent said that each individual plant has flexibility in decision making.

Intervention - Policies/Practices

The participants were asked to explain how changes in their company's policies/practices were made. Many companies have a safety department that will review policies/practices and will make recommendations to human resources or senior management. One company has a safety suggestion box where employees can place their comments and have them reviewed by the safety committee.

Next, the participants were asked what evidence or information would be needed to stimulate change in their company's policies/practices regarding shift worker sleepiness in the workplace. The managers stated that accidents, excessive use of health benefits, absenteeism, decreased productivity and employee suggestions might stimulate change in company policies.

When asked if evidence that more/better sleep produces a better quality of life for employees would be more or less likely to stimulate a change, the majority of participants stated that yes, it would. Five participants said that it would not, or would be unlikely.

When asked if evidence that more/better sleep increases productivity, morale, quality of work, and retention on the job would be more or less likely/effective to stimulate a change, all but one of the participants said that it would. One participant remarked that the company cannot dictate personal practice.

Next, the participants were asked if evidence to the cost-of-injury employers sustain when an employee is injured in a motor vehicle crash whether on-and off-the-job and how this cost cuts into the bottom line of company profits would be more or less likely/effective to stimulate a change. Ten of the respondents stated this issue was very important and likely to stimulate a change. Three of the respondents felt that the evidence would be looked at. Only two participants felt that this issue would not likely stimulate a change.

When asked if evidence to the cost-of-productivity losses would be likely to stimulate policy/practice change, all but one of the managers said that they felt that it would.

The participants were then asked if they felt specific case studies from other companies' experiences would be likely to stimulate change. All of the participants felt that this would be likely to stimulate a change.

Participants were asked what of all the reasons discussed would encourage their employer to make a change in their corporate policies/practices regarding workers sleepiness in the workplace. Most participants felt that costs and productivity would be the most important determining factors in making a change. Quality of work, crash statistics, morale, and case study evidence were also mentioned as reasons.

Intervention - Employee Awareness

Next, the participants were asked what could be done to increase awareness among their shift worker employees about the importance of getting enough/better sleep to increase performance and safety on the job and while driving. Most managers believed that education programs would increase awareness. Other more tactical ways of increasing awareness that were noted were through e-mail, bulletin boards, materials distribution, lectures and supervisor training.

In previous discussions with shift workers and front line supervisors, there were a number of interventions they thought employers could do to encourage proper sleep habits and to reduce the risk of their employees from drowsy driving. Such interventions include:

• Installing bright lights in the work environment and encouragement to shift workers to darken their room during daytime sleeping hours.
• Making certain supplies/equipment available (or more affordable) to shift workers like darkening shades, white noise machines or ear plugs that would help the employee get better sleep during daytime sleeping hours.
• Allowing shift workers to be involved in setting work schedules in order for them to have a better acceptance of their schedules and better control over their lifestyles.
• Providing education on how moderate physical activity and eating low calorie, non-greasy health foods can help people to get regular sleep and maintain alertness.
• Making a place available for employees to walk/exercise prior to work or during breaks (whether on company property or financial supplement at a local gym).
• Increasing the availability of healthy foods on the night shift.
• Allowing shift workers to sleep/take naps on lunch or breaks and provide a quiet and safe place for them to take these naps.

The managers were asked about their level of interest in the suggested interventions and which ones they felt would be effective and would receive company support.

Installation of Bright Lights

Overall, most managers felt that companies provided adequate lighting at all times. The participants who worked in the health care field said that the lights were turned down in the evening for the benefit of their patients. One participant in the health care field felt that the company would look at installing brighter lights in the nurses stations if there was evidence to support that bright lights were beneficial. One company had recently increased illumination in break rooms, reservation areas, and on the shop floor.

Availability of Sleep-aid Supplies/Equipment to Shift Workers

This idea didn't generate much interest. The majority of the participants felt that this idea would not be supported by companies because of cost issues, even if proven effective. Two of the participants did say that their company supplied earplugs and one said the company may support if there was a demonstrated correlation with productivity.

Allowing Shift Workers to Be Involved in Setting Work Schedules

Self scheduling was allowed to some degree by a slight majority of the companies. Self scheduling did not seem to be a problem with most companies as long as the work was covered. Union contracts were mentioned as a limitation to flexible scheduling. Two of the managers said their companies would not allow flexible scheduling because of production needs.

Education on Physical Activity, Nutrition and How it Effects Sleep/Alertness

This idea was well received. Several companies are already providing this kind of information to their employees through e-mail, bulletin boards, newsletters, handouts in cafeteria, and wellness programs.

Availability of Safe Walk/Exercise Area

About half of the managers said that their company offers a gym or walking facility, but only two of them said they were opened at night. Others said that their company might look at the idea. Some participants raised concerns about security at an on-site exercise facility.

Increasing the Availability of Healthy Foods on the Night Shift

All but one of the participants stated that their company provided food during the evening. Most of the companies had vending machines that offer a wide variety of foods, including health foods. Five of the managers said that their facility has a late night or all-night cafeteria.

Sleep or Napping During Break

Most companies do not have a formal policy dealing with this issue. Three managers said that napping/sleeping while at work was against company policy. A few managers said that napping does occur, although the companies provided no place to rest. Three managers said that sleeping does occur in staff lounges.

Management/Company Support of Suggested Interventions

Education, nutrition, and exercise are the interventions most managers believed would be most effective and receive the most company support. Napping on breaks and lighting were also mentioned as being effective interventions. Scheduling and child care were also noted, but to a lesser degree.

Next, the managers were asked how much freedom/flexibility front line supervisors have in adopting practices to accommodate the needs of shift workers. Most managers felt that they had some level of flexibility of minor practices when it came to accommodating shift workers.

Wrap Up

Next, the managers were asked if they had any additional or final ideas that they believed would help companies assist corporate support for shift workers to get more/better sleep. Most participants felt education through literature and videos would be most helpful. Other ideas mentioned were staff meetings on the issue, 24 hour confidential help line, carpooling, family education, and one-on-one discussion of topic.

MANAGEMENT: SUMMARY OF VERBATIM RESPONSES

[Rtn to TOC]

Shift Work Experience

• Little or no personal shift experience.
• 30 years in industry; yes, had shift experience - all 3 shifts, advanced forward; crashed on motorcycle - fell asleep at 70mph!
• Was nurse years ago rotated all 3 shifts; hospital now rotates 2 shifts, allows permanent shifts, much flexibility.
• Brief experience, swing shift.
• Former police officer on all shifts.
• Yes, 2:00 p.m. to 10:00 p.m. or 12:00 midnight shift in college days.
• No shift work, but is a paramedic who does work some nights - on-call basis; aware of diminished capability, alertness, etc.
• Worked as a nurse 4 years on night shift.
• Yes, worked as nurse, all shifts; tired constantly; driving impaired.
• Yes, evening shift.
• Have 400 employees; 300 on 2nd or 3rd shift, mostly janitorial workers; he monitors all shifts and meets with all shifts; has seen accidents of all sorts including sleepiness/fatigue.

Problem Identification

• Yes, flip-flop shifts 3 days on or 4 on; production errors on day 1 after break; sleep and sleepiness complaints.
• On-job had large bridge cranes, hundreds of forklifts; had mishaps of all sorts, crashes on road, not easy to determine causality.
• Not documented. Personal experience stays within department; addressed privately if at all.
• Have problems with part-time employees who may have other jobs. Employees in several categories; press operators (are full time), mail room/distribution; part-timers with other jobs - hard to control fatigue; drivers part-time, may have other jobs; have had accidents on road.
• No driving problems known of, but nights are least productive time of day.
• Had instances of supervisor asleep on break! Schedules can flip-flop on annual basis. Company imposes mandatory overtime on some employees, can work 14 days straight!
• Problems driven by union contract - low overtime people get first choice on overtime; 4000 people hard to track fatigue-related problems; set shifts until they bid for new shift.
• 24 hour operation, rotated 4 on 3 off or 3-4 12 hour shifts, 4 different shifts; new people tend to go on nights, but some prefer nights; remote plant, no highway crashes known of; have had physical problems manifest on return to work from day off; complaints e.g., can't sleep, disoriented; production problems can result.
• Few problems, if any.
• None aware of.
• None reported; staff reports exceeding tiredness, traffic accidents have not been reported to her.
• Absenteeism, lateness, health problems; complaints of schedule.
• Some employees live as far as 50 miles. University has vanpool program with designated driver (done for fuel savings) but driver as fatigued as anyone. Finding workers asleep is a big problem; send home as policy. 10% - 25% of workforce cannot seem to adjust to 3rd shift.
• Have not identified as problem, but tough to get data on.

