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Impact of shift work on critical care nurses.

The health care system provides patient care, 24 hours a day, seven days a week. To provide 24-hour healthcare, most critical care nurses work shift work. Shift work is characterized as having a schedule that fluctuates between working days, evenings, or nights (Treuer, Fuller-Tyszkiewicz, & Little, 2014). Critical care nurses work in a high-pressured environment, as they care for patients with life-threatening conditions (Seright & Winters, 2015). It is imperative for frontline staff to be aware of the negative impact of shift work, as it can have harmful health implications for nurses and their patients (Lin, Liao, Chen, & Fan, 2014). There are positive aspects of shift work such as, working 12-hour shifts allows nurses to have additional days off and an hourly premium when working evenings, nights, and weekends. However, this manuscript will focus on the negative aspects of shift work and will provide strategies to mitigate these effects.

Literature Search

To identify the impact of shift work on critical care nurses, a review of the literature using an online database was conducted. The search terms included 'shift work', nurse, 'critical care', impact, and health. The search was limited to 2011-2016 articles, English language, full text, and peer-reviewed journals. The databases were CINAHL Plus with full Text, Academic OneFile, and Info Trac Health Reference Center Academic.

Potential Negative Impact of Shift Work

Impact on nurses' health

When considering the impact of shift work, the age of the critical care nurse may have an impact on his or her health and nursing practice. For example, weight gain often occurs with age (Letvak, Ruhm, & Gupta, 2013). Reaction time and speed are also known to decrease with age (Letvak et al., 2013). Letvak et al. (2013) state that older workers take longer to recover from fatigue after work. Bogossian, Winters-Chang, & Tuckett (2014) indicated that the older a nurse was, the more difficult it was for him or her to sleep during the day after working a night shift.

However, Bjorvatn et al. (2012) provided conflicting research, as they indicated that the more years worked in shift work coincided with sleeping better. Bjorvatn et al. also found that increased age and experience with shift work may lead to better coping skills with managing shift work. However, Bjorvatn et al. also stated that shift workers' increasing age results in an increased risk for health problems such as cardiovascular disease, anxiety, depression, and gastrointestinal issues.

Stress. Not only is the critical care field highly stressful because of its acuity (Berg, Harshbarger, Ahlers-Schmidt, & Lippoldt, 2016), shift work has also played a role in producing stress (Fallis, McMillan, & Edwards, 2011). Stress is defined as a feeling of being exhausted of all resources and reacting to either a perceived or actual threat (Galdikiene, Asikainen, Balthiunas, & Suominen, 2014). It is known as one of the key contributors to disease (Rathore, Shukla, Singh, & Tiwari, 2012). Stress can cause negative effects to one's physical, emotional, and cognitive well-being (De Bore, Van Rikxoort, Bakker, & Smit, 2014; Galdikiene et al., 2014; Rathore et al., 2012).

Shift workers who commonly work long hours, may be sleep deprived, and are expected to provide competent and efficient care in a loud and possibly chaotic intensive care unit (ICU) (Riemer, Mates, Ryan, & Schleder, 2015). All of which can cause stress. Stress is one of the essential links between shift work and disease (Rathore et al., 2012). Excessive noise levels have also been noted to activate a stress response, in which one's sympathetic nervous system releases epinephrine and norepinephrine, causing the vessels to vasoconstrict and increasing blood pressure and heart rate (Riemer et al., 2015). Riemer et al. (2015) also states that there is a correlation with noise-induced stress and burnout. Implementing strategies to prevent stress will be key in encouraging a healthy lifestyle.

Sleep deprivation. Travel to and from the hospital, providing a report on patient information during shift change, and additional time for home activities all limit nurses' opportunity to achieve adequate sleep (Allen et al., 2014). Sleep deprivation has resulted in multiple adverse effects for nurses, such as loss of appetite, heartburn (Allen et al., 2014; Rathore et al., 2012; Scott, Arslanian-Engoren, & Engoran, 2014; Treuer et al., 2014) cardiovascular disease, hypertension, breast cancer, mental illness, diabetes, and obesity (Allen et al., 2014). Nurses should make considerable effort in attempting to achieve adequate sleep to prevent some of these effects.

Nurses may also experience a decreased amount of sleep when working multiple consecutive night shifts, due to their bodies' internal circadian rhythm, which reduces the drive to sleep during the day (Allen et al., 2014; Boivin, Boudreau, James, & Ying Kin, 2012). The circadian rhythm is an internal clock where attentiveness and the ability to function are often better during the daytime compared to the night. Unfortunately for shift workers, and more so for permanent night workers, their circadian rhythm is misaligned, as they are working during the sleeping phase (Bjorvatn et al., 2012).

Bjorvatn et al. (2012) reported that critical care nurses have poorer quality sleep and are more exhausted when compared to other professions. High levels of stress have also resulted in a poorer quality of sleep compared to a nurse with less stress (Lin et al., 2014). The older population of female shift workers tends to sleep less on their days off due to other responsibilities, such as social obligations or household activities (Matheson, O'Brien, & Reid, 2013; Rathore et al., 2012). Shift workers may also experience disturbed sleep when trying to sleep during the day because of the unavoidable light, heat, and noise. Furthermore, being over-tired and anxious could cause restless sleep (Rathore et al., 2012). Identifying these triggers, which may cause a decreased amount of sleep, should be acknowledged so that the nurse could prevent these disturbances to achieve a better quality of sleep.

Sleep deprivation can also delay a nurse's motor function and reduce awareness, which may result in an increased risk for adverse outcomes for his or her patients (Scott et al., 2014). Allen et al. (2014) noted that a health care worker who is awake for greater than 24 hours has similar psychomotor skills as a person with a blood alcohol concentration of 0.10%, which is above the legal limit in Canada. During sleep deprivation, the prefrontal cortex of the brain is impaired. The prefrontal cortex is responsible for complex cognitive processes that control a person's ability to make decisions, remain calm and maintain alertness, which is imperative in an acute environment such as the ICU (Scott et al., 2014). Either an acute or chronic state of sleep deprivation can lead to impaired cognitive function, such as reduced alertness, attentiveness, response time, and performance. There is also an increase in risk-taking behaviours. These effects are further concerning for critical care nurses who provide care for the severely ill, where patients are unable to protect themselves from the potential mistakes made by a healthcare provider (Fallis et al., 2011; Scott et al., 2014).

Cardiovascular disease. Shift work has been linked to an increased risk for cardiovascular diseases (Bjorvatn et al., 2012; Matheson et al., 2013; Rathore et al., 2012; Treuer et al., 2014). Additionally, shift work can result in unhealthy lifestyle habits, for example, an unbalanced diet, minimal physical activity, and increased smoking habit (Treuer et al., 2014). These behaviours could further transition to additional health concerns, such as obesity or diabetes (Soares et al., 2012).

Gastrointestinal symptoms. Critical care nurses may also suffer from gastrointestinal issues because of working shift work (Bjorvatn et al., 2012; Lin et al., 2014; Matheson et al., 2013; Rathore et al., 2012). Some of the most common gastrointestinal symptoms of a shift worker include "... indigestion, heartburn, stomachache, and loss of appetite.." (Rathore et al., 2012, p. 4310). During the night shift, the nursing staff are more prone to eat poorly and are less likely to have a balanced diet, as they are more inclined to choose "junk" food rather than a healthy snack (Rathore et al., 2012). They are also more prone to drinking soda or caffeinated drinks to keep themselves awake (Rathore et al., 2012). Decisions such as these have led to unhealthy diets, which increase the risk for comorbidities (Rathore et al., 2012).

Mental health illnesses. Shift work has resulted in an increased risk for developing depression and anxiety (Bjorvatn et al., 2012; Fallis et al., 2011; Rathore et al., 2012; Treuer et al., 2014). Bjorvatn et al. (2012) noted that permanent night staff experienced an increased level of depression, as compared to those in a permanent day shift rotation. Rathore et al. (2012) also found that shift workers reported an increased amount of mental health issues, such as sadness and difficulty concentrating.

Critical care nurses must make multiple decisions throughout their shift when caring for critically ill patients. Scott et al. (2014) examined the frequency of clinical decision regret experienced by critical care nurses when fatigued, and additional factors influencing decisional regret. It was found that nurses who worked the night shift and worked 12-hour shifts were more likely to have decisional regret. A nurse with decisional regret also tends to report significant fatigue, poor sleep, and lack of recovery during non-work periods compared to nurses without regret (Scott et al., 2014). Critical care nurses play a vital role as healthcare providers. It is essential that they are aware of the impact that poor sleep and fatigue could have on their care.

Impact on social life

The majority of society functions during the daytime and socializes during the evenings, while nighttime is for sleeping. This is not always the case for shift workers, as they fluctuate between day, evening, and a night schedule. This type of work scheduling can have a major impact on one's social life by making it difficult to maintain a balanced social life. This may result in many events being missed (Powell, 2013; Rathore et al., 2012). As well, because of the risk of developing anxiety and depression, shift work has been linked to an increase in social isolation (Treuer et al., 2014).

