Sleep Medicine Reviews 47 (2019) 112e118

Contents lists available at ScienceDirect

Sleep Medicine Reviews

journal homepage: www.elsevier.com/locate/smrv

CLINICAL REVIEW

Why healthy sleep is good for business

Christopher M. Barnes a, *, Nathaniel F. Watson b
a
Department of Management and Organization, Foster School of Business, University of Washington, United States
b
Department of Neurology, University of Washington (UW) School of Medicine, UW Medicine Sleep Center, United States

a r t i c l e i n f o s u m m a r y

Article history: People spend large portions of their lives working, often to the detriment of sleep. Businesses often
Received 21 February 2019 ignore the importance of employee sleep despite evidence showing sleep health is crucial to positive
Received in revised form employee outcomes. In this review we address the effect of sleep on employee health, performance, and
2 July 2019
workplace relationships. We examine the impact of work characteristics on employee sleep. Finally, we
Accepted 22 July 2019
Available online 27 July 2019
discuss opportunities for businesses to improve employee sleep to maximize success.
© 2019 Elsevier Ltd. All rights reserved.
Keywords:
Sleep
Business
Employees
Corporate

A healthy employee is an effective employee, but how we employees miss less work [4], do a better job when present [4],
define employee health has tremendous implications for iden- have fewer workplace accidents [5], make better decisions [6],
tifying and implementing interventions to maximize employee and interact more positively interpersonally [7]. Unfortunately,
effectiveness. Although a proper diet and regular exercise are these positive impacts on workplace performance are often un-
well-understood crucial elements of employee health [1], the derappreciated by managers. Pressure to meet challenging per-
vital role of sleep is often overlooked. This represents both a formance objectives provokes them to extend work hours or
massive blind spot and tremendous opportunity for employers create work schedules antithetical to human circadian rhythms.
to create policies leveraging employee sleep health to maximize These managers weigh productivity gains of additional work time
commercial success and create a harmonious workplace [2] (see against productivity losses of impaired employee sleep. More
Fig. 1). often than not, sleep ends up compromised [3,8]. Until managers
Sleep is established as a major contributor to overall human fully understand the breadth and depth of the untoward effect of
health and well-being, yet attainment of healthy sleep remains out insufficient sleep and circadian misalignment on work-related
of reach for many. Employment related factors such as work outcomes, they will continue to shape the work context in a
schedules, workload, norms, stress, and interpersonal mistreat- manner which undermines sleep. Contemporary business cli-
ment are severely overlooked contributors to poor population sleep mates often assume a zero sum game between sleep and corpo-
health [3]. Broad based societal sleep optimization will not occur rate success. However, a deeper exploration of the issue reveals an
until businesses appreciate the massive opportunity cost of sleep opportunity which forward thinking organizations already un-
damaging workplace policies. derstand - healthy employee sleep and corporate success are
Businesses answer to many stakeholders, but shareholders directly correlated [3,9e12].
focused on profit maximization get the most attention. Efforts to In this manuscript we review the literature examining the ef-
improve employee sleep by the sleep medicine community would fects of sleep on employee health and work-related outcomes. We
do well to focus their efforts on demonstrating how sleep posi- summarize the current literature and clarify how employees
tively impacts corporate bottom lines. Indeed, well-rested become less effective at conducting their work (and more harmful
to the businesses themselves) when they get insufficient or poor
quality sleep. We then discuss the manner in which businesses can
* Corresponding author. 585 Paccar Hall, University of Washington, Seattle, WA,
address these workforce-related sleep issues.
98195, United States. Fax: þ206 221 4719.
E-mail address: [email protected] (C.M. Barnes).

https://doi.org/10.1016/j.smrv.2019.07.005
1087-0792/© 2019 Elsevier Ltd. All rights reserved.
 C.M. Barnes, N.F. Watson / Sleep Medicine Reviews 47 (2019) 112e118 113

Fig. 1. How Work Influences and is Influenced by Sleep.

Impaired health-related outcomes Shiftwork sleep disorder, characterized by both sleepiness and
insomnia, is becoming more common, with 1 in 5 employees
Sleep health encompasses a combination of factors necessary worldwide working nontraditional shifts. Shift-work schedules
for sleep optimization. Sleep duration of seven or more hours on a typically result in insufficient, poor quality sleep as it occurs outside
nightly basis is recommended to support optimal health in adults traditional sleep hours at night and is misaligned with circadian
[13]. Bedtimes and wake times must be consistent and allow sleep rhythms. As such, shift-work is associated with cardiovascular [32]
to regularly occur at night in harmony with human circadian and metabolic [33] diseases and is considered a likely carcinogen
physiology. Sleep quality (e.g., minimal arousals, normal sleep ar- [34].
chitecture) must be good and sleep disorders must either be absent,
or if present, treated. Sleep is impaired when devoid of any of these Increased health care utilization
components. From a workplace perspective, sleep curtailment,
along with circadian disruption due to shift-work schedules Sleep-related illnesses increase healthcare utilization affecting
causing irregular sleep-wake times, and undiagnosed and un- corporate financial health, particularly for self-insured organiza-
treated sleep disorders are the biggest contributors to sub-optimal tions. Insomnia is associated with high health care utilization with
sleep. direct and indirect costs valued in the tens of billions of dollars
annually [35e38]. Annual direct costs of insomnia are estimated at
Increased disease burden nearly $14 billion, while physician and medical expenses for
insomnia patients are estimated at $5580 annually, nearly $4220
Habitually insufficient sleep is the most common cause of more than matched controls [39]. Another analysis indicates that
sleepiness in society. Indeed, the Centers for Disease Control and poor sleep health among shift-workers carries an estimated eco-
Prevention indicate approximately a third of U.S. adults sleep less nomic impact of between $30 and 40 billion U.S. annually in terms
than the recommended 7 h per night, with 15% sleeping <6 h of direct and indirect health care costs [4,31,40,41]. Annual direct
[14,15]. Short sleep is associated with a myriad of chronic health and indirect costs of sleep disorders (e.g., OSA, insomnia, narco-
conditions, including cardiovascular diseases (e.g., stroke, hyper- lepsy, parasomnias, sleep-related movement disorders) in Australia
tension, myocardial infarction) [16e19], diabetes [19e21], and were recently estimated at 4.5 billion, representing 0.8% of GDP and
psychiatric disorders including depression, substance dependence, nearly $4000 per citizen with a sleep disorder [42].
and suicidal thoughts and behaviors [22e24].
Insufficient sleep, along with snoring, negatively impacts cancer Absenteeism and presenteeism
survival and short sleep compromises immune function with un-
toward effects on vaccine response and increased susceptibility to At the macro-level, the association of short sleep with increased
the common cold [25e27]. Inadequate sleep increases motor mortality reduces the size of the workforce. Moreover, insufficient
vehicle accident risk [28,29]. Falling asleep at work at least once a sleep is a major contributor to absenteeism (e.g., workplace
week occurs in 32%e36% of shift workers and risk of occupational absence due to illnesses) and presenteeism (e.g., sub-optimal work
accidents is at least 60% higher for non-day shift workers [30]. Road performance due to working while ill). Short sleep related absen-
and workplace accidents related to excessive sleepiness, to which teeism and presenteeism both reduce workplace efficiency.
shiftwork is a significant contributor, are estimated to cost $71-$93 When compared to workers sleeping the normal 7e9 h per
billion per annum in the United States [31]. More broadly, an in- night, those sleeping <6 h lose approximately six working days per
dividual sleeping on average < 6 h per night has a 13% higher year due to absenteeism and presenteeism [4]. As a result those
mortality risk than an individual sleeping between 7 and 9 h [4]. sleeping <6 h per day report on average a 2.4% loss in productivity
114 C.M. Barnes, N.F. Watson / Sleep Medicine Reviews 47 (2019) 112e118

