TY - JOUR
AU - Hurtado, Suzanne, L
AB - Abstract Introduction Sleep disturbance is prevalent among service members; however, little is known about factors that compromise sleep in unique operational environments, such as naval ships. Given the importance of sleep to health and performance, it is critical to identify both causes and potential solutions to this serious issue. The objective of this qualitative study was to elucidate the barriers to sleep and the strategies service members use to improve their sleep and combat fatigue while living and working aboard ships (i.e., underway). Methods and Materials Interviews were conducted with 22 active duty service members assigned to sea duty. The semi-structured interview guide assessed the experiences of service members sleeping in shipboard environments. Interview transcripts were analyzed using applied thematic content analysis by two independent coders. Results Participants were largely male (77.8%) and enlisted (88.9%). The most common barrier to obtaining sufficient sleep was stress, followed by rotating schedules, and environmental factors (e.g., noise and light). Additionally, many participants reported prioritizing other activities over sleep when off duty. Many participants did not report using any specific strategies to improve their sleep while underway. Among those who did, most described mitigating environmental barriers (e.g., noise-cancelling headphones or sleep masks). However, some participants also acknowledged these strategies are not always feasible, either attributable to cost or because sailors must be able to respond to alarms or commands. Notably, few sailors reported using stress mitigation or relaxation strategies to help sleep. Ingesting caffeine was the only strategy sailors reported using to alert themselves while fatigued. Conclusions Service members reported many unique barriers to sleep in the shipboard environment, yet many did not report the use of strategies to mitigate them. Further, few used alerting techniques when fatigued. This at-risk population could benefit from targeted educational interventions on sleep-promoting behaviors, prioritization of sleep, and fatigue mitigation. INTRODUCTION Sleep disturbance is highly prevalent among military service members. Not only do most service members not sleep the recommended minimum of 7 to 9 hours each night,1,2 but many report sleeping fewer than 5 hours at a time.3–7 Further, over half of all service members who participated in the 2015 Department of Defense Health Related Behaviors Survey8 reported they got less sleep than they felt they needed, and nearly one-third were moderately-to-severely bothered by a lack of energy due to inadequate sleep. Insufficient sleep is associated with a variety of short- and long-term adverse outcomes, including reduced productivity and increased risk for mental and physical health issues.9–14 Therefore, research is needed to identify both causes and potential solutions to this serious issue. Though little formal research has been conducted to identify the causes of sleep disturbance among service members, the available evidence indicates many factors are at play. For example, a 2015 study consisting of interviews with military clinicians and leaders concluded that sleep is hindered by the operational environment, service member knowledge about healthy sleep, and military culture.15 In terms of operational environment, various physical characteristics may impede sleep, such as light, noise, temperature, air pollution, and uncomfortable sleeping surfaces.15–17 Another contributing factor may be knowledge. Many service members may be unaware of the relationships between sleep, health, and performance and/or may be unable to recognize symptoms of sleep deprivation.18 Finally, in military culture, sleep may not be viewed as a priority; service members may use time available for sleep to instead work or take care of other responsibilities.15 It is apparent that service members face many challenges to obtaining adequate sleep, but identifying the barriers to healthy sleep marks only the first step in addressing the issue. It is also critically important to identify strategies service members can use to both mitigate those barriers and combat subsequent fatigue. Few studies have assessed the strategies used by service members in the field. One recent study that assessed sleep habits of soldiers reported approximately half practiced frequently recommended sleep hygiene behaviors, such as minimizing light and sound in the sleeping environment and limiting caffeine.18 However, this study did not assess a comprehensive list of sleep hygiene behaviors, nor did it specify how behaviors were used in varied settings (e.g., at home, in garrison). Another recent qualitative study of National Guard soldiers indicated that service members often seek pharmacological aid and/or use alcohol to help them sleep.19 This work echoes the findings of other studies15 that indicate many service members find themselves in a cycle of using medication to facilitate sleep and then high amounts of caffeine to alert themselves or enable performance.20–22 Although some research has investigated the barriers faced by service members in general and the mitigation strategies employed,15–17 many gaps remain. One notable gap is the lack of documented information regarding sleep quality and the sleep environment among shipboard sailors who work and live aboard ships at sea, which is often referred to as “underway.” Specifically, although several studies have examined sleep duration alongside performance and mood in U.S. sailors,22 no research to date has assessed barriers to sleep specific to this operational environment. Indeed, all prior service-wide research either excluded sailors, did not stratify results by service, or only assessed sleep following return from sea. Further, to our knowledge, no prior efforts have assessed the strategies used by sailors to improve their sleep or combat fatigue while underway. Considering that sailors report among the highest rates of insufficient sleep8 and that the shipboard environment is unlike any other operational setting, it is important to understand the unique experiences of this group. The objective of this study was to elucidate barriers to sleep and mitigation strategies employed in shipboard environments using data from qualitative interviews with service members with shipboard experience. Qualitative studies provide critical contextual information—through first-person accounts from service members, we can better understand the attitudes and experiences that influence their sleep-related behaviors. The results of this study can guide the development of more targeted interventions for