Current Company Policies and Practices

• Push belt/restraint use, some drunk driving; belt use required on job driving; driver pledge - awards given.
• Conducted all types of safety training and health, including NSC materials and defensive driving course.
• Not for employees, have accident prevention team for children. Active in Safe Community Program, safety education - diseases, violence, etc.
• Corporate safe driving policy, qualification and re-qualification, check insurance and driver history (hampered by driver confidentiality act 1997); drug screening after accidents; use Smith safety system - copyrighted commercial system; videos; designated driver trainer for truck drivers in one paper.
• Offers NSC defensive driving class, require 3 hours if drive company vehicle; subsidize full course if employees want to take it - get insurance discount; require seat belts; hazard safety training.
• Power and industrial vehicle safety program; nothing on on-road vehicles. Get wellness credits towards benefits for health behaviors, company policy for belt use on job.
• Traffic safety - none. May be a policy on belt use; lacerations & strains biggest problems - most cluster at 5:00 p.m.; have an older workforce.
• Company puts on campaign at health fair, including MADD, all issues; chemicals, environmental concerns.
• Not traffic safety, take flight crews to airport; back injuries - training. Belt use required for drivers.
• Hazmat, worker safety, ergonomics. Defensive driving NSC course required for hospital drivers, course offered to other employees at discount.
• Have community education department has covered health safety, motorcycle helmet, belt laws, child seats; safe driving history checked for company drivers; ergonomics via OSHA; back injuries number one issue.
• Not traffic safety. They conduct shift worker/fatigue classes, look at scheduling; 1 vs. 2 week rotations, forward rotations used; have unionized work force; pilot fatigue - started fatigue countermeasure program that addresses: what it is, symptoms, countermeasures including napping, foods, exercise.
• Have had bulletins and information on drinking and driving; signs on buckle up at parking lots exits; belt; ergonomic issues - education program. Union shop formed committee to review ergonomic issues.
• University provides transportation to employees for emergencies to encourage car pooling; policy if impaired send home; truck services group have special rules regarding pedestrians; blood borne pathogens is another safety issue.
• Workers comp issues; ergonomics; driving on job. Policy to buckle up, do follow-up surveys; vehicle training use NSC utility drive program - 3 hour course.

• No policies.
• Over-the-road drivers subject to DOT regulations; no other programs. Workers must declare prescription use and get approval from a doctor.
• Training given in physiology, exercise programs, food, health club discounts, sleep hygiene.
• None, can refer to Employee's Assistance Program.
• Interested in issue, but have no personal program; looking at retinal reflex system for driver alertness.
• None. Employees are disciplined if found asleep on the job.
• Work fatigue is muscle related, not sleepiness; no limit on number of straight days work; can work 14 days straight with mandatory overtime on 1 & 2 shift.
• No. Overtime solicitation is a problem. Union agreement; people want overtime.
• Health center on site, full medical facility has gym with equipment, have classes, instructors, sleeping habits tips provided in wellness program.
• Not traffic safety; do take flight crews to airport; biggest problem - back injury. Training used to address.
• Yes, fatigue countermeasure program in pilot's recurrent training program, now flight attendants are included as are simulator technicians.
• No, not an issue; experimenting with 4 day 10 hour shift for better service, less fuel use, parking and safety to minor extent.

• Safety officer generates ideas, then raised to executive committee - upper management attorneys.
• Plant level sets policy. This was flagship plant; had much autonomy from corporate headquarters.
• No policies on sleep/fatigue driving. Human resources department administration can make changes. Procedure: safety committees/safety manager, then to senior management. Safety manager sets safety policies as guidelines. Each company unit is autonomous; request review of labor relations, human resources.
• Human resources committee; first line supervisors have discretion.
• Goes through human resources or safety department subject to review. Pretty flexible.
• Little safety policy on corporate level; plants have all flexibility.
• Risk management, human resources; raise to senior management. Limited flexibility.
• Three areas of policy at hospital: administrative policies - administrative studies; clinical studies regarding patient care; and department specific studies, e.g., nuclear medicine. Thus depends on issue: most sleep/fatigue issues would go to administrative level.
• Corporate policy delegated to departmental level, e.g., flight services department; flight or field services; policy idea might start with manager, employee, then to field services.
• Very limited flexibility; when issue raised, investigated, safety department review; VP manufacturing review then to company president.
• Established safety department for all university 6 years ago. They keep accident records and reports; are independent but by removing from his department, caused less safety concern in his department, but helpful to university overall. To fill gap in his department, formed safety task force looks at day to day issues; publishes manual on safety practices and issues, publish safety gram for employees, video provided for training/information system vice chancellor is top decision maker.
• Because the corporation has 20 clusters of semi-autonomous management, it is hard to generalize; ideas usually come from the corporate safety office as advisory in nature or can bubble up to each cluster management structure.

Intervention

• Initiated by safety officer, human resources department; plant "teams" or special study, then sent to the executive committee (company self-insured).
• Workers or union raise issue or anyone - plant management was receptive.
• Identify problem, take to safety committee. Can make changes in own department.
• Depends on problem relation to size of problem, workers comp., costs; fatigue problems do not show in this measure, more in lost productivity, errors; can be conflict with other organizational units - is barrier; divisional managers around country can initiate action on own semi-autonomous.
• Every three years all hospital policies are reviewed by hospital accreditation committee; whoever owns policy initiates changes or updates; employees or supervisors can initiate suggestions to appropriate committee, e.g., human resources.
• Start with him then to health and human resources, safety committee of employees; then to senior management.
• Safety office would work with union safety representatives, then review with human resources and union bargaining committee; if no contract, then safety department review by plant manager.
• Individual employees can initiate, as well as safety department. Staff at property, then up the chain.
• Usually initiated by environment, health and safety department; reviewed by health and safety committee. Vice presidents, doctors and administrators are members. Ideas can emanate from any department up the chain.
• Through formal safety committee from accident & incidents; could come from employees; would contact safety director or risk manager; could go to unions and labor relations committees - employees have raised issue of 8 vs. 12 hour shifts. Employees wanted 12 hour shifts for lifestyle reasons, but hospital kept 8 hour shifts because of safety concerns, but some areas did go to 12 hour shifts.
• Corporate policy a departmental one, e.g., flight services department; flight or field services; policy idea might start with manager, employee, then to field services department, human resources and other effected units are involved.
• Very limited flexibility; when issue raised, investigated. Safety department review, VP manufacturing review then to company president.
• Have safety shopping list, e.g., proper wearing of equipment. If have good idea, take to shop safety representative, have safety suggestion boxes; take to safety committee. Could do full study if appropriate; take to director of physical plant; put in safety procedures manual.
• 20 cable systems across US very decentralized, therefore varies with policies. Ideas could begin with safety coordinator for cluster then to safety manager for technical input, then to cluster management for approval.

What evidence or information would be needed to stimulate change in your company's policies/practices regarding shift worker sleepiness in the workplace? (Probe for unaided response, then discuss the following:)

• Would evidence that more/better sleep produces a better quality of life for employees be more or less likely/effective to stimulate a change?
• Would evidence that more/better sleep increases productivity, morale, quality of work, and retention (less turnover) on the job be more or less likely/effective to stimulate a change?
• Would evidence to the cost-of-injury employers sustain when an employee is injured in a motor vehicle crash whether on- and off-the-job and how this cost cuts into the bottom line of company profits be more or less likely/effective to stimulate a change?
• Would evidence to the cost-of-productivity losses be more or less likely/effective to stimulate a change?
• Would specific case studies from other companies' experiences be more or less likely/effective to stimulate a change?

• Accident problem.
• Suggestions okay, good ideas are welcomed. If supervisor have employees in accident.
• Accident statistics, absenteeism, excessive use of health benefits, use of prescription medications (problems with over the counter medications). Hard to monitor OTC drug use, productivity, quality of work, meeting deadlines.
• Go to human resources committee; discuss financial and other impact, draft policy for review by department heads, then to hospital VP.
• Talk to employees, get information, work with employees, document. Cost of sleep loss in other companies. If cost implications, more documentation.
• Company has complex shift options, a-d, have recently started e&f shift which allows weekends off every other week; came from employees idea, with pros & cons evidence.
• Evidence of increased losses, retention problems.
• Nursing probably most affected group. Have to show evidence of benefit. If it effects bottom line, need data, would support if numbers are there and what the community standard among other hospitals is.
• Document problem; have local sleep deprivation clinic at BroMenn Health Center Hospital. 5 - 6 years ago had breakfast presentation at clinic; had one employee go through it, self referred, very helpful.
• Would first look at state or federal OSHA regulations, but hard to regulate personal habits. One reason is that people hold other jobs for child care or extra money, then work for him on 3rd shift.

Quality of life

• Yes.
• No.
• Unlikely.
• Maybe, CEO health oriented.
• Would look at.
• Yes and no, depends on cluster. Health and off job behavior is a voluntary employee fitness issue.

Productivity

• Yes, more important.
• Major issue.
• Yes, could if numbers.
• No, cannot dictate personal practice.
• Must demonstrate value. Even one costly incident could stimulate change.

Cost of injuries to employers

• Yes, very important.
• Yes.
• Probably not.
• Would look at.
• Would get attention, but needs supporting evidence.

Cost of productivity losses

• Yes, important.
• Major, but data is softer.
• More likely.
• Some influence because hard to detect.
• No.

Specific case studies

• Persuasive, especially if from similar industry.
• Yes, helpful; case studies were reviewed.
• Yes, on job case studies effective; are used in other areas, e.g., blood-borne pathogens, etc.
• More likely to help; reviewing navel safety center fatigue work.
• More likely, haven't seen case studies on fatigue or drowsy driving. Yes, e.g., ergonomics case studies.
• Have some effect, some literature from insurers. Yes, get OSHA, articles.
• Have looked at, but company specific data is most important. Would publicize; case studies are in trade magazines.
• Yes, APA American Physical Plant admin. publication.

4b.  What of all the reasons discussed would encourage your employer to make a change in their corporate policies/practices regarding workers sleepiness in the workplace? Why?

• Productivity.
• Productivity and costs.
• Bottom line costs, injuries.
• Cost savings most important.
• Productivity and quality of work.
• Productivity, crash statistics (but accident reporting systems inadequate).
• Productivity and morale.
• Case study evidence.

4c.  What can you do to increase awareness with your shift worker employees about the importance of getting enough/better sleep so they perform their best on the job and to ensure they are not a safety risk on the job and while driving? (Probe: If they feel they can't do anything, then ask if not them, who could?)

• Educate employees on sleep hygiene practices, eating sleep aids; company uses "target vision" in-house TV monitors.
• Varied by supervisor, but most were pro-education; safety crew meetings used, video good idea, union and supervisors were involved.
• Supervisors can and should educate their own people.
• Provide information on issues relating to sleepiness, sleep hygiene. Front line supervisors need to be properly informed to intervene.
• Self awareness, e.g., allowing naps; small percentage of total workforce are night workers; not his primary responsibility.
• Conduct awareness program through associate meetings, signs, bulletin boards, in safety committee, team meetings.
• If had statistics, put in newsletters, give to safety deputies in each department; work with second and third shift management.
• Provide education via company e-mail system, department meetings, shift meetings, company newsletter, bulletin boards.
• Quarterly newsletter, shift work a focus on next issue; kitchen at night; get coupons for accident free week.
• Mandatory education on entry, annual education refresher training, lectures, newsletter bimonthly to all employees; in-house video; review modules used for annual re-certification are very popular, many computerize.
• Start awareness campaign; reach employees at their level, go to each department and make it relevant, in-service training; add newsletter information.
• Education, education. Educate management and employees, form task force to advance ideas.
• Make information available; use bulletins company wide; monthly in-plant factory newsletters; quarterly paper to entire workforce.
• Improve training (2 week) have safety module; could include information on fatigue/safety; use safety task force - monthly emphasis.
• Education, research; gather information on subject; newsletters, internet e-mail, payroll stuffers.

4d.  In previous discussions with shift workers and front line supervisors, there were a number of things (interventions) they thought employers could do to encourage proper sleep habits and to reduce the risk of their employees from drowsy driving.

Such interventions include:

1. Installing bright lights in the work environment and encouragement to shift workers to darken their room during daytime sleeping hours. What is your level of interest in this idea? Would it be effective? Would your company support it? Why or why not?
   • Yes, in use.
   • No special bright lights for night shift, did cut down incidents when plant went to sodium lamps.
   • Not done, turn down lights. Yes, company would support if case studies or other evidence demonstrate benefit; could implement in hallways and at nurses stations.
   • Keep it bright all day, no change at night she is aware of; color of light important in color printing.
   • Effective but tough to apply in this environment. Some areas would work, need to assess impact on patients.
   • Very well lit same around the clock; could encourage better sleep hygiene ideas through education.
   • Looking at re-lamp effort, not aware of role in sleepiness, constant level; sleep hygiene education important but not done.
   • Light level stay same; company might be interested in safety benefit.
   • Stay lit all the time.
   • Would look at but some areas can and cannot do; staff decreases light in some areas.
   • Seasonal effect in NE USA - staff gets better sleep in winter because darker, when sunny they don't sleep but play - strong environmental effect; do not keep standard sleep practices; don't understand importance of sleep hygiene; lights are dimmed at night for patients; now with workplace violence problem, it would be good to tie these two together, but need to be careful of adverse health effects of light flicker at higher luminance levels.
   • Have done, increase illumination in break rooms, reservation areas, on shop floor.
   • Provide adequate lighting same always.
   • Yes lights effective. Custodians turn on lights when work.
   • Constant light in call facilities; would not be likely to change. Have many different environments from on road line repair crews to office help.
2. Making certain supplies/equipment available (or more affordable) to shift workers like darkening shades, white noise machines or ear plugs that would help the employee get better sleep during daytime sleeping hours. What is you level of interest in this idea? Would it be effective? Would your company support it? Why or why not?
   • Would look at, but not likely - cost issues.
   • No, not likely. We do give out earplugs.
   • No, would not.
   • Earplugs available on job. Company would not support - cost issue.
   • Employees were trained on sleep hygiene issues; earplugs made available.
   • Don't do. Maybe if shown effective, but company not in business of home furnishings.
   • He uses; question of priorities, not likely to be adopted.
   • Personal choice, not at company expense.
   • Effective but company wouldn't support, might help get reduced cost through volume buying.
   • Can't even buy recognition pins; tough to get money.
   • If demonstrated correlation with productivity.
3. Allowing shift workers to be involved in setting work schedules in order for them to have a better acceptance of their schedule and better control over their lifestyle. What is your level of interest in this idea? Would it be effective? Would your company support it? Why or why not?
   • Partially done -/+ 1 hour shift in schedule start allowed.
   • Yes, much latitude allowed as long as job was covered.
   • Have self scheduling within departments. Is working and popular; within limits, i.e., keeping work coverage.
   • Not done, good idea; divisional managers would support on a location by location basis.
   • Supports; flex scheduling allowed, as long as work is covered.
   • Would look at, but would be big change. Company probably would not support.
   • Assembly line, no flexible shifts.
   • Yes, done.
   • Not done, senior employees get better shifts.
   • To a point; flex shifts allowed on a unit by unit basis depending on function.
   • Needs to be done in conjunction with unions and management. No flex shifts allowed.
   • Some individuals have, but union contracts constrain flexibility; shift scheduling is addressed on a department by department basis.
   • No, is union seniority shop; senior employees bid best shifts; no flex time, set time because of production needs.
   • Yes, very important. Have flex shifts; some front line supervisors support and some don't, hard to get all supervisors to be flexible; considering experiment at one site allow total flexibility (U. of MI tried) even task flexibility at 24 hour facility.
   • If job can be done; some flex shifting to a small degree.
4. Providing education on how moderate physical activity and eating low calorie, non-greasy, health foods can help people to get regular sleep and maintain alertness. What is you level of interest in this idea? Would it be effective? Would your company support it? Why or why not?
   • Interested - could use programming for Target Vision system.
   • Yes, was part of plant education program.
   • Nutrition department sends out information, recipes, but not focused on sleep and driving.
   • Important, would be well received. Not sure if information is distributed, probably by human resources.
   • Done through staff bulletins, newsletters, wellness program for entire workforce; probably least recognized understood by night shift workers.
   • Interested. Would support as part of wellness program.
   • Could be done, have fitness center at local hospital, seminars; could add if he requests.
   • Yes, done via company newsletter; cafeteria has healthy foods, but not focused on sleep benefits.
   • Not considered but probably would. Very feasible, done on limited basis through wellness program.
   • Important, would support. Recent e-mails from nutrition service, part of health promotion, but not linked to sleep.
   • Yes, cafeterias post information; special classes for work groups.
   • Health insurance company sends out information on this, does address sleep.
   • Against Wisconsin culture - bratwurst, cheese and beer, bring own food.
   • Yes, would support.
5. Making available a place for employees to walk/exercise prior to work or during break (whether on company property or financial supplement at a local gym). What is you level of interest in this idea? Would it be effective? Would your company support it? Why or why not?
   • Walking tracks laid out in some plants/parking lots; supplement club memberships.
   • Arranged for on-job exercise program/aerobics and training back in 1970s; very popular because of attractive instructor, discontinued eventually.
   • Have gym but closes at 8:00 p.m., opens at 7:00 a.m. Workers would have to use at end of shift; but do have daytime programs; swimming, aerobics, etc. Shift breaks so short (15 minutes) can't exercise except walking the halls or stairs.
   • Mixed reaction. Done at corporate headquarters and at major facilities with large number of employees. Walking facilities not common; may not be practical due to security issues.
   • Have program with gym, not on site, security issues. Gym opens at 6:00 a.m. Could be used then.
   • Would look at; saw Boeing's walking facility, would be a morale boost; some employees do walk, but not the safest area; could get wellness credits; might supplement gym membership.
   • People do walk during first shift outside plant; fitness center opens at night, 8:00 p.m.
   • Have company gym, free, with classes. Have jogging path, can walk outside.
   • Not considered, wouldn't. Gym for the guests.
   • Would consider, but night shifts have limited time away.
   • Issue recently raised, local health clubs have offered discounts, is feasible; employees do use stairs and hallways for exercise.
   • Offer discounts for purchasing equipment or health club membership, underground tunnels marked for walking at headquarters; in terminals map off.
   • Have in-plant walking area that employees use; used to supplement health club, not sure if still do.
   • Suppose to be moving during work.
   • Have hiking trails, running paths on campus, exercise facilities in large facilities; Zen garden at California. Call center!
6. Increasing the availability of health foods on the night shift. What is your level of interest in this idea? Would it be effective? Would you company support it? Why or why not?
   • No cafeteria, vending machines only. Most people brown bag it.
   • Yes, all night cafeteria at one call center.
   • Have vending machines, would look at better foods. Employees have raised issue.
   • Cafeteria or vending machines in all plants. Range of food available, but fatty southern is preferred. Full employee physicals required.
   • Being done; cafeteria open. Have questionnaires on food preferences.
   • Most newspapers have some facility/cafeteria; will look into.
   • Have vending program with healthy foods.
   • Cafeteria open until 2:30 a.m., 24 hours for drinks, fruit free.
   • Would entertain; cafeteria open on limited basis. Vending machine filled with cafeteria food.
   • Yes, have cafeteria, room service for employees on day, evening. Nights go to a cafeteria window for food of all types.
   • Yes, gone to health food in vending machines, some cafeterias open at airports.
   • No food available.
7. Allowing shift workers to sleep/take naps on lunch or breaks and provide a quiet and safe place for them to take these naps. What is your level of interest in this idea? Would it be effective? Would your company support it? Why or why not?
   • Allowed on breaks. No formal policy.
   • Break time is their time. Can do, not against policy, occurs in staff lounges.
   • Prohibited, some probably occurs. Would take change in company policy.
   • No naps, against policy. In smelter not possible - breaks done on person to person relief basis.
   • No formal hospital company policy. Unofficially, it occurs, but only 15 minute breaks and � hour lunch.
   • Not done except for physicians; not for others. Would need proof of cost effectiveness for others, e.g., nurses to do; no policy against.
   • Not likely, no formal policy. Some may do, but no place to sleep.
   • No, not considered, want guests to do the sleeping.
   • Might be receptive. No policy on it; problem is skeleton staff at night, hard to get full breaks to eat, much less sleep.
   • Certain work groups can do it, e.g., flight operations have quiet rooms.
   • Okay during lunch, no special place, could use cafeteria, some do use it for resting.
   • Do this, go to break room.
   • If effective would support. Okay on own time.
8. Which of all these interventions would be most effective? Which would your company most likely support? Why?
   • Physical shape, exercise, food, sleep.
   • Scheduling, education, light conditions.
   • Provide discounted day care service, very important because can't sleep. Most serious losses are mothers on night shift schedule - plan to raise idea to corporate level; nutrition, exercise and sleep.
   • Education, foods, lighting, because it's least costly.
   • Education on physical activity and foods.
   • Do allow naps and walking; continue lamping program. More education on foods and in vending.
   • Changes in work schedule effective and may be able to do more; e.g., longer breaks, anything that would improve safety is of interest to company.
   • Bright lights and health foods.
   • Education most likely to be effective.
   • Work shift scheduling most important from staff perspective; management would choose education or exercise/health.
   • Illumination important, naps important, foods yes.
   • Naps used, company probably would support health foods information campaign.
   • Naps on breaks most important, then education and nutrition.
   • Setting schedules; education, healthy foods.

4e.  How much freedom/flexibility do front line supervisor have in adopting practices to accommodate the needs of shift workers? What can supervisors do to help their employees get better/more sleep? (Probe: What level of permission is need for them to make changes in policies/practices?)

• Yes, this plant was committed to safety.
• Within department can make changes, e.g., leaving lights on at night. Could raise major suggestions to higher level.
• Not sure. Depends on location.
• Very flexible, if job accomplished; more approval if resources required.
• Yes, can intervene if drowsy.
• Not much flexibility, could educate; union contract restricts.
• Have limited freedom to make major changes, need to coordinate with other units; but can intervene with individuals, e.g., send home if needed.
• Some flexibility, could send sleepy employee home.
• Limited ability to change policy; must treat everyone the same.
• Need to be consistent; can deal with individual employee problems, e.g., could keep lights up, for example, in common/public area.
• Most have capability to make changes in department, can respond to individual needs.
• Union shop, little flexibility. Could intervene if employee in danger.
• Very much flexibility; extensive program to accommodate disabilities, e.g., sleep apnea.
• Do what peer supervisors do. If cost item must get approval, but education or counseling is their prerogative; are not trained in recognizing sleep deprivation.

Wrap Up

• Must work with families, bring families to education sessions; emphasize economic costs, documentary, case histories, before and after studies. Need more work on fatigue driving.
• Need more literature, use all media, including TV broadcasts. Suggest video and pamphlets as best.
• Video tapes; stress management training would be helpful; side effects of drugs/medications, caffeine content of foods. Provide discounted day care services. Recent study of losses indicates high number of working mothers on night shift having mishaps. Need sleep.
• Provide staffing grant to study effectiveness. Need to show evidence.
• Work with big unions, educate them on importance of these issues. UAW master contract could influence whole industry.
• Transportation - could have own bus service; shuttles might even be implemented someday!
• Education most important.
• Educate whole family and extended family to help support sleep patterns; use answering machines, keep quiet, etc. Maybe employer should offer transportation alternative for sleepy worker - promote carpools. Provide one on one orientation on this topic when hire night shift employees, i.e., importance of sleep hygiene, tips, etc.
• Sent out questionnaire to employees/workgroup on fatigue issue; should put out information in computer or mailable form; have periodic safety meetings, use videos 20 minute maximum. Have had for 3.5 years an anonymous 24 hour help or resource line that employees can call for help, suggestions, relating to fatigue, sleepiness on job. Calls are answered on a confidential basis.
• No, make information available. Often becomes bargaining issue. Must be careful what issues raised.
• Fatigue in snow removal crews - work 36 hours - have had accidents. Education, awareness important, relate to own quality of life; encourage supervisors to find out reasons for problems, help resolve without punishment.
• No, difficult to control people on own time; only expect marginal gains unless employer can mandate action.

RECOMMENDATIONS

[Rtn to TOC]

Interventions to decrease the risk of drowsy driving among shift workers should consider the following recommendations:

Educational efforts should be aimed at the following targets:

• Shift workers
  • Education about the "myths" of various tactics to stay awake while driving (e.g., listening to loud music, sticking head out the window)
  • Education on why to make sleep a priority
  • Education about the importance of good sleep hygiene and strategies to promote better quality sleep (e.g., sleep aids, timing of sleep)
  • Education about the importance of healthy lifestyle behaviors (diet, physical activity) to combat fatigue and drowsiness
  • Education for family members about the sleeping schedule of shift workers and strategies to help the shift worker get better sleep
• Shift supervisors
  • Increase awareness of the risks of drowsiness and drowsy driving to their employees.
  • Educating co-workers and supervisors how to attend to cues for drowsiness and encouraging interventions to prevent drowsy driving (e.g., take the keys, call a cab, share a ride)
  • Education about the benefits of an improved work environment (i.e., bright lights, cool temperature)
• Upper-level managers
  • Increase awareness of the risks of drowsiness and drowsy driving in their workforce.
  • Encourage a re-evaluation of policies regarding sleeping during break time
  • Investigate ride-sharing opportunities for employees of the night shift
  • Encourage an evaluation of the services offered to shift workers, including healthy food offerings (e.g., cafeteria, vending machines), opportunities to engage in physical activity (e.g., health club incentives, safe areas to walk on breaks), innovative child care offerings, ride sharing, and sleep aids and consideration of night shift workers when scheduling training and in-services.
  • Promote the use of mandated break times (i.e., "lunch break," and 15-minute breaks) for strategies that can reduce fatigue. Many workers do not seem to use their break time. This time could be used to nap or get some physical activity (e.g., 15-minute brisk walk). These activities could be promoted in a more programmatic fashion in a workplace intervention.
  • Promote the low-cost aspects of sleep hygiene by making use of available resources.
  • Use communication channels such as e-mail, newsletters, in-service training, and posters to enhance awareness of drowsy driving and contributors to fatigue.