compared to those sleeping between 7 and 9 h [4]. Even workers learning through formal and informal venues. Many important
sleeping on average 6e7 h per night still experience a loss of 3.7 memory-related processes occur during sleep [50,51]. Sleep
workdays and an overall 1.5% productivity loss [4]. All told, from a deprivation impairs memory and learning, compromising the
macro-economic perspective, the U.S. economy loses the equivalent benefits of these training efforts. Sleep deprivation also un-
of 1.23 million working days due to insufficient sleep annually, dermines efficiency in switching among tasks, increasing task
corresponding to roughly 9.9 million working hours [4]. switching costs and compromising multitasking performance
Overall, the effects of insufficient sleep and sleep impairment on [52,53]. Indeed, attention management in general suffers [54], with
human health impact corporate bottom lines in myriad ways. An attention often drifting toward the employee's own sleepiness
Australian group assessed the economic costs of sleepiness result- rather than the task at hand [55]. Thus, insufficient sleep can impair
ing from insufficient sleep and sleep disorders (e.g., obstructive on the ability of employees to effectively manage their attention
sleep apnea, restless legs syndrome, insomnia) e collectively and apply their most relevant knowledge to making effective
referred to as “inadequate sleep”. They factored in related pro- decisions.
ductivity losses, caregiving, work and vehicle related accidents, The strategic and tactical direction of a business is driven by
welfare payments, and foregone tax revenue. The total annual employees, particularly those occupying influential management
financial cost of inadequate sleep was $17.9 billion dollars, of which positions. These managers must decide appropriate levels of risk
68% was comprised of productivity losses largely due to absen- and reward when making decisions. Risk processing becomes
teeism and presenteeism [43]. The RAND corporation estimates increasingly distorted as managers become more sleep deprived,
that various forms of sleep curtailment costs the U.S. Economy $411 such that insufficient sleep leads to increased pursuit of irrationally
billion dollars per year, equivalent to 2.28% of GDP [4]. high levels of risk. For example, 75 h of sleep deprivation led to a
As previously mentioned, the absence or effective treatment of 40% increase in the propensity to take risks, even given the same
sleep disorders is an important element of sleep health and another payoff probabilities [56]. Sleep deprived entrepreneurs are less
major sleep factor impacting corporate bottom lines. A recent effective at avoiding bad opportunities [57], leaving them vulner-
economic analysis demonstrated the diagnosis and treatment of able to wasting resources and potentially jeopardizing the business
obstructive sleep apnea (OSA) for the estimated 25 million Amer- venture itself.
icans with this disease would save the U.S. economy over $100 Of broad relevance to many work activities, insufficient sleep
billion per year [44]. The single largest contributing factor to these increases impulsivity and reduces self-control [58]. Thus sleep
costs are lost productivity from absenteeism and presenteeism deprived managers and other employees struggle to make rational
(58%), followed by increases in healthcare utilization (20%), motor intertemporal choices between short term investments and long
vehicle accident cost (18%) and workplace accidents (4%) [45]. In- term payoffs [59]. A review of the literature on sleep and decision
direct costs such as absenteeism, productivity loss, and motor making indicates insufficient sleep leads to broad decrements in
vehicle collisions resulting from insomnia were estimated annually decision effectiveness such that sleep deprived decision makers are
to top $100 billion [38]. especially likely to lead their businesses astray. Even worse, people
These previous estimates focus almost entirely on health-based lack insight into their increased propensity to make errors when
reasons that poor or insufficient sleep is bad for business. A sepa- sleep deprived and they underestimate the degree to which they
rate literature examines a litany of other negative outcomes at work are impaired [60,61]. As a result, sleepy decision makers in business
beyond the health-mediated effects of absenteeism and pre- contexts making bad decisions fail to realize their mistakes and
senteeism. Thus, current estimates of the business cost of insuffi- miss opportunities to fix them, ultimately harming the business.
cient sleep narrowly focused on health-based mechanisms are However, it is not just extreme sleep deprivation which pro-
severe underestimates of the sum total cost to businesses. duces harmful cognitive effects. The effects of cumulative sleep
restriction on cognitive performance have also been explored as
Individual performance-related outcomes well. In one study, subjects were restricted to 5 h of sleep per night
for four consecutive nights. Resultant cognitive performance dec-
Job satisfaction and customer service rements were compared to that of alcohol consumption and found
to be on par with having a blood alcohol concentration close to the
Sleep deprivation, insomnia, and, poor sleep quality lead to legal limit for driving [62].
negative and unstable moods and emotions [46] as well as low job Innovation is highly valued and considered the lifeblood of
satisfaction [47,48]. Displaying specific moods or emotional states many industries and businesses. Unfortunately, creativity and
to customers is an important aspect of many service-related oc- innovation are substantially compromised by the harmful cognitive
cupations (e.g., “service with a smile”). Sleep deprived employees effects of impaired and shortened sleep. Insufficient sleep lowers
experiencing negative moods are unable to regulate emotional the likelihood of achieving creative insight into solutions to difficult
displays and become less effective in customer-facing roles. This problems. For example, a full night of sleep deprivation leaves
increases the risk of negative customer experiences. Moreover, people 60% less likely to reach such insight [63]. Similarly, sleep
managers seeking to inspire employees are more challenged when deprivation undermines the ability to find linkages between
addressing sleep deprived employees. Indeed, an individual who is seemingly unrelated concepts [64], as well as undermines flexi-
sleep deprived by 2.2 h will perceive his or her leader as 7% lower in bility in cognitive processes [6]. In a field study examining entre-
charisma, even holding constant the characteristics of the leader preneurs, researchers found that the entrepreneurs were less
and the leader's behavior [49]. It is reasonable to assume that creative after a short night of sleep [65].
employees in customer service roles similarly suffer decrements in
their charisma as well. Work engagement and unethical behavior

