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Night shift: problems and coping strategies; here's how to adapt to a way of life that is at odds with the body's natural circadian rhythms.

Night shift: Problems and coping strategies

During my five years on the night shift. I found out that it is a way of life generally incompatible with the human organism. But since almost all of us work nights at some point in our careers as medical technologists, we do well to acquire some coping strategies.

Why would anyone want to work nights? One study claims that nurses go on the night shift so they can be home with their children while their spouses are at day jobs.1 Very few technologists I have known work at night for that reason. Laboratorians usually take the late shift because it is the only job available to them. They stick it out until a day position opens.

In my case, a night supervisor's job was open in the community where I wanted to move, and the shift paid a significant differential. In addition, the hours enabled me to continue my education toward a master's degree with a minimum of conflict.

I found other advantages to working the night shift. Without the support system available to daytimers, you quickly gain confidence in your own knowledge and in your ability to answer questions and solve problems. At the same time, reduced night staffing in all hospital departments draws you closer to others on the health care team.

The night shift is not without problems, however. First of all, most people who work at night are chronically sleepy. They also have an increased risk of gastrointestinal disturbances, including constipation, diarrhea, gastric and peptic ulcers, and gastritis; a higher incidence of neurotic disorders, including anxiety and depression severe enough to require treatment; and increased respiratory and cardiovascular problems.1-4

Basically, health problems occur because the body's natural circadian rhythms say the individual should be sleeping instead of working. Many of the body's physical and chemical functions vary with the time of day. For example, most of us are familiar with the daily changes in cortisol concentration, which peaks in the morning when glucose is needed for activity and reaches its low point late in the evening.

Core body temperature, serum potassium, and growth hormone vary at times during the day, as does urinary excretion of potassium, calcium, and inorganic phosphate. The efficacy of certain medications--insulin and antiepileptic drugs, for example-- changes with the time of day so that either greater or lesser quantities may be needed to obtain the desired therapeutic effects. In fact, one report concludes that every lab value and physiological measurement should be interpreted with regard to the circadian phase at which it was obtained.

Circadian rhythms fall into two groups regulated by intrinsic oscillators called Y and X. The Y oscillator, because of a connection with the optic nerve, is able to detect the presence (or absence) and intensity of natural light, one of the body's timekeepers. Our sleep-wake cycle is controlled by the Y oscillator.

The X oscillator controls the body's temperature cycle, regulates cortisol concentration, and seems to respond to activity. It has a natural 25-hour cycle that adapts to 24 hours with a normal work schedule.

While the two groups of rhythms are synchronized in most people, certain circumstances cause them to get out of phase. Night shift workers are frequently desynchronized because their Y oscillator remains controlled by the presence of natural light, while their X oscillator adjusts to after-dark social and activity stimuli. The result is sleeping difficulties similar to those in jet lag, another condition brought on by desynchronization.

One problem night workers face is an inability to sleep during the day. And since the sleep-wake cycle regulates when they will awaken, it's hard for them to sleep extra hours in preparation for a long night of activity. On the other hand, the cycle does not regulate when someone will fall asleep. This makes it possible to stay up far beyond normal sleeping times.

I used to work from 11 p.m. to 7 a.m., go home, help get my wife and children off to work and school, and fall exhausted into bed between 8 and 9 a.m. About four or five hours later, usually between noon and 2:30 p.m., I would wake up, unable to sleep anymore that day.

Like most night shift workers, I suffered from chronic sleep loss and ran the risk of microsleeps: 3-to 5-second lapses in consciousness that can lead to deep sleep and errors or accidents. Sometimes while doing differentials, I would suddenly find my eyes hitting the oculars as a result of a microsleep. Chronic sleep loss can also lead to a slow but steady decline in performance.5

Night shift workers' problems are not just physiological. Decreased contact with people outside the lab may create social problems, and these are important to the lab because they relate to job satisfaction and the ability to adapt to the shift. Those who are dissatisfied will probably not continue to work nights for very long.

Without family help and support, any tenure on the night shift would have been impossible for me. To spend more time with members of my family, I tried to switch to their schedule during days off from work. But often this would aggravate the problem of circadian desynchronization and fatigue me even more.

A night job leaves significantly less time for sports, hobbies, discussing family problems, working around the house, and entertaining and visiting relatives and friends.2 There are fewer social opportunities because you have to report to work before the party starts or leave when it's getting interesting.

Coping with night work is a problem for the employer as well as the employee. Managers need to select individuals who have a high probability of succeeding on the shift. Although a good test for adaptability to night work has not been devised, the questionnaire shown in Figure I may be helpful for job applicants to use as a self-screen.

Promising applicants are the ones who really want to work nights and feel they can adapt. Those who have never tried such duty should be apprised of the problems that can occur and how one can adjust to them.

Managers should bear in mind that individuals with certain health problems make poor candidates for night work. In the case of diabetics, for example, insulin dosage is hard enough to regulate on a day schedule. With epileptics, there's an increased risk of seizures around 10 p.m., right before the night shift begins. Desynchronization aggravates this and also alters the effectiveness of their medication.2 Anyone with either condition who insists on being considered for the third shift should have a doctor's clearance. Individuals with hypertension, difficulty sleeping, asthma, and gastrointestinal problems should also consult their doctors before applying for a night position.

Scheduling for the night shift should take into account the body's circadian rhythms. That means limiting consecutive work nights to seven or eight at most under normal circumstances and grouping as many days off together as possible. A single night off only enhances desynchronization by starting the employee on a day schedule but not giving him or her a chance to adjust. The employee instead feels more tired and in need of some real time off.

