Sleep, Occupation and the Passage of Time
Green, Andrew, British Journal of Occupational Therapy
This article explores the extent to which sleep has been considered in occupational therapy and occupational science and finds that the coverage of the subject is patchy: many authors do not mention it whereas some provide comprehensive and useful information. One reason for this variability could be that it is unclear whether sleep is an occupation and this question is debated. Although it is widely acknowledged that sleep is essential to the performance of daytime activity, most definitions of occupation and activity exclude sleep unless occupation is defined in the context of time use.
A brief review of the social history of sleep and the timing of occupations suggests that modern life and the natural sleep-wake cycle might be out of synchrony. The science of sleep is explored and the factors necessary for initiating sleep are examined, with aspects of daily occupation being found to influence sleep. It is suggested that, given the range of conditions affecting sleep that are seen by occupational therapists, it may be helpful to have a better understanding of sleep and the measures that might improve it. Because sleep occupies so much time, research in occupational science is recommended.
Key words: Sleep, occupation, time use.
In his early exposition of the philosophy of occupational therapy, Adolf Meyer named sleep as one of the 'Big Four' factors that a person should balance for the maintenance of health, along with work, play and rest (Meyer 1922, 1977, p641). Westhorp (2003) and Christiansen and Matuska (2006) have addressed the complexities of balance and Weinblatt and Avrech-Bar (2003) have examined the concept of rest but, as Christiansen and Baum (1997) observed, little attention has been paid by occupational therapists to sleep. Howell and Pierce (2000) suggested that Meyer's message might be ignored in western society because of beliefs that time spent sleeping is time wasted. Another possible reason is that influential writers have omitted it from definitions and classifications of occupation. For example, Kielhofner and Burke (1985) stated that 'occupational behaviour' is 'activity in which persons engage during most of their waking time' (p12), thereby appearing to exclude sleep from the domain of occupational therapy. More recently, Persson et al (2001) dismissed sleep from discussion about occupation, despite acknowledging its importance for daytime performance, because 'it is an unconscious process that cannot be influenced or directed' (p12). Similarly, Larson et al (2003) ruled out sleep by stating that occupations are 'consciously executed' (p16).
The main purposes of this article are to propose that the neglect of this interesting area is unjustified and to raise awareness among occupational therapists of issues relating to sleep. The article first reviews the existing information on sleep in the occupational therapy and occupational science literature. Secondly, the theoretical relationship between sleep and occupation (and the nature of occupation itself) is explored in order to determine the relevance of sleep to occupational therapy. Lastly, it takes an overview of the current knowledge of sleep science insofar as it relates to occupation and to the promotion of good sleep.
Before proceeding, it is appropriate to define sleep and stress its importance by summarising the effects of poor sleep. Carskadon and Dement (2005) offered a behavioural definition of sleep:
Sleep is a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment ... typically (but not necessarily) accompanied by postural recumbence, behavioral quiescence, closed eyes and other indicators ... (p13).
According to Alford and Wilson (2008), the varied consequences of poor sleep include:
increased daytime sleepiness and fatigue leading to cognitive impairment and poor work performance and absenteeism in addition to increased accident risk including driving, increased risk of new or recurrent psychiatric disorder and increased substance use, poorer prognosis, increased healthcare-related financial burden, and poorer social functioning at work and at home (p51). …