Shift Work Nurses Research Articles

Work‐related fatigue and recovery: the contribution of age, domestic responsibilities and shiftwork

This paper reports a study of the relationship between age, domestic responsibilities (being partnered and having dependents), recovery from shiftwork-related fatigue and the evolution of maladaptive health outcomes among full-time working female nurses. Several studies have suggested that full-time working women with family responsibilities are at greater risk of developing work-related fatigue problems than single women without these responsibilities. A questionnaire was distributed in 2004 to 2400 nurses at two hospitals in Australia, and 1280 responses were obtained (response rate 54%). The data from a purposive sample of 846 full-time working nurses are reported here. Domestic responsibilities were not related to differences in fatigue and recovery. Our results suggested that for full-time shiftworking nurses, being part of a family structure, may actually be protective against the development of maladaptive fatigue. The most important factor determining maladaptive fatigue outcome was shift pattern worked, particularly rotation including night duty. The effect of age was equivocal. The youngest age group reported the highest fatigue and poorest recovery compared to the oldest group, who reported the best characteristics. However, this latter group may represent a particularly well-adapted 'survivor cohort'. The relationship between age and fatigue was partly confounded by older, experienced, nurses with greater job responsibilities, working fewer multiple shifts including night duty. In general, increasing age was not associated with poorer recovery or higher maladaptive fatigue. Unpredictable internal shift rotations, including night duty, which are traditional and typical in nursing, are inimical to maintaining nurses' health. More creative approaches to rostering for nurses working multiple shifts are a necessary step towards reducing wastage from the profession due to chronic work-related fatigue. Younger nurses in particular, may need more support than is currently recognized if they are to be retained within the profession.

P2086 交代制勤務に従事する看護職員の日中の眠気について(一般演題:ポスター,地方の時代の産業保健,第79回日本産業衛生学会)

P2086 交代制勤務に従事する看護職員の日中の眠気について(一般演題:ポスター,地方の時代の産業保健,第79回日本産業衛生学会)

Effects of Shift Work on Autonomic and Neuromotor Functions in Female Nurses

Thirty-seven nurses with shift work, working under a rotating three-shift system, and 37 nurses without shift work, having worked during the daytime for one or more years prior to this study, were examined to assess the effects of shift work on cardiac autonomic and neuromotor functions. Their ages ranged from 25 to 58 yr. The electrocardiographic (ECG) R-R interval variability, %LF and %HF (i.e., proportions of sympathetic and parasympathetic activities, respectively), and LF/HF ratio were computed by means of autoregressive spectral and component analyses. The %LF and LF/HF ratio were significantly larger in the nurses with shift work than in those without shift work, although there was no significant difference in the heart rate-corrected QT interval on ECG between them. And, hand-ear coordination differed significantly between the nurses with shift work and those without. Despite the presence of potential selection bias, it is suggested that shift work in nurses may cause not only a long-term sympathodominant state but also some neuromotor impairment.

Determinants of shift-work adjustment for nursing staff: the critical experience of partners.

Levels of congruence between shift workers and their partners on experiences of shift work are rarely addressed. Partners, however, might be a potential source for validation of shift-work issues in terms of their understanding of these issues and might have an impact on the shift workers' experience of support or personal disruption. Participants consisted of 59 hospital shift-working nurses (55 women, 4 men) and their 59 partners. Two parallel versions of a previous questionnaire (Smith & Folkard, 1993a, 1993b) were used to obtain subjective data from workers and their partners on perceptions of the workers' experience of sleep flexibility and chronotype and lifestyle factors (sleep/fatigue, health/stress, and social/family) relating to tolerance across three shift types: day, evening, and night. All participants provided information on ideal shift choice and ratings of their own personal disruption and family, communication, and relationship issues. Results indicate that shift workers and their partners are congruent in their perceptions of the impact of shift work on the worker in all three lifestyle factors relating to tolerance across the three shift types. Shift workers experience more health/stress and social/family problems on the evening shift; this is related to their partners' increased sense of personal disruption. Similarly, when partners report the perceived impact of shift work on these same dimensions, it is associated with shift workers' heightened sense of personal disruption. Fewer sleep/fatigue and health/stress problems on the night shift are related to greater sleep flexibility, and evening types experience increased sleep/fatigue problems on the day shift. Social measures (particularly the personal disruption of the partner) rather than biological measures are the greatest predictors of shift workers' personal disruption. Findings are supported by qualitative data. It appears that the partner's understanding and own sense of disruption is critical to the experience of the shift worker regarding coping and predictability of tolerance.

