This week I read the poignant and humorous essay “Lullaby” by Rebecca Ashcroft about her work as a night shift nurse at a hospital (In: The Healing Art of Writing. U CA Press, 2011). She makes the case for why night duty nursing works best for her while she is raising two children. She gets to go to soccer practices and piano recitals. But she doesn’t gloss over the downsides of night nursing—the falling asleep at inconvenient times and in inconvenient places, the mood swings/crabbiness of sleep deprivