Shift work: its challenges and management.

Shift work has always been required in nursing homes and hospitals. What is changing is the number of nursing personnel required to participate in shift work. While over one-fifth of the United States workforce is required to do some shift work, the percentage of nurses and health care workers asked to work outside the period from 7:00 a.m. to 6:00 p.m. is considerably higher. As the number of the nation's health care personnel increases, more people are required to work around-the-clock.

Current estimates of the numbers of nursing personnel involved in shift work in nursing homes are not available, but a 1985 survey of registered nurses employed in nursing homes reported that over 40% were shift workers.[1] Approximately 32% of the RNs worked permanent evening or night shifts, and an additional 9% worked rotating shifts. Based on estimates from the last National Sample Survey of Registered Nurses in March, 1992, there were 128,983 RNs working in nursing homes or other extended-care facilities.[2] By calculating 41% of 128,983, we can estimate that 52,883 of these nurses are involved in shift work. Of course, the number of licensed practical nurses and nursing assistants engaged in nursing home shift work is much higher.

With so many nursing personnel assigned to shift work, we can anticipate a high incidence of related problems and concerns for nurse managers and the shift workers themselves. Increased accident rates and decreased productivity are often associated with night work. As a result of the Three Mile Island and Chernobyl nuclear power station incidents, as well as other well-publicized nighttime accidents, the news media have focused increasingly on the dangers of a chronically fatigued and sleep-deprived workforce in the health care, transportation, and nuclear power industries. From the work of many chronobiologists and other scientists researching the effects of shift work on the workers and their output, we now know much more about the problems of shift workers, as well as their solutions. Fortunately, nurses have been the subjects of some of the research studies (although, unfortunately, many limited their samples to European male workers).

In this short article we describe some of the most common problems identified by nurses we interviewed in preparing our recent book[3] and in the shift work literature. We also describe the challenges faced by nurse administrators and managers who supervise shift workers, and most importantly, outline strategies that will help nurse shift workers cope with the stresses they face because of their work schedules.

Problems of Shift Workers

If you were to interview a large group of nurse shift workers, as we did, you would soon be faced with a long list of complaints. The biggest problems for night shift workers are sleep and sleepiness -- often described as not being able to sleep when one is in bed and desiring sleep when at work. These problems are triggered by disruptions of the biological clock, located in the suprachiasmatic nucleus of the hypothalamus, which can interfere with daytime sleep and performance of work.

The biological clock is a circadian pacemaker that regulates the daily rhythms in most of the measurable physiological and psychological functions. Since we are diurnal creatures, these circadian rhythms prepare us for activity during the day and sleep at night. When we change our routine to night work and day sleep, it usually takes well over a week to shift circadian rhythms to accommodate a ten-hour delay in bedtime -- for example, from 1 1:00 p.m. to 8:00 a.m. Field studies show that a complete adjustment rarely occurs, particularly if the day sleep pattern is interrupted on days off.

Interpersonal conflicts and anxiety are also common problems of shift workers on both evening and night shifts. These difficulties arise when the workers' schedules are not synchronized with the day-oriented, Monday-through-Friday pattern of much of society, and most important, of spouses and children. Feelings of isolation, loneliness, and professional isolation can also result. Other nurses complain of a loss of physical and mental well-being. When shift workers do not adapt to the stress of coping with shift work, they may experience sleep disorders, gastrointestinal problems, depression, and substance abuse.

Challenge to Nurse Administrators

and Managers

Although shift work is unnatural for human beings, it is not necessarily a high-risk activity. Except for the approximately 20% of shift workers who have great difficulty adapting to night or rotating shift work, most nurse shift workers can minimize the risks to themselves and their patients by learning and implementing shift work coping strategies. Some of these interventions, however, are beyond the direct control of nursing staff members. Nurse managers assign personnel to shift work and determine the types and hours of shifts, timing of in service education programs, orientation programs, and other supportive services. In view of all this, nurse managers should be familiar with the contraindications to shift work, so that prospective shift workers can be screened appropriately[4] (see Table 1).

Table 1. MEDICAL CONTRAINDICATIONS FOR SHIFT WORK

Definite
Epilepsy requiring medication within the
   last year
Coronary artery disease (especially unstable
   angina or history of MI)
Asthma requiring regular medication (especially
   steroids)
Insulin-dependent diabetes mellitus (permanent
   night shift may be tolerated if
   regularity of regimen can be maintained
   on work days and days off)
Hypertension requiring multiple medications
Polypharmacy (if there are circardian variations
   in medication effectiveness)
Recurrent peptic ulcer disease
Severe irritable bowel syndrome
Psychiatric disorder requiring medication
   (such as chronic depression)
History of shift maladaptation syndrome
Relative
Mild asthma
Non-insulin-dependent diabetes mellitus
History of depression
History of seizures prior to past year (not
   requiring medication)
Mild irritable bowel syndrome, Crohn's disease,
   frequent indigestion
Insomnia
Cardiac risk factors (ie, hypertension or
   elevated serum cholesterol)
Use of medication with significant time-of-day
    variations in effectiveness

Adapted from Scott and LaDoue, 1990, for The Nurse's Shift Work Handbook

Nurse managers must also know the symptoms of Shift Maladaptation Syndrome[5] (see Table 2), so that help can be given to those who do not cope well with shift work.