Decision errors, creativity, and innovation Given the untoward effect of sleep impairment on affect and
cognition, it is no surprise that an interdisciplinary literature exists
The untoward cognitive effects of insufficient sleep are directly examining how sleep influences behaviors relevant to workplace
relevant to work outcomes. Businesses spend tremendous re- success. The effect of sleep deprivation on mood and job satisfac-
sources training employees and actively encourage ongoing tion leaves employees less likely to engage in helping behavior
 C.M. Barnes, N.F. Watson / Sleep Medicine Reviews 47 (2019) 112e118 115

toward their colleagues [48]. More broadly, insufficient sleep leads relationships with their subordinates. The same works in reverse;
to lower levels of overall work engagement the next day [66]. One sleep deprived subordinates express more hostility as well, which
study in particular revealed that an hour less sleep led to an in- undermines their leader's estimation of the quality of that work
crease of approximately 5% in procrastination [67], and a 3%e6% relationship. Subordinates are also unaware of the harmful effects
increase in cyberloafing (measured as Google searches within the their insufficient sleep has on the relationship.
entertainment category) [68]. In the extreme, insufficient sleep can Sleep restricted leaders are also less charismatic and inspira-
even lead to people falling asleep on the job; indeed nearly a third tional and less effective in displaying positive emotions when
of Americans fall asleep at work at least once per month [69]. communicating with subordinates, lowering perceptions of the
Moreover, because insufficient sleep compromises self-control leaders charisma [49]. Thus, sleep restricted leaders are less able to
and moral awareness, unethical behavior becomes more preva- excite and motivate employees to fully commit to their business
lent in the sleep deprived state; a 2.2 h decrement in sleep leads to mission. Given the importance of leader charisma to business
a 10% decline in moral awareness [70]. Because sleep deprivation success, this is potentially a devastating effect.
undermines self-control, it leads to an increase in the prevalence of
unethical behavior [71]. This finding is perhaps the most replicated Team effectiveness
effect of sleep deprivation in the management and applied psy-
chology literature [72e74]. Thus, sleep deprived employees are not A bird's eye view of these aggregated effects highlights how
only less effective in conducting their work, but also more likely to insufficient sleep erodes the value of human capital within busi-
cause harm to the businesses employing them or the customers nesses [3]. Overall, sleep deprived employees conduct their work
they serve through unethical behavior. Simply put, insufficient less productively and ethically, work less well together, make
sleep increases the probability of business scandal. poorer decisions in pursuit of business goals, and lead others less
Overall, the literature indicates a clear impact of sleep on indi- effectively. As a result, work groups are less effective when their
vidual work outcomes. Indeed, one recent study in particular members are sleep deprived [80]. The breadth and depth of this
highlights the breadth of these outcomes. Participants experiencing impairment is undoubtedly underestimated by business leaders,
insomnia were randomly assigned to receive internet-based provided they consider it at all.
cognitive behavioral therapy for insomnia or a waitlist [75]. In
contrast to the control condition, the treated group not only Work characteristics
experienced improvements in their insomnia, but also showed
improvements in their mood, self-control, job satisfaction, helping These harmful effects of insufficient sleep on work are especially
behavior toward colleagues at work, and decreases in negative problematic because workplaces themselves are often a major
behaviors at work. Thus, employees with insomnia become happier contributor to inadequate sleep. Time is a scarce resource and
and more effective employees when their sleep improves. working long hours often comes at the expense of sleep [8]. Further,
work is often scheduled at times conflicting with natural circadian
Interpersonal outcomes rhythms and processes, such that employees trade away sleep time
that otherwise would occur in optimal circadian windows for work
Social loafing and trust activity that is undoubtedly impaired [81]. Late nights spent at
work, early morning start times, and shift work schedules are the
Overall, sleep deprived employees are less effective in con- most obvious example of this tradeoff [11,82e84].
ducting their individual work. However, business success also re- Shiftwork is the most extreme example of mismatches between
quires employees to work together effectively. Unfortunately sleep natural circadian processes and required work schedules. In most
deprivation compromises effective workplace collaboration by people, sleep occurs best at night in conjunction with natural
causing social loafing [76], in which a given member of a group free melatonin secretion patterns from the pineal gland. Many em-
rides on the efforts of others. In the context of negotiation, sleep ployees engaged in work schedules inconsistent with circadian
deprivation undermines trust and lowers the probability of reach- rhythms suffer from shiftwork sleep disorder [41,85]. Suboptimal
ing an agreement [77]. timing of sleep due to shiftwork is a difficult phenomenon that is
unevenly distributed across various groups [86]. Shiftwork is
Abusive supervision, work relationships, and charismatic leadership especially common in hotels and restaurants, transportation and
communication, agriculture, and health industries. Younger adults
Leadership is a topic of paramount importance to businesses. and men tend to be more likely to engage in shiftwork. Those
Leaders are disproportionately influential in directing the efforts of identifying as black are most likely to engage in shiftwork, followed
employees to the benefit of the business. Effective leadership en- by those identifying as Latina and then Asian. Whites are least likely
hances the performance of an entire workgroup, whereas ineffec- to engage in shiftwork. Age is inversely correlated with probability
tive leadership harms workgroup performance. A study examining of engaging in shiftwork. Moreover, a study conducted in Canada
88 leaders across a variety of industries plus their subordinates indicated that immigrants were especially likely to engage in reg-
indicates that abusive supervision increases following a night of ular shiftwork [87].
poor sleep quality, and this led to an immediate commensurate Even lesser forms of work-based circadian mismatches are
decrease in the work engagement of subordinates [78]. In contrast, problematic for the sleep of employees. For example, using
when the same leader gets a night of high quality sleep, abusive smartphones late at night undermines the sleep of employees [66],
supervision the next day is low, with a commensurate benefit to the in part from exposure to blue light that suppresses the natural
work engagement of his or her subordinates. production of melatonin occurring in dim light at night. Travel
Related research indicates sleep of both leaders and sub- among different time zones and being on call for work can also be
ordinates influences their working relationship [79]. When leaders problematic for employee sleep [11].
are sleep deprived, they express more hostility, which undermines Moreover, employee experiences at work can undermine sleep.
their subordinates' estimation of the quality of the working rela- Above and beyond the effects of the number and timing of work
tionship. Even worse, sleep deprived leaders are unaware of the hours, heavy and stressful job demands create anxiety making it
degree to which their own insufficient sleep harms their work more difficult for employees to sleep well at night [81]. Even the act
116 C.M. Barnes, N.F. Watson / Sleep Medicine Reviews 47 (2019) 112e118

of managing emotions when interacting with customers during a physical activity levels, referral for sleep disorders treatment, and
workday can lead to anxiety which produces insomnia [88]. modifying workplace environmental characteristics such as light-
Perhaps not surprisingly, experiencing job insecurity [89], work- ing may serve as effective approaches [103,104]. There are likely
place injustice [90] incivility from colleagues [91,92], and abusive many effective interventions which will be revealed in future
supervision from leaders [93] can all lead to difficulties sleeping research, potentially targeting employees, supervisors, the social
well at night. context at work, and activities outside of work.
Social norms at work can promote the idea that sleep should be Businesses can and should act in their own self-interest by
deprioritized to ensure workplace and career success. Sadly, many facilitating the sleep health of their employees. Sleep medicine
work contexts portray sleep as for the weak, and sleep deprivation researchers must continue deepening their investigations of the
as a badge of honor [2,94]. Leaders can be central nodes for these relationships between sleep and work. Business leaders should
ideas based on the manner in which they communicate about sleep, seek ways to translate this research into work policies not only as a
their role modeling behavior, and how they reward employees for means to improve employee health, but also to improve their own
being available for work during typical sleep hours. These actions bottom lines.
send clear signals that undermine the importance of sleep within a
corporate culture [95]. Conclusion
In addition to these external work factors, employees' own
dedication to work can undermine their sleep opportunities. Em- The sleep community has only recently begun to investigate the
ployees pursuing a calling (having a high passion for work, and impact of sleep on work-related outcomes. However, the literature
experiencing it as meaningful) often have difficulties psycholog- has advanced to the point at which a clear conclusion is possible:
ically detaching from work to get a good night of sleep [96]. When healthy sleep is good for business. Many business outcomes are
employees leave unfinished tasks at work, they often ruminate aided by healthy sleep, and in turn work characteristics also in-
about those tasks in a manner that impairs sleep [97], an effect fluence sleep. Managers of businesses can benefit their organiza-
especially pronounced when leaders have high or unrealistic per- tions by shaping their workplace environments to create better
formance expectations. conditions for employees to get the sleep that they need.
Finally, recent research highlighting work-to-family conflict can
lead to longer sleep latency, insufficient sleep, poor sleep quality,
and insomnia [98e100]. Thus, work can influence sleep through
pressure work puts on family demands, and the time scarcity and Practice points
strain which accompany this role conflict [8,88]. Moreover
increasing the degree to which leaders are sympathetic to  Managers should focus on human sustainability when
employee family demands leads to improvements in sleep [101], leading employees, focusing specifically on sleep health
suggesting that there are workplace interventions which can as a way to sustain high levels of performance and work
address the issue of harmful effects of work on sleep. satisfaction over time
 Ensuring sleep-friendly schedules for employees (or at
least minimizing sleep-disrupting schedules) will improve
Research Agenda for Workplace Health Promotion Programs
employee sleep and work outcomes and increase the
likelihood of attracting and retaining top talent.
Corporate environments which undermine sleep are clearly
 Managers (especially those working in the context of 24 h
harmful to the financial well-being of these business entities. A
operations) should seek ways to mitigate the harmful ef-
corporate culture devaluing sleep encumbers high opportunity cost
fects of non-sleep-friendly work schedules when the de-
akin to commercial aircraft flying with empty seats e the plane is
mands of a work environment forestall the optimization
still in the air, but profits are compromised. The simple, unavoid-
of work schedules for sleep.
able facts are: we spend a third of our life sleeping, sleep impacts
every aspect of human physiology, and there is no substitute for
sleep. Successful corporate leaders understand the crass sentiment
that “sleep is optional” undermines corporate culture and success
by harming employee health and well-being.
All told, businesses that understand the opportunity sleep Research agenda
health affords to strengthen their bottom line would do well to
create a corporate culture valuing sleep. This is best accomplished  Continued expansion of investigations of the effects of
by implementation of Workplace Health Promotion Programs sleep into a broader array of work-relevant outcomes, as
(WHPPs) focused on sleep-wellness and fatigue management to well as the effects of work experiences on sleep
optimize employee sleep health [31]. Indeed, health care spending  Extension of the literature examining the effects of sleep
per employee falls by approximately $3 for every $1 spent on on work outcomes to include chronic sleep restriction
WHPPs, while absenteeism and presenteeism costs fall about $2 for rather than just acute sleep deprivation
every $1 spent on WHPPs [31]. This investment in employee health  Assessment of the benefits of transitioning to a corporate
serves to not only recoup some of the aforementioned costs, but culture that values sleep to prove to upper management
also create a happier workplace that will attract and retain top the investment is worth the cost.
talent [102]. Specific to the context of sleep, an emerging literature  Development of a broader set of interventions businesses
examining employer-initiated interventions to improve employee can use to improve the sleep of their employees
sleep reveals preliminary indications that a potentially broad swath  New research to examine how best to translate this
of interventions such as sleep hygiene education programs, timed literature into policy changes in businesses
napping before or after work, promoting increased daytime
 C.M. Barnes, N.F. Watson / Sleep Medicine Reviews 47 (2019) 112e118 117

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