this unique population. METHODS Procedures This qualitative study was a part of a formative evaluation of a sleep education intervention that was being developed by the authors. The interviews described here were conducted with active duty service members to help tailor the novel sleep education intervention to this particular population. Service members were recruited from local naval commands through fliers and in-person recruitment events; participants were eligible if they had shipboard experience. Participants were interviewed either one on one (by phone or in person) or in a group (on board their ship). One trained interviewer (E.S.) conducted all interviews and reviewed the recordings regularly to assess content; recruitment was discontinued once the interviewer determined saturation was achieved (i.e., no new information emerged). Interviews were audio recorded and transcribed for analysis. Participants also completed a brief, anonymous survey to assess their demographic characteristics and military service history. All study procedures were approved by the Institutional Review Board at the Naval Health Research Center. Participants Participants included active duty personnel recruited from two naval commands. Measures Interview Guide The semi-structured interview guide included four questions, each with several prompts to elicit further detail. The items aligned with study goals, which were to assess the experiences of service members sleeping in shipboard environments (including strategies employed to improve sleep) and to elicit recommendations for how to improve sleep service-wide. The interview items included, “What are some of the things that you think uniquely affect the sleep of sailors/service members?”, “Describe your experiences sleeping on ship.”, and “What strategies do you use to improve your sleep while underway?” One-on-one interviews took approximately 10 minutes, focus groups approximately 30 minutes. Survey A 10-item electronic survey assessed participant characteristics and service history, including age, sex, rank, marital status, service branch, and length of service. Participants also reported how much they slept each night over the past month, on average. Analysis Following transcription, interviews were analyzed using applied thematic analysis.23 In this process, which is a commonly used methodology for interpreting qualitative data, the researchers review data for common themes related to predefined content areas or “codes.” As such, in this study, a codebook specifying three broad content areas to align with the goals of the study was developed prior to reviewing the transcripts: (1) barriers and facilitators to sleep, (2) strategies used to improve sleep, and (3) specific recommendations they think would serve tot improve sleep service-wide. Two coders (E.S. and R.D.) trained in qualitative analysis reviewed a subset of the transcripts and independently noted common themes and subthemes that emerged under the three specified content areas. The coders then met and updated the codebook to include the newly identified subthemes, as well as two new content areas that emerged from the review: effects of sleep disturbance and strategies used to stay awake. The coders each reviewed 100% of the transcripts using the updated codebook; agreement between coders was 91% and thus a third coder was not required. In the few cases in which the codes were discrepant, the coders rectified the disagreement through discussion and recoded accordingly. Qualitative analysis was conducted using NVivo version 12 (QSR International Pty Ltd). Means and frequencies were computed for all survey items using SPSS version 25 (IBM SPSS Statistics for Windows). RESULTS Participants included 22 active duty service members (see Table I for characteristics). Ten (45.5%) participants completed telephone interviews, 5 (22.7%) completed in-person interviews, and 7 (31.8%) participated in the single group discussion. TABLE I. Participant Characteristics . N (%) . Mean (SD) . Sex Male 14 77.8 Female 4 22.2 Age, years 18-24 3 16.7 25-29 7 38.9 30 + 8 44.4 Rank E1-E6 7 38.9 E7-E9 9 50.0 Officer 2 11.1 Branch of service Navy 12 66.7 Coast Guard 5 27.8 Other 1 5.5 Marital status Married/cohabitating 12 66.7 Unmarried 6 33.3 Method of interview Phone (one on one) 10 45.5 In person (one on one) 5 22.7 In person (group) 7 31.8 Hours of sleep/night in past month (Range: 4-7; mean) 5.67 0.84 . N (%) . Mean (SD) . Sex Male 14 77.8 Female 4 22.2 Age, years 18-24 3 16.7 25-29 7 38.9 30 + 8 44.4 Rank E1-E6 7 38.9 E7-E9 9 50.0 Officer 2 11.1 Branch of service Navy 12 66.7 Coast Guard 5 27.8 Other 1 5.5 Marital status Married/cohabitating 12 66.7 Unmarried 6 33.3 Method of interview Phone (one on one) 10 45.5 In person (one on one) 5 22.7 In person (group) 7 31.8 Hours of sleep/night in past month (Range: 4-7; mean) 5.67 0.84 Open in new tab TABLE I. Participant Characteristics . N (%) . Mean (SD) . Sex Male 14 77.8 Female 4 22.2 Age, years 18-24 3 16.7 25-29 7 38.9 30 + 8 44.4 Rank E1-E6 7 38.9 E7-E9 9 50.0 Officer 2 11.1 Branch of service Navy 12 66.7 Coast Guard 5 27.8 Other 1 5.5 Marital status Married/cohabitating 12 66.7 Unmarried 6 33.3 Method of interview Phone (one on one) 10 45.5 In person (one on one) 5 22.7 In person (group) 7 31.8 Hours of sleep/night in past month (Range: 4-7; mean) 5.67 0.84 . N (%) . Mean (SD) . Sex Male 14 77.8 Female 4 22.2 Age, years 18-24 3 16.7 25-29 7 38.9 30 + 8 44.4 Rank E1-E6 7 38.9 E7-E9 9 50.0 Officer 2 11.1 Branch of service Navy 12 66.7 Coast Guard 5 27.8 Other 1 5.5 Marital status Married/cohabitating 12 66.7 Unmarried 6 33.3 Method of interview Phone (one on one) 10 45.5 In person (one on one) 5 22.7 In person (group) 7 31.8 Hours of sleep/night in past month (Range: 4-7; mean) 5.67 0.84 Open in new tab Barriers and Facilitators to Sleep Under the first content area of interest, barriers and facilitators to sleep, three themes emerged: intrapersonal factors, organizational/operational factors, and environmental factors. Intrapersonal-level factors were defined as cognitions or behaviors that affected sleep. Organizational/operational factors were those that related to the nature of the job and/or policies and practices specific to the military. Environmental factors included aspects of the physical environment. Under each theme emerged various subthemes. Participants provided numerous examples of barriers to sleep but very few examples of facilitators. Tables II and III include quotations to demonstrate identified content areas, themes, and subthemes regarding barriers and facilitators derived from the interviews. Intrapersonal Barriers Of all levels of influence, intrapersonal-level barriers were the most commonly reported. Participants