Days off that fall on weekends are desirable because of their social value. In the middle of the week, days off do not allow an employee to fulfill as many social needs and thus may be demotivating. I have also found that a schedule with a regularly repeating pattern enables the employee to plan ahead better and accords equal treatment to everyone.

Ultimate responsibility for adapting to the night shift belongs to the worker who chooses the shift. There are two basic rules to live by: Be good to yourself, and don't feel guilty about getting adequate sleep.

Proper sleep rates the highest priority. A period of four to five hours set aside at the same time every day and reserved for sleep will minimize fatigue. You may, of course, sleep longer or additionally at other times.

Remember that watching television or eating in bed is not equivalent to rest. Also recognize that sometimes--usually on days off--you will be exhausted and sleep a long while. Occasionally, I would sleep as much as 16 hours or very soundly. My wife once let the telephone ring for 20 minutes, and I didn't hear it.

If you plan to work nights for an extended period of time, it may pay to buy blackout shades or soundproof your bedroom walls. Before going to bed, you can unplug the telephone and put a "day sleeper' sign by the door bell. In addition, consider staying awake mornings and sleeping later because afternoon sleep tends to be longer and less affected by the sleep-wake rhythm. This involves a trade-off, though--the loss of valued afternoon and early evening social time. One word of caution: Sleeping pills work by enhancing normal circadian rhythms and their use is not recommended.

When you have the luxury of several days to prepare for the night shift, try to go to bed an hour later each night, following the body's 25-hour temperature cycle. If your schedule doesn't permit doing that, see if napping helps before going to work. Some get a boost from naps, but others have so much difficulty awakening that the benefits are lost.

Don't let yourself become both a day and night person by failing to allot enough time for sleep. You will end up doing nothing well. Try to arrange social obligations, classes, and other activities to complement your sleep and work schedule.

Diet is another important consideration. The same amounts of food eaten at different times during the circadian cycle will have different effects. Because food tends to be deposited as fat when eaten near the end of the cycle, it is best to have your largest meal of the day shortly after awakening. A light snack such as a banana or a sweet roll before going to bed often helps because it can induce serotonin release, which is associated with sleep.1-4,6,7

Intake of caffeine should be controlled to coincide with the times you need to be awake. It has a half-life of about 3 1/2 hours and should be avoided for at least that long before bedtime.8

A modification of the anti-jet lag diet has been suggested for night shift personnel.9 It consists of feasting on the last day of one time schedule and relative fasting or light eating on the first day of the new schedule. I have never tried this diet because it's difficult to implement with two days off, but it may be worth looking into if you work seven days and have seven days off.

Finally, leisure-time activities and exercise are especially important to your well-being. Too often, daily routine degenerates into work, sleep, afternoon soap operas, eating, more television, possibly a nap, and then back to work. Take advantage of the afternoon as a time for physical and educational activities. I studied for a master's by day, bicycling to classes and feeling better for it.

My night shift colleagues pursued a variety of activities before work, including quilting, sewing, painting classes, and playing on a recreational soccer team. Don't let your avocational interests die because you work nights.

After five years I switched to a day assignment, leaving the problems of the night shift behind. The self-reliance I learned at night serve me and my laboratory well in my day position.

1. Reinberg, A.; Vieux. N.; and Andlauer, P. "Night and Shift Work: Biological and Social Aspects.' Elmsford, N.Y., Pergamon Press, 1981.

2. Johnson, L.C.; Tepas. D.I.; Colquhoun, W.W.; and Colligan, M.J. "Biological Rhythms: Sleep and Shift Work.' Jamaica, N.Y., SP Medical and Scientific Books, 1981.

3. Folkard, S.; Monk, T.H.; and Lobban, M.C. Towards a predictive test of adjustment of shift work. Ergonomics 22(1):79-91, 1979.

4. Moore-Ede, M.C.; Czeisler, C.A.; and Richardson, G.A. Circadian timekeeping in health and disease: Part 1. N. Engl. J. Med. 309: 469-476, 1983.

5. Webb, W.B., and Agnew, H.W. The effects of chronic limitation of sleep length. Psychophysiology 11(3): 265-274, 1974.

6. Weston, L. "Body Rhythm: The Circadian Rhythms Within You.' New York, Harcourt Brace Jovanovich, 1979.

7. Moore-Ede, M.C.; Czeisler, C.A.; and Richardson, G.A. Circadian timekeeping in health and disease: Part II. N. Engl. J. Med. 309: 530-536, 1983.

8. Brezinova, V. Effects of caffeine on sleep: EEG study in late middle age. Br. J. Clin. Pharmacol. 1: 203-208, 1974.

9. Ehret, C.F. "The Argonne Anti-Jet Lag Diet.' Washington, D.C., U.S. Department of Energy Publication No. 754-319, Government Printing Office, 1983.

Photo: Figure I How well would you adapt to the night shift?

Complete the following quiz as quickly as possible. Your immediate reaction to each question is sought. Indicate where you fall between the two extremes by placing a short vertical line through the horizontal line under each question.

This is part of a questionnaire developed by Timothy H. Monk, Ph.D., and his colleagues at the University of Sussex, Brighton, England, Dr. Monk is now with the Sleep Evaluation Center, Western Psychiatric Institute and Clinic, Pittsburgh. For questions 1, 3-6, and 8, marks to the far left would indicate you can adapt easily to night work, while marks to the far right would indicate difficulty to adapting. For questions 2 and 7, marks to the far right indicate ease in adapting. If you show no strong preference or your answers are mixed, it cannot be determined how you would adapt to the night shift.
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Author:Sehloff, James A.
Publication:Medical Laboratory Observer
Date:Aug 1, 1986
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