Free cortisol awakening responses are influenced by awakening time

Psychobiological investigations on the hypothalamus–pituitary–adrenal (HPA) axis depend on markers that adequately describe the activity of this system. There is evidence that the free cortisol response to awakening, proposed as a marker for the HPA axis, can be influenced by time of awakening. To further investigate this possible confounder, 24 shift working nurses and 31 female students on a regular sleep–wake cycle collected saliva samples 0, 30, 45 and 60 minutes after awakening. Nurses were investigated on the first and second day of their early (awakening: 0400–0530 h), late (awakening: 0600–0900 h), and night shift (awakening: 1100–1400 h), respectively. Students were studied after taking a short nap on two consecutive weekdays (awakening: 1845–2030 h). Mean cortisol levels after awakening increased significantly under all three shift conditions ( p<0.01), but decreased in the student sample ( p<.05). Within the three shift conditions, cortisol responses following waking in the early shift were more pronounced than in late ( p<.01) and night shift ( p<.05). The present study shows that in a sample with a large range of awakening times, an impact of this variable on the cortisol awakening response can be observed. The data furthermore strongly suggest that waking up per se is insufficient for adrenocortical stimulation.

Does shift work lead to poorer health habits? A comparison between women who had always done shift work with those who had never done shift work

Shift work has been reported to predict health problems, and a possible explanation is that shift work may lead to poorer health habits, thereby increasing a person's vulnerability to illness. This study examined the association between shift work and health habits, as indicated by smoking, alcohol intake, physical activity and by being overweight. A questionnaire was sent to all 2795 female nurses working in the 10 hospitals of two Finnish health care districts. From the 2299 respondents, we selected those 506 shift workers who reported having always done shift work and those 183 day workers who had never done shift work. Shift workers were found to smoke more and to be overweight more often than day workers. These differences gradually increased in each successive age group, being 1.94 pack-years in smoking and 0.9 kg m-2 in body mass index among nurses over 45 years of age. Shift work was not associated with alcohol intake or sedentary lifestyle. This evidence is compatible with the possibility that shift work in nurses increases smoking and being overweight to a degree that contributes to health problems, including coronary heart disease.

Reply

Deputy Anaesthetist-in-Chief, TGD, Department of Anaesthesia, The Toronto Hospital, 585 University Avenue, Toronto, Ontario M5G 2C4, Canada.In Reply:-I appreciate the comments made by Drs. Dexter and Macario regarding our prospective, randomized, controlled trial on the economics of “fast-tracking CABG surgery.”[1] They agreed with our conclusion that early extubation reduces cardiovascular intensive care unit (CVICU) and hospital length of stay and does not increase the rate or cost of complications when compared with patients in the late extubation population. High CVICU costs can be shifted to the lower surgical ward costs, and early extubation improves resource utilization after cardiac surgery. However, they questioned the methodology used for our findings that early extubation reduces overall hospital costs of CABG patients by 25%, mostly in nursing and CVICU costs.As stated in our methodology, we included discharge criteria costs to show the potential for further cost savings in patients having cardiac surgery when postoperative management is maximized. We calculated direct variable costs as the product of the hourly salary of overtime and part-time nurses. The cost of full-time nurses and respiratory therapists were added as direct fixed costs. Our conclusion that early tracheal extubation reduces overall hospital costs by 25%, mostly in nursing and CVICU costs, was referred to in table 2. In this table, we included all of the actual CABG costs adjusted for all complications from preoperation to hospital discharge. Our findings confirmed that the time savings equate with our budgetary savings in a decrease in the number of scheduled staff.Drs. Dexter and Macario correctly indicate that having enough nurses “on average” is insufficient when scheduling CVICU nurses and respiratory therapists for cardiac surgery. Nurses should be present to care for patients at all times. Our cost savings in the CVICU came from reduction in the number of afternoon and evening shifts of nurses and respiratory therapists working in the CVICU. As indicated in our discussion, to maximize the cost savings in early tracheal extubation, early tracheal extubation should be instituted as part of a fast-track cardiac program. A comprehensive or coordinated preoperative, intraoperative, and postoperative management or clinical pathway will minimize variation and maximize patient discharge from the CVICU and hospital.Regarding the comments about the source of variation in our analyses: First, at our institution, we do not have much variation in the number of patients having CABG surgery. Each day, we have five cardiac operating rooms with 10–12 patients processed through our system for admission to the CVICU and step-down unit. Second, the variation in patient discharge time from the CVICU also is kept at a minimum. At our institution, we have two transfer times for patients out of the CVICU at 10:00 AM and 2:00 PM, so that we have the flexibility of reducing the nursing:patient ratio in the PM hours by not having to call in part-time or shift nurses to the CVICU. These cost savings are made possible with early extubated patients.There is no easy answer for what is the necessary minimal daily volume of CABG patients for a CVICU to gain from a decrease in time to discharge by using early tracheal extubation. This depends on the flexibility of the CVICU to adjust their nursing shift work, e.g., three 8-h shifts per day or two 12-h shifts per day. Early tracheal extubation will allow the reduction or shifting of nursing staff costs to other cost centers in the PM hours, according to the ratio of nurses-to-patients after extubation. There should not be any excuse, even from smaller centers with a fixed number of CVICU nurses, to not practice early extubation because we also have demonstrated that early extubation after cardiac surgery does not increase perioperative morbidity. [2] Nonetheless, to give an example from our own institution, we did 2,303 cardiac cases this past year with a pool of 40 full-time equivalent (FTE) nurses, plus 11 FTE part-time nurses for a total of 51 FTE. This equates to an average of 45 cardiac cases per 1 FTE. Holiday time and flexible time schedules for the nursing staff also were considered. With early extubation and lowered clinical acuity of the patients in the CVICU, further savings can be achieved by teaming nursing staff with nursing assistants.Davy C. H. Cheng, F.R.C.P.C.Deputy Anaesthetist-in-Chief, TGD; Department of Anaesthesia; The Toronto Hospital; University Avenue; Toronto, Ontario M5G 2C4; Canada(Accepted for publication April 25, 1997.)

Effects of bright artificial light on subjective mood of shift work nurses.

The effects of bright artificial light on the subjective mental state of 10 female nurses working shifts at a university hospital were assessed. We investigated two series of five consecutive workshifts rotations comprising one normal, two night and two evening shifts, using two self-administered rating scales. The subjects were exposed to artificial light, brighter than 3,000 lux, for a total of 30 min during each workshift of the second series, whereas they worked under normal lighting conditions (approximately 250 lux) during the first series. A three-way layout ANOVA, with repeated measures, revealed that bright light tended to improve eagerness and reduce tension, and improved vigor, eagerness, appetite and impairment (the latter only on the second night) significantly or nearly significantly during night, but not evening, shifts. These results suggest that bright artificial light affects the mental state of nurses during night, but not evening, shift work.

Focus group evaluation of night nurse shiftwork difficulties and coping strategies.

Focus group interviews were performed on 45 intensive care nurses who worked 12-h shifts in a large metropolitan hospital. The purpose of this study was to identify nurses' perceptions of difficulties associated with shiftwork and coping strategies used to combat them. Overall, the findings were not different than those currently discussed in the literature. For example, nurses frequently utilized white noise, telephone answering machines, and light-darkening shades to improve the quality and quantity of day sleep. They also used exercise and increased early shift caffeine consumption to improve night work performance. However, the major incentive for performing night work for these nurses was a high shift differential that equaled approximately 20% of their hourly salary. Most nurses also felt that group educational interventions regarding shiftwork difficulties and coping strategies would be preferred to individual counseling. The most significant finding of this study was the discovery of an extremely high incidence (95%) of automobile-related injuries and near-accidents that occurred while driving to and from the workplace, potentially posing a significant public health risk.

The Use of Survey Measures to Assess Circadian Variations in Alertness

Current models of sleep regulation postulate both a homeostatic and circadian component and promise an understanding of disturbed and displaced sleep. Estimates of these components have traditionally required relatively cumbersome and costly measures, including sleep electroencephalograms and continuously recorded rectal temperature, but it has recently been demonstrated that they may successfully be based on frequent (e.g. 2-hourly) concurrent ratings of alertness. This paper examines whether similar results might be obtained using retrospective survey measures of alertness obtained from shiftworking nurses at a single sitting. These retrospective measures are shown to be sensitive to both time of day and shift, to have a high level of reliability even for relatively small sample sizes (e.g. 10) and to be valid predictors of more traditional concurrent measures of alertness. It is concluded that retrospective alertness ratings may prove to be an extremely cost-effective method for examining the trends in alertness in various groups, including those suffering from specific types of sleep disorder.

Recovery from work shifts: how long does it take?

Although regulations on work hours usually include a minimum weekly rest period, there is little empirical evidence concerning recovery from work. Shift-working nurses (N = 61) used a handheld computer for 28 days to complete self-ratings, cognitive-performance tasks, and a sleep diary. Many measures were worse on rest days that followed a night shift rather than a day shift and tended to be worse on first rest days compared with subsequent rest days. Alertness was lowest on the 1st rest day following a night shift. Social satisfaction was better on workdays that were preceded by 2 rather than 1 rest day. Reaction time decreased over consecutive night shifts and tended to increase over rest days following night shifts. The results are interpreted as being consistent with the combined adaptive costs of fatigue and adjustment to and from a nocturnal routine. The practical implications for scheduling rest days are considered.

The effect of music, therapy, and relaxation on adrenal corticosteroids and the re-entrainment of circadian rhythms.

The purpose of this study was to measure the effects of music, progressive muscle relaxation (PMR), and guided imagery (GI) on the adrenal corticosteroids, or "stress hormones." Hypotheses were designed to evaluate the effect of a taped induction of music/PMR/GI on the mean level (1), circadian amplitude (2), and circadian re-entrainment with body temperature (3) of urinary corticosteroids. Urine collections and body temperature were recorded in shift-working nurses during three 4-5 day intervals over a 1-month period. The nurses listened to the tape on a daily basis, commencing after the first recording period. Results indicated that circadian amplitude decreased significantly (p = .007), and corticosteroid and temperature rhythms were significantly (p less than .01) more entrained during the tape conditions. The mean corticosteroid level also declined during tape listening, but nonsignificantly (p = .15). Because of the close relationship between corticosteroids and the immune system, these data suggest a relationship between music/relaxation techniques and physical health.