described three distinct intrapersonal-level barriers to sleep: stress, competing priorities, and sleep hygiene behaviors. TABLE II. Barriers to Sleep in Shipboard Settings Reported by Service Members With Shipboard Experience (N = 22) Theme . Subtheme . Selected Supporting Quotations . Intrapersonal Stress “I think stress definitely impacts sleep. And, you know, maybe for the next day you’re doing something you haven’t done yet whether it’s like, for another qualification like the physical parts of it like roping out of a helicopter or climbing like a 60 foot ladder on the side of a boat without being strapped in. So that all falls under stress and, you know, what if.” “A lot of my sleeping problems are self-induced. I think a lot at night and I can’t shut my brain off. So sometimes I’ll lay down and I’ll be like, oh, I need to do this tomorrow, oh, I forgot to do this today. So sometimes it can take 30 minutes to two hours to fall asleep.” “You don’t just have like your one job. Everyone wears 20 hats so I’m sure it’s for everyone, like for me, it’s the same way, just sitting there thinking of all the stuff you didn’t get done yet.” Competing priorities “There’s so much other priorities in your life that it’s a hard time prioritizing sleep. You’ve only got a certain amount of hours a day and so you’ve got to make use of it and something has to give.” Sleep hygiene behaviors “…Sometimes I’m like, oh, it’s okay, I really want to watch this next show so I’ll just get, I’m fine with five (hours of sleep)…” “…comes nighttime and you had coffee two or three hours ago, and you’re bouncing around and you can’t go to sleep.” Organizational/Operational - “…our duty sections are small so we have duty every four days so even if you do kind of catch up a little bit, it’s like it’s just because you’re always on duty. Your sleep is always disturbed” “…if you have watch check in the middle of the night, because we didn’t do the circadian, if there were meetings during the day that you had to go to that would interrupt your sleep, too. And so I think just things being scheduled during the day, or during sleep time… Environmental Berthing conditions Sleeping around all different kinds of people sucks, because a lot of people have different sleeping habits. Some people are restless and they’ll get up or they snore really loud. There’s nothing you can do about it… Some people are just loud.” Light “…it’s required to keep the berthing lights on during working hours. It’s like, you could still see the light coming in through the cracks of your curtains so you really still can’t get that much sleep.” Noise “I share a wall with a treadmill on the other side.” Ship Motion “The rocking of the ship sometimes, depending on where you are. You know, you could feel like nauseous or you maybe feel like just shaken up. Depending on how the ship is rocking, it could bother your sleep.” Bedding “…there’s been certain ships that I’ve been on where I couldn’t turn on my side, to rotate onto my stomach without getting out of the bed and crawling back in.” Theme . Subtheme . Selected Supporting Quotations . Intrapersonal Stress “I think stress definitely impacts sleep. And, you know, maybe for the next day you’re doing something you haven’t done yet whether it’s like, for another qualification like the physical parts of it like roping out of a helicopter or climbing like a 60 foot ladder on the side of a boat without being strapped in. So that all falls under stress and, you know, what if.” “A lot of my sleeping problems are self-induced. I think a lot at night and I can’t shut my brain off. So sometimes I’ll lay down and I’ll be like, oh, I need to do this tomorrow, oh, I forgot to do this today. So sometimes it can take 30 minutes to two hours to fall asleep.” “You don’t just have like your one job. Everyone wears 20 hats so I’m sure it’s for everyone, like for me, it’s the same way, just sitting there thinking of all the stuff you didn’t get done yet.” Competing priorities “There’s so much other priorities in your life that it’s a hard time prioritizing sleep. You’ve only got a certain amount of hours a day and so you’ve got to make use of it and something has to give.” Sleep hygiene behaviors “…Sometimes I’m like, oh, it’s okay, I really want to watch this next show so I’ll just get, I’m fine with five (hours of sleep)…” “…comes nighttime and you had coffee two or three hours ago, and you’re bouncing around and you can’t go to sleep.” Organizational/Operational - “…our duty sections are small so we have duty every four days so even if you do kind of catch up a little bit, it’s like it’s just because you’re always on duty. Your sleep is always disturbed” “…if you have watch check in the middle of the night, because we didn’t do the circadian, if there were meetings during the day that you had to go to that would interrupt your sleep, too. And so I think just things being scheduled during the day, or during sleep time… Environmental Berthing conditions Sleeping around all different kinds of people sucks, because a lot of people have different sleeping habits. Some people are restless and they’ll get up or they snore really loud. There’s nothing you can do about it… Some people are just loud.” Light “…it’s required to keep the berthing lights on during working hours. It’s like, you could still see the light coming in through the cracks of your curtains so you really still can’t get that much sleep.” Noise “I share a wall with a treadmill on the other side.” Ship Motion “The rocking of the ship sometimes, depending on where you are. You know, you could feel like nauseous or you maybe feel like just shaken up. Depending on how the ship is rocking, it could bother your sleep.” Bedding “…there’s been certain ships that I’ve been on where I couldn’t turn on my side, to rotate onto my stomach without getting out of the bed and crawling back in.” Open in new tab TABLE II. Barriers to Sleep in Shipboard Settings Reported by Service Members With Shipboard Experience (N = 22) Theme . Subtheme . Selected Supporting Quotations . Intrapersonal Stress “I think stress definitely impacts sleep. And, you know, maybe for the next day you’re doing something you haven’t done yet whether it’s like, for another qualification like the physical parts of it like roping out of a helicopter or climbing like a 60 foot ladder on the side of a boat without being strapped in. So that all falls under stress and, you know, what if.” “A lot of my sleeping problems are self-induced. I think a lot at night and I can’t shut my brain off. So sometimes I’ll lay down and I’ll be like, oh, I need to do this tomorrow, oh, I forgot to do this today. So sometimes it can take 30 minutes to two hours to fall asleep.” “You don’t