Shift work also interferes with family structure and schedule. It may impede parents from seeing their children because of conflicting schedules. This occurs more commonly with adults who have young children who go to bed early. The parent who works shift work may also have an increased amount of stress because of his or her inability to go to school functions or juggling multiple responsibilities. Not only does shift work interfere with family dynamics, it may also have an adverse impact on adult relationships. This could be because a couple may have opposite work schedules and, when this is combined with other competing responsibilities, it may result in the couple having little quality time to spend together (Rathore et al., 2012). Adjustments to one's schedule will be needed to manage these impeding responsibilities.

Patient harm

There is a severe shortage of critical care nurses in Canada (Sawatzky, Enns, & Legare, 2015). This has resulted in multiple overtime shifts and, occasionally, the nurse may be mandated to work an additional shift. Working additional hours can cause mental and physical fatigue, which could put patients at risk for harm (Bjorvatn et al., 2012; Lin et al., 2014; Scott et al., 2014). Not only do critical care nurses work longer hours, the length of shifts has now commonly increased from eight to 12 hours. Unfortunately, there are negative correlations of increased work hours with decreased quality of care, and increased medication errors and near misses (Scott et al., 2014). Frontline staff must be aware of the harmful effects of working additional hours and consider the health implications to not only themselves, but also their patients.

Many critically ill patients in the ICU are dependent on mechanical respiratory support and vasoactive medications for their survival. The possibility of errors could have severe effects on these patients (Calhoun, Boone, Dauer, Campbell, & Montgomery, 2014; Fallis et al., 2011; Trinier, Liske, & Nenadovic, 2016). Edwards, McMillian, and Fallis (2013) identified a correlation between fatigue and patient safety. In their study, managers noted that during the night shift there was an increased amount of medication errors, missed orders, or incorrectly labelled blood samples. They also identified that tiredness not only increased risk of harming patients, but also increased workplace injury and near misses--for example, a nurse experiencing a back injury from moving a patient without the appropriate equipment or a needlestick injury (Edwards et al., 2013).

A medication error could also have detrimental effects on a critically ill patient. It is imperative that the nurse intercepts errors prior to reaching the patient (Ulrich, Lavandero, Woods, & Early, 2014). Unfortunately, sleep deprivation has also resulted in uncoordinated muscle movement and cognitive impairment, such as difficulty problem-solving and decision-making, which could also put the nurse at increased risk for medication errors and accidents (Allen et al., 2014; Bjorvatn et al., 2012; Lin et al., 2014; Scott et al., 2014; Treuer et al., 2014).

Critically ill patients' health conditions could change rapidly. These patients require close monitoring, high-alert medications and invasive interventions. This type of nursing requires the nurse to be alert and observant of any subtle changes. The nurse's ability to deliver timely interventions and avoid unfavourable incidents is essential in fostering the best outcome (Fallis et al., 2011; Newman & Doran, 2012; Trinier et al., 2016). Unfortunately, sleeplessness decreases one's alertness and the ability to recognize other staff errors, which could jeopardize the safety of the patient. Therefore, it is crucial that these risks are identified and minimized to provide safe patient care (Fallis et al., 2011; Scott et al., 2014).

Strategies to reduce the negative impact of shift work

Several authors identified that shift work can cause physical and psychological impairment (Allen et al., 2014; Bjorvatn et al., 2012; Bogossian, Winters-Chang, & Tuckett, 2014; Edwards, McMillan, & Fallis, 2013; Lin, Liao, Chen, & Fan, 2014; Rathore, Shukla, Singh, Tiwari, 2012; Treuer et al., 2014). Identifying strategies to prevent some of these adverse effects of shift work is crucial for critical care nurses, as minor errors may have significant impact on the critically ill (Scott et al., 2014). Critical care nurses and managers must make changes in an effort to reduce the negative impact of shift work.

Preventing fatigue

Fatigue not only impacts the health of the nurse, but also the safety of the patient. Napping during a night-shift break has been identified as an effective strategy to reduce fatigue and improve workplace performance (Edwards et al., 2013). Restorative napping is defined as a short sleeping period for the purpose of reducing fatigue and increasing vigilance during a lengthy shift or a night shift (Fallis et al., 2011). Edwards et al. (2013) found that napping during a night shift resulted in an increase in alertness and a reduction in fatigue and tiredness. Managers should support frontline staff by providing a space that is comfortable and quiet for nurses to nap during their scheduled breaks (Edwards et al., 2013; Fallis et al., 2011). This will also require that the manager encourages frontline staff to take their breaks in an attempt to reduce issues resulting from shift work, such as fatigue (Fallis et al., 2011).

Fatigue has also coincided with the number of hours worked. Rathore et al. (2012) identified workers were increasingly tired at the end of a 10- or 12-hour shift compared to an eight-hour work day. There is also a correlation with increased risk of medication errors and near misses when working a 12-hour shift compared to eight hours (Calhoun et al., 2014). Managers should adjust shift schedules to facilitate an eight-hour day in the hope of reducing fatigue and improving patient safety. Frontline staff should also consider changing their schedules to an eight-hour workday for their own health and the safety of their future patients (Rathore et al., 2012).

Managing stress and overall health

As there is a correlation between stress and shift work, managing stress is ideal to further prevent adverse health effects. There are various approaches to reducing stress. Authors have recommended improving workplace unity, using a multidisciplinary teamwork approach when managing workload, providing a safe environment, and offering guidance at work (Galdikiene et al., 2014; Treuer et al., 2014). Implementing some of these approaches by a critical care manager could foster a work environment that prevents the potential negative health outcomes produced by stress (Treuer et al., 2014).

Nurses' lifestyle choices could also impact their individual health. As there are many additional health implications of shift work, maintaining a balanced lifestyle is very important. Therefore, it is essential to be physically active, eat a balanced diet, and refrain from smoking. It is also important to participate in relaxing activities such as walking, yoga or Pilates throughout the work week and during holidays (Rathore et al., 2012). These approaches will help decrease stress and improve overall health (Rathore et al., 2012).

Improving mental health

Critical care nurses are exposed to excessively noisy and brightly lit ICUs, which can produce an unfavourable effect to their emotional state. Artificial lighting has resulted in changing a person's mood and attentiveness. The combination of a noisy environment, bright lights, and hectic ICU can cause over-stimulation. In the ICU, the level of noise and the brightness of lights commonly surpass health parameters and are considered an environmental pollutant (Riemer et al., 2015). Riemer et al. (2015) recommend the implementation of quiet time, which consists of turning down the lights in the ICU from two to four o'clock in the afternoon. This helps control some of the environmental pollutants, as bright lights can increase stress among the staff. In addition to quiet time, Riemer et al. suggest using dynamic lighting in the ICU. Dynamic lighting provides different hues and brightness to create both a relaxing and mentally alert environment. This type of lighting is similar to the natural changes in daylight, which can provide staff with a healthy work environment (Riemer et al., 2015).

In addition to adjusting the lighting in the ICU, it is also imperative to decrease the noise level. As noise has an adverse effect on nurses, "The World Health Organization recommends sound levels of 35 dB or less in patients' rooms" (Riemer et al., 2015, p. 397). Managers should attempt to reduce the noise level in the ICU to prevent the adverse effects of increasing stress and the probability of staff burnout (Riemer et al., 2015).


In conclusion, shift work can impact nurses' health and social life in a negative way. Additionally, these adverse effects of shift work may also affect the quality of patient care and increase the risk of medical errors. As these negative effects influence critical care nurses' practice and health, it is imperative that they are made aware of these effects and make the appropriate changes to reduce these influences. Strategies to prevent the adverse health implications of shift work on frontline staff include maintaining a healthy lifestyle with a balanced diet and a moderate amount of exercise each week, refraining from smoking, using relaxation techniques, and napping during a night shift. It is important for the manager to introduce a supportive environment that encourages multidisciplinary team work, facilitate eight-hour work shifts, implement quiet time and dynamic lighting, and provide staff with a quiet, dark room to nap in during scheduled breaks.

Even though eight-hour shifts are recommended, they may not be achievable. For some nurses, 12-hour shifts are the preferred shift length. However, these nurses should still consider these strategies to maintain health. The combination of changes made by both critical care nurses and managers will have the greatest impact on preventing adverse effects from shift work.

Cheryl Pryce, MN, RN, Critical Care Clinical Educator, Concordia Hospital, Winnipeg Regional Health Authority (WRHA)

Address for correspondence: Cheryl Pryce, 1095 Concordia Avenue, R2K 3S8, Winnipeg, Manitoba



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By Cheryl Pryce, MN, RN
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Author:Pryce, Cheryl
Publication:The Canadian Journal of Critical Care Nursing
Article Type:Report
Geographic Code:1CANA
Date:Dec 22, 2016
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