Table 2. PARTIAL LIST OF THE CHARACTERISTICS OF SHIFT MALADAPTATION SYNDROME

Sleep disturbances and chronic tiredness
Gastrointestinal complaints, ie, heartburn,
   constipation, diarrhea
Alcohol or drug abuse (usually related to
   self-treatment of insomnia)
Higher rates of accidents or near-misses
Depression, fatigue, mood disturbances,
   malaise or personality changes
Difficulties with interpersonal relationships

Adapted from Moore-Ede and Richardson, 1985, and Scott and LaDoue. 1990, for The Nurse's Shift Work Handbook

Ignoring shift work issues can exacerbate patient liability and personnel management problems. These include a high number of patient falls and medication errors; high absenteeism, turnover, and vacancy rates; low recruitment rates; and other quality control and job satisfaction issues.

For nursing home managers a primary concern is whether the best possible shift system is used in the facility. Unfortunately, that concern has no simple solution, as experts do not always agree on a "best" system. In general, there is agreement that a weekly shift rotation pattern is the most harmful to the worker's circadian system. Just as the biological clock begins adjusting to one sleep-activity pattern, it is required to resynchronize to another schedule.

Performance studies of night shift nurses largely support voluntary permanent shifts. Two important factors in recommending this system are the nurse's self-selection of work hours and the nurse's subsequent level of commitment to that shift based on professional, social, domestic, educational, or financial reasons for the selection.

Most nurses who cannot adapt to permanent night work will request a transfer or resign, but some will attempt to work nights in a severely sleep-deprived condition. Thus, nurse managers have an obligation to monitor nurses' performance to ensure that productivity, patient safety, and nursing quality standards are maintained.

Shift Work Adaptation

Strategies

The primary goal of a shift worker, particularly if rotating or permanent night work is involved, is to adapt as quickly as possible to an acute shift in the sleep-activity cycle. Adjusting to night shift work requires a comprehensive set of strategies. Sleep, biological clock, and social/domestic requirements must be viewed as an integrated whole, with the factors affecting each other and how well the individual copes with shift work.

We should also point out that adaptation techniques are different for nurses working a long rotation or permanent night shift than for those working only two or three nights before reverting to a day or evening schedule. The goal of the latter worker is to remain in synchrony with the predominant work schedule and to tolerate the briefly disrupted sleep-activity cycle as well as possible.

Recommended Sleep

Strategies

To aid shift workers in their all-important adaptation, nurse managers can recommend several strategies:

1. Sleep at the same time each day and prevent any interruptions.

2. Sleep in a comfortable, dark, quiet room.

* Disconnect doorbells

* Use an answering machine

* Buy a white noise machine

* Install heavy draperies

3. Eat a light, carbohydrate-type snack before bedtime.

* Don't go to bed hungry

4. Drink warm milk before retiring.

5. Avoid caffeine, alcohol, and nicotine before sleep.

6. Avoid naps if possible, or at least keep them short to avoid confusing your biological clock.

7. Avoid long periods of wakefulness while in bed.

8. Do not depend on sleep medications on a regular basis.

Strategies for different types of shift workers are as follows:

Permanent or long rotation shift worker

1. Go to bed as soon as possible after the shift ends.

2. Avoid sunlight on the drive home after work by wearing sunglasses (this prevents the suppression of melatonin, a pineal gland hormone associated with sleepiness)

3. Eat three regular and balanced meals a day.

4. Initiate or maintain regular physical fitness program (but do not exercise vigorously before going to bed.

5. On days off, maintain as much of the night-active/day-sleep pattern as possible (i.e., go to bed as late as possible and get up late the next day; wear dark sunglasses and stay indoors before noon, eat and exercise as close to the working day as possible).

Rapid rotation shift worker

1. Take naps to prevent excessive sleep debt.

2. Maintain the diurnal orientation by exposure to daylight and a day-active routine of meals and exercise.

3. On days off, take a two-hour nap after the last night shift and sleep as long as possible the next night.

Social and Domestic Strategies

All shift workers can be asked to:

1. Make certain that family and friends understand the shift work schedule and sleeping schedule.

* Post a work schedule

* Hang "Quiet" signs when sleeping

2. Buy headphones for radios, television, and stereo sets.

3. Reserve time specifically for sleep, family interaction, social and professional activities.

4. Share domestic responsibilities with household members.

5. Schedule all appointments and activities outside the fixed sleeping period.

Conclusion

Directors of nursing cannot afford to overlook the large proportion of personnel who work evening and night shifts. Unfortunately, educational and support services that encourage informed shift selection and adaptability are rare. In addition, night shift nurses often feel isolated and ignored by directors of nursing who fail to make rounds or hold regular staff meetings with them. A practical and personalized approach is necessary for coping with the multifaceted problems involved in managing shift work. The challenge we face is to disseminate widely to shift-working nurses and their managers the background concepts, assessment tools, and coping strategies necessary for successful adaptation.

Ruth R. Alward, EdD, RN, is President of Nurse Executive Associates, Inc., Washington, DC.

References

[1.] Jones DC, Bonita AJ, Gowen SC, Williams, RL. Analysis of the environment for the recruitment and retention of registered nurses in nursing homes. US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Washington, DC, 1987.

[2.] Moses EB. The registered nurse population: Findings from the national sample survey of registered nurses, March 1992. US Dept of Health and Human Services, Public Health Service, Health Resources and Services Administration, Division of Nursing, Washington, DC, 1994.

[3.] Alward RR, Monk TH. The Nurse's Shift Work Handbook. American Nurses Publishing, Washington, DC, 1993.

[4.] Scott AJ, LaDoue J. Shiftwork: Effects on sleep and health with recommendations for medical surveillance and screening. Occupational Medicine 1990; 5:273-299.

[5.] Moore-Ede MC, Richardson GS. Medical implication of shiftwork. Annual Review of Medicine 1985; 36:607-617.