just have like your one job. Everyone wears 20 hats so I’m sure it’s for everyone, like for me, it’s the same way, just sitting there thinking of all the stuff you didn’t get done yet.” Competing priorities “There’s so much other priorities in your life that it’s a hard time prioritizing sleep. You’ve only got a certain amount of hours a day and so you’ve got to make use of it and something has to give.” Sleep hygiene behaviors “…Sometimes I’m like, oh, it’s okay, I really want to watch this next show so I’ll just get, I’m fine with five (hours of sleep)…” “…comes nighttime and you had coffee two or three hours ago, and you’re bouncing around and you can’t go to sleep.” Organizational/Operational - “…our duty sections are small so we have duty every four days so even if you do kind of catch up a little bit, it’s like it’s just because you’re always on duty. Your sleep is always disturbed” “…if you have watch check in the middle of the night, because we didn’t do the circadian, if there were meetings during the day that you had to go to that would interrupt your sleep, too. And so I think just things being scheduled during the day, or during sleep time… Environmental Berthing conditions Sleeping around all different kinds of people sucks, because a lot of people have different sleeping habits. Some people are restless and they’ll get up or they snore really loud. There’s nothing you can do about it… Some people are just loud.” Light “…it’s required to keep the berthing lights on during working hours. It’s like, you could still see the light coming in through the cracks of your curtains so you really still can’t get that much sleep.” Noise “I share a wall with a treadmill on the other side.” Ship Motion “The rocking of the ship sometimes, depending on where you are. You know, you could feel like nauseous or you maybe feel like just shaken up. Depending on how the ship is rocking, it could bother your sleep.” Bedding “…there’s been certain ships that I’ve been on where I couldn’t turn on my side, to rotate onto my stomach without getting out of the bed and crawling back in.” Theme . Subtheme . Selected Supporting Quotations . Intrapersonal Stress “I think stress definitely impacts sleep. And, you know, maybe for the next day you’re doing something you haven’t done yet whether it’s like, for another qualification like the physical parts of it like roping out of a helicopter or climbing like a 60 foot ladder on the side of a boat without being strapped in. So that all falls under stress and, you know, what if.” “A lot of my sleeping problems are self-induced. I think a lot at night and I can’t shut my brain off. So sometimes I’ll lay down and I’ll be like, oh, I need to do this tomorrow, oh, I forgot to do this today. So sometimes it can take 30 minutes to two hours to fall asleep.” “You don’t just have like your one job. Everyone wears 20 hats so I’m sure it’s for everyone, like for me, it’s the same way, just sitting there thinking of all the stuff you didn’t get done yet.” Competing priorities “There’s so much other priorities in your life that it’s a hard time prioritizing sleep. You’ve only got a certain amount of hours a day and so you’ve got to make use of it and something has to give.” Sleep hygiene behaviors “…Sometimes I’m like, oh, it’s okay, I really want to watch this next show so I’ll just get, I’m fine with five (hours of sleep)…” “…comes nighttime and you had coffee two or three hours ago, and you’re bouncing around and you can’t go to sleep.” Organizational/Operational - “…our duty sections are small so we have duty every four days so even if you do kind of catch up a little bit, it’s like it’s just because you’re always on duty. Your sleep is always disturbed” “…if you have watch check in the middle of the night, because we didn’t do the circadian, if there were meetings during the day that you had to go to that would interrupt your sleep, too. And so I think just things being scheduled during the day, or during sleep time… Environmental Berthing conditions Sleeping around all different kinds of people sucks, because a lot of people have different sleeping habits. Some people are restless and they’ll get up or they snore really loud. There’s nothing you can do about it… Some people are just loud.” Light “…it’s required to keep the berthing lights on during working hours. It’s like, you could still see the light coming in through the cracks of your curtains so you really still can’t get that much sleep.” Noise “I share a wall with a treadmill on the other side.” Ship Motion “The rocking of the ship sometimes, depending on where you are. You know, you could feel like nauseous or you maybe feel like just shaken up. Depending on how the ship is rocking, it could bother your sleep.” Bedding “…there’s been certain ships that I’ve been on where I couldn’t turn on my side, to rotate onto my stomach without getting out of the bed and crawling back in.” Open in new tab TABLE III. Facilitators of Sleep in Shipboard Settings Reported by Service Members With Shipboard Experience (N = 22) Theme . Subtheme . Selected Supporting Quotations . Organizational/Operational - “I didn’t have to follow … the ship’s schedule and our watch was, it’s a modified watch … our primary purpose was to eat, sleep and maintain our fitness … so we had the flexibility to get plenty of sleep. I’d say I’d get eight to ten hours, no problem.” “Whenever we did the circadian rhythm [watch schedule], like it was pretty good. It was a lot better. We were doing four section underway so you stand watch for three hours, you’d work or whatever, and then you’d have watch another three hours, twelve hours later. And then you get up to nine hours of sleep.” Environmental Ship features “When you first go out to sea, the waves are kind of like keeping you up…But eventually you get used to it. So, a lot of times I find myself, as soon as I get into my rack, I’m knocked out within a couple of minutes.” “…we had these sort of L shaped racks. They are comfy. You can sit up in your rack, read a book, get on your tablet. Not every ship is like that though.” Theme . Subtheme . Selected Supporting Quotations . Organizational/Operational - “I didn’t have to follow … the ship’s schedule and our watch was, it’s a modified watch … our primary purpose was to eat, sleep and maintain our fitness … so we had the flexibility to get plenty of sleep. I’d say I’d get eight to ten hours, no problem.” “Whenever we did the circadian rhythm [watch schedule], like it was pretty good. It was a lot better. We were doing four section underway so you stand watch for three hours, you’d work or whatever, and then you’d have watch another three hours, twelve hours later. And then you get up to nine hours of sleep.” Environmental Ship features “When you first go out to sea, the waves are kind of like keeping you up…But eventually you get used to it. So, a lot of times I find myself, as soon as I get into my rack, I’m knocked out within a couple of minutes.” “…we had these sort of L shaped racks. They are comfy. You can sit up in your rack, read a book, get on your tablet. Not every ship is like that though.” Open in new tab TABLE III. Facilitators of Sleep in Shipboard Settings Reported by Service Members With Shipboard Experience (N = 22) Theme . Subtheme . Selected Supporting Quotations . Organizational/Operational - “I didn’t have to follow … the ship’s schedule and our watch was, it’s a modified watch … our primary purpose was to eat, sleep and maintain our fitness … so we had the flexibility to get plenty of sleep. I’d say I’d get eight to ten hours, no problem.” “Whenever we did the circadian rhythm [watch schedule], like it was pretty good. It was a lot better. We were doing four section underway so you stand watch for three hours, you’d work or whatever, and then you’d have watch another three hours, twelve hours later. And then you get up to nine hours of sleep.” Environmental Ship features “When you first go out to sea, the waves are kind of like keeping you up…But eventually you get used to it. So, a lot of times I find myself, as soon as I get into my rack, I’m knocked out within a couple of minutes.” “…we had these sort of L shaped racks. They are comfy. You can sit up in your rack, read a book, get on your tablet. Not every ship is like that though.” Theme . Subtheme . Selected Supporting Quotations . Organizational/Operational - “I didn’t have to follow … the ship’s schedule and our watch was, it’s a modified watch … our primary purpose was to eat, sleep and maintain our fitness … so we had the flexibility to get plenty of sleep. I’d say I’d get eight to ten hours, no problem.” “Whenever we did the circadian rhythm [watch schedule], like it was pretty good. It was a lot better. We were doing four section underway so you stand watch for three hours, you’d work or whatever, and then you’d have watch another three hours, twelve hours later. And then you get up to nine hours of sleep.” Environmental Ship features “When you first go out to sea, the waves are kind of like keeping you up…But eventually you get used to it. So, a lot of times I find myself, as soon as I get into my rack, I’m knocked out within a couple of minutes.” “…we had these sort of L shaped racks. They are comfy. You can sit up in your rack, read a book, get on your tablet. Not every ship is like that though.” Open in new tab Stress Stress was the most commonly reported barrier to sleep among participants; it was reported by over half of all participants. Stress was defined and described differently by different participants. Many of these participants described losing sleep over work-related concerns. For example, one service member stated, “Stress is a big thing. I know for me personally, if I’ve got a mission coming up or if I’ve got a high visibility, high pressure task and it’s going on, I do not sleep well knowing what’s coming up and what I’ve got to do and what possibly could go wrong.” Similarly, many participants described being in a state of hypervigilance while on the ship, which contributed to stress and negatively affected their sleep. One participant said, “…So you’re always a little bit on alert; you’re never completely detached. And being on alert- that kind of vigilance that means you wake up at the slightest nudge, at the slightest inclination that you think your phone might be ringing…” Lastly, a few participants reported losing sleep attributable to stress over personal concerns, “Even if you are single, you’re still dealing with stress. Maybe you have a friend that’s going through something, or maybe a family as well.” Competing Priorities Many participants explained that when faced with the choice, they frequently chose to prioritize other activities or responsibilities over sleep. For example, one participant explained, “Unfortunately in the military, there’s so many things we do, and sleep becomes one of the first things you sacrifice.” Several participants gave specific examples of the activities they do instead of sleep while on the ship, which included exercising and studying for exams or qualifications. Sleep Hygiene Behaviors In terms of sleep hygiene, several participants noted that they would get caught up reading, studying, watching TV, or playing video games and stay up later than planned (e.g., “I find that if I’m watching videos instead, my brain just keeps going if I don’t fall asleep right away.”). Additionally, one participant specifically noted that drinking coffee too close to bedtime affected his sleep. Intrapersonal Facilitators Participants rarely described intrapersonal facilitators of sleep. In fact, only one participant provided an example, though it is an example of both an intrapersonal and organizational facilitator; he stated that he was able to sleep very well when he did not have to follow the ship’s watch schedule and had relatively less responsibility in his job during the day, or few competing priorities. Organizational/Operational Barriers Most participants stated that watch rotations affected their sleep while underway, with some describing in detail how it impacted their schedules, “On one day you might be able to get a full night’s sleep if you don’t have that night watch. And then the next day, you’ve got the 22 to 03 and, you know, you’re going to bed at like say, hopefully no later than five just to wake up at 09…” Some participants felt their schedules were further affected due to under-manning, for example, “…we’re limited on manning…I’m sure with a lot more people, that wouldn’t be as much of an issue and you could allot those people, who have night watch, sleep…” Organizational/Operational Facilitators Conversely, participants also described how the watch schedules either did not impede or actually facilitated sleep. One participant specifically described how the newly implemented circadian-based shipboard routines and watch bills improved his sleep: Whenever we did the circadian rhythm [watch schedule], like it was pretty good. It was a lot better. We were doing four section underway so you stand watch for three hours, you’d work or whatever, and then you’d have watch another three hours, twelve hours later. And then you get up to nine hours of sleep. Environmental Barriers Nearly half of all participants described factors of the physical shipboard environment that negatively affected sleep; these factors can be further classified into the following categories: berthing conditions, light, noise, ship motion, and bedding. The most commonly reported environmental barrier was cramped living quarters or sharing a berthing area with many other shipmates who may be on different schedules and/or just cause crowding (e.g., “I’m enlisted so you live in an area with like a hundred or so guys or females…dealing with other people as well, that can be something that can affect my sleep.”). This subtheme overlapped with the noise and light subthemes, as many participants described being awakened by noise and light from their bunkmates (e.g., “I hear steps, people moving around, so it’s kind of hard for me to stay asleep the whole night.” and “Maybe someone likes to sleep with the light on and their light may be shining into your face.”). However, they also described how other features of the ship can impede sleep, like the sound of the speaker system, equipment, or the overhead lighting in the berthing areas; e.g., “doing MCON drills all through the night or ETT drills when they were on watch or just using the 1MC all night long…” and “…if there’s an aircraft that’s like slamming down on your roof every couple of minutes or so, it’s like, I don’t know how people sleep like that.”, and “…it’s required to keep the berthing lights on during working hours. It’s like, you could still see the light coming in through the cracks of your curtains so you really still can’t get that much sleep.” The other environmental barriers to sleep reported by participants were the motion of the ship and uncomfortable bedding. Many service members described how the rocking of the ship kept them awake, sometimes by causing motion sickness, “One of the biggest things is obviously going to be motion sickness. Everybody is affected by motion sickness in one way or another.” Additionally, several described their shipboard beds or “racks” as not conducive to sleeping because they were either too small (e.g., “…there’s been certain ships that I’ve been on where I couldn’t turn on my side, to rotate onto my stomach without getting out of the bed and crawling back in..”) or the bedding is not sufficient, “We are not provided the best sleeping stuff that you may need like pillows, you know, things that would help your body sleep better.” One participant also described how difficult it was to fit his sleep apnea equipment in his bed. Environmental Facilitators Some of the same factors reported as barriers by some service members were reported as facilitators by others. Specifically, many stated that the motion or rocking of the ship had a calming effect that helped them sleep, “When you first go out to sea, the waves are kind of like keeping you up…But eventually you get used to it. So, a lot of times I find myself, as soon as I get into my rack, I’m knocked out within a couple of minutes.” Additionally, some participants reported comfortable or spacious beds and/or berthing areas, “…we had these sort of L shaped racks. They are comfy. You can sit up in your rack, read a book, get on your tablet. Not every ship is like that though.” Strategies to Improve Sleep When asked what they did to improve their sleep while underway, many participants did not report using any specific strategies. Those who did largely described two subthemes: mitigating environmental barriers and using behavioral strategies (see Table IV for example quotations). For example, several participants used noise-cancelling headphones, white noise, or simply asked their bunkmates to quiet down. However, some of these same participants explained that these strategies would not always work as a result of not being able to respond in an emergency: “I’ve used hearing protection but I had to stop that because then I was completely shutting myself off and not being able to hear anything and respond. So that wasn’t an option.” Another acknowledged that noise-cancelling headphones may be unaffordable for many service members. In addition to altering ambient sound, several participants mentioned efforts to minimize their light exposure by closing their bunk curtains, using eye masks, or turning off lights, as possible. Similarly, several reported intentionally avoiding use of electronics before bedtime, though they reported doing so to avoid the stimulation rather than to reduce light exposure. TABLE IV. Strategies Used to Improve Sleep in Shipboard Environments Reported by Service Members With Previous Shipboard Experience (N = 22) Theme . Supporting Quotation . Strategies to alter the physical environment “I’ve used, like a blindfold, the eye mask.” “Most of the time you have to bring your own sleeping stuff so if you want to be comfortable; so your own sets of pillows and sleeping bags. You have to make it as comfortable as possible. Some of us bring sleeping pads, memory foam pads to help with the mattresses.” “Then I had noise cancelling headphones and that way I wouldn’t have to worry about hearing anything.” Behavioral strategies “I like to meditate and kind of wind down before I get into my rack to sleep.” “Read something you don’t want to read and, yeah, you’ll get tired.” “I try and minimize like, watching TV in bed or watching Facebook videos about cute pets or whatever. You know, I’ll try and read a book or read on article or catch up on the news and then I’ll eventually get tired of looking at the screen.” “I worked out and tried to exhaust myself. That was probably my main strategy.” “You might have to cut that working out or eating a little short just to get sleep.” Theme . Supporting Quotation . Strategies to alter the physical environment “I’ve used, like a blindfold, the eye mask.” “Most of the time you have to bring your own sleeping stuff so if you want to be comfortable; so your own sets of pillows and sleeping bags. You have to make it as comfortable as possible. Some of us bring sleeping pads, memory foam pads to help with the mattresses.” “Then I had noise cancelling headphones and that way I wouldn’t have to worry about hearing anything.” Behavioral strategies “I like to meditate and kind of wind down before I get into my rack to sleep.” “Read something you don’t want to read and, yeah, you’ll get tired.” “I try and minimize like, watching TV in bed or watching Facebook videos about cute pets or whatever. You know, I’ll try and read a book or read on article or catch up on the news and then I’ll eventually get tired of looking at the screen.” “I worked out and tried to exhaust myself. That was probably my main strategy.” “You might have to cut that working out or eating a little short just to get sleep.” Open in new tab TABLE IV. Strategies Used to Improve Sleep in Shipboard Environments Reported by Service Members With Previous Shipboard Experience (N = 22) Theme . Supporting Quotation . Strategies to alter the physical environment “I’ve used, like a blindfold, the eye mask.” “Most of the time you have to bring your own sleeping stuff so if you want to be comfortable; so your own sets of pillows and sleeping bags. You have to make it as comfortable as possible. Some of us bring sleeping pads, memory foam pads to help with the mattresses.” “Then I had noise cancelling headphones and that way I wouldn’t have to worry about hearing anything.” Behavioral strategies “I like to meditate and kind of wind down before I get into my rack to sleep.” “Read something you don’t want to read and, yeah, you’ll get tired.” “I try and minimize like, watching TV in bed or watching Facebook videos about cute pets or whatever. You know, I’ll try and read a book or read on article or catch up on the news and then I’ll eventually get tired of looking at the screen.” “I worked out and tried to exhaust myself. That was probably my main strategy.” “You might have to cut that working out or eating a little short just to get sleep.” Theme . Supporting Quotation . Strategies to alter the physical environment “I’ve used, like a blindfold, the eye mask.” “Most of the time you have to bring your own sleeping stuff so if you want to be comfortable; so your own sets of pillows and sleeping bags. You have to make it as comfortable as possible. Some of us bring sleeping pads, memory foam pads to help with the mattresses.” “Then I had noise cancelling headphones and that way I wouldn’t have to worry about hearing anything.” Behavioral strategies “I like to meditate and kind of wind down before I get into my rack to sleep.” “Read something you don’t want to read and, yeah, you’ll get tired.” “I try and minimize like, watching TV in bed or watching Facebook videos about cute pets or whatever. You know, I’ll try and read a book or read on article or catch up on the news and then I’ll eventually get tired of looking at the screen.” “I worked out and tried to exhaust myself. That was probably my main strategy.” “You might have to cut that working out or eating a little short just to get sleep.” Open in new tab Besides altering the physical environment, participants discussed behavioral strategies to improve sleep. Some participants felt that engaging in physical activity during the day helped to tire and/or relax them, for example, “I would essentially try to tire myself out.” Others fit sleep in their schedules by either choosing it over other activities or napping. Finally, some participants described using relaxation techniques, such as counting sheep or numbers, reading, or meditating. Strategies to Stay Awake Few participants reported means of avoiding fatigue; among those that did, the responses could be categorized into two subthemes: caffeine consumption and alerting behaviors. Several participants volunteered that sailors rely heavily on caffeine to stay awake and/or alert while on duty, “Oh, you just drink Red Bull™ and go right through it.” Only one participant described using a strategy other than caffeine, though he also suggested coffee: “sip on some coffee, splash some cold water in your face, take a shower, whatever you need to do to wake yourself up.” Effects of Sleep Disturbance Some participants described ways in which lack of sleep affected them, specifically two identified subthemes included their moods and job performance. For example, when asked about how much sleep he got while deployed, one participant said, “It was enough to do the jobs that I was tasked with. It was not enough to do the jobs that I was tasked with extraordinarily well. And you start to notice the changes. You know, people are a bit grumpy. The quality of work starts to slip.” Another volunteered, “If I don’t have a good rest at night then I’m going to be groggy and angry… I was actually getting more work done after I actually took a nap or slept. I realized I was making a lot of mistakes (when sleep deprived), too. When we switched to that (napping), my mood got better. My work quality got better.” Recommendations to Improve Sleep When prompted to think of recommendations for how to improve sleep for shipboard sailors, participants’ suggestions could be categorized into two subthemes: changes to the shipboard environment and schedules. Specifically, participants recommended altering the berthing areas so that either fewer people were assigned to each area or separating individuals who are on different schedules (e.g., “The only thing I can possibly think of is maybe being a better way of having smaller berthing areas with less people so you have less people to worry about as far as coming in and out.”). In terms of scheduling, some participants advocated the circadian-based watch schedules or “a wider range of watches,” whereas others recommended what they called, “mandatory sleep time.” It is important to note that several participants who recommended changes to the watch schedule also acknowledged that staffing limitations may prohibit such changes. For instance, one participant said that while guaranteed sleep time would be optimal, “most of the time a lot of ships are understaffed,” and so it would not be possible. Another said, “There is a bottom threshold. You are never going to reduce it (sleep deficits) based on the nature of the Navy, based on ship life, and based on the nature of the job.” DISCUSSION Substantial research shows that military service members are at risk for sleep disruption and that insufficient sleep can adversely affect health, reduce job performance, and increase the likelihood of accidents.1–14 As such, it is critical that researchers identify the factors that inhibit sleep in all operational settings so that tailored interventions can be implemented. Despite the known need for sleep research and interventions, few studies have specifically examined the factors that influence sleep in shipboard settings—from the perspective of the service members. This qualitative study fills this gap by elucidating shipboard sailors’ experiences sleeping while underway. As with any qualitative study, the results cannot be used to draw conclusions about relationships between variables or to quantify observed themes; however, the descriptive information derived from this study can be used as a foundation for future quantitative efforts. Study participants detailed the factors that impede their sleep while underway. In line with previous research noting that sleep is impacted by multiple levels of influence,12,24,25 these interviews indicate that service members are affected by intrapersonal, organization, and environmental factors. Further, several of the themes and subthemes identified here parallel those observed in previous work.15,16,26,27 For instance, participants frequently described environmental or physical attributes of the ship that hindered sleep, including noise, light, cramped berthing areas, and the quality of the bedding. Additionally, watch schedules, a known barrier to sleep in military populations,28 were frequently reported as an organizational barrier. However, a surprising finding was that the most commonly reported barriers to sleep were intrapersonal, such as the participants’ own behaviors and stress levels. Participants described poor sleep hygiene practices and high degrees of stress and anxiety that kept them awake at bedtime, and a hypervigilance that reduced sleep quality. Although some previous studies have reported barriers and facilitators to sleep in operational settings,16 this study went a step further by also providing important new information about the strategies some service members may already be using to improve their sleep. Several participants used strategies to reduce ambient noise; however, perhaps most notable was the fact that many did not report using any strategies. Similarly, although stress was the most commonly reported barrier to sleep, very few participants described using stress mitigation or relaxation techniques. Teaching service members simple behavioral strategies or sleep hygiene practices that are feasible to employ in shipboard settings before deployment or field training operations could improve sleep-related behaviors and thus increase both quantity and quality of sleep.29 For instance, research suggests that educational interventions that incorporate principles of cognitive behavioral therapy for insomnia can significantly improve sleep among service members and other occupational athletes.30–32 The results of this study also highlight the need for improved education regarding fatigue management. Few participants described using strategies to alert themselves when sleep deprived, but all of those who did indicated that caffeine was their primary fatigue countermeasure. The lack of strategies to maintain alertness was somewhat troublesome—as several participants acknowledged that lack of sleep affected their job performance and mood, and alerting strategies could improve performance.33,34 Sleep education programs should include information on how to safely and effectively combat fatigue while optimizing sleep quality in order to optimize performance. Limitations Three limitations must be considered when interpreting these results. First, though saturation was achieved, data from small, qualitative studies cannot be generalized to the population at large. This work provides a glimpse into the thinking of shipboard sailors and is likely to resonate with many, though it may not be comprehensive. Second, because of participant availability, the data from this study was collected using multiple methods (i.e., focus group and one-on-one interviews; telephone and in person). Although we did not observe differences in responses across the methods, it is possible that the method of data collection altered participant responses. Third, though it was required for all participants to have shipboard experience, information regarding the recency of their last underway and information related to total career time spent underway, or ship types was not collected. As such, recall bias could play a role (as with any self-report data collection), and participant experiences could vary widely by type of assignment or ship. Future Directions/Recommendations The shipboard working environment is unlike any other, as shipboard sailors live in their workplace, in extremely tight quarters and under strict schedules. To our knowledge, this article is the first to detail service members’ experiences sleeping under these conditions, the strategies they use to improve sleep, and their perceptions of how they are impacted by lack of sleep. The results of this study confirm that although many barriers to sleep in the shipboard environment cannot be overcome, some can be mitigated through interventions that address behavioral, environmental, or organizational policies and procedures. Specifically, and in line with the recommendations stated by previous researchers,6,15,17,35 future work should develop and evaluate educational interventions to increase service member sleep-related knowledge and improve sleep hygiene, continue to study evidence-based practices for increasing healthy sleep in military settings/populations, consider roommate sleeping schedules when assigning duty, and address sleep-related cultural norms by disseminating “positive messages about sleep as an operational imperative” (p. 3).15 Improving both the opportunities for sleep aboard ships and service members’ sleep-related motivation, knowledge, and behaviors could have a significant positive impact on service member readiness, performance, and well-being. Our interviews indicate that service members would welcome sleep interventions that could improve their work; as one interview participant put it, “Sailors want to do a good job. They take a lot of pride in their work.” ACKNOWLEDGMENTS The authors would like to express their gratitude to the following individuals who offered critical research support: Michelle Stoia, Kathrine Haluch, and Bianca Colon. I have obtained written permission from all persons named in the Acknowledgment. FUNDING This work was supported by the Department of Defense Congressionally Directed Medical Research Programs, Joint Program Committee-5 Early Assessment and Intervention Working Group under work unit no. N1702. CONFLICT OF INTEREST The authors have no conflicts of interest to report. REFERENCES 1. Watson NF , Badr S, Belenky G et al. : Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion . Sleep 2015 ; 38 ( 8 ): 1161 - 83 . Google Scholar Crossref Search ADS PubMed WorldCat 2. 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Title 17, U.S.C. §101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. The study protocol was approved by the Naval Health Research Center Institutional Review Board in compliance with all applicable Federal regulations governing the protection of human subjects. Research data were derived from an approved Naval Health Research Center Institutional Review Board protocol, number NHRC.2017.0010. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government. © The Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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TI - A Qualitative Examination of Factors That Influence Sleep Among Shipboard Sailors
JO - Military Medicine
DO - 10.1093/milmed/usaa321
DA - 0020-04-11
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SP - 1
EP - 1
VL - Advance Article
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DP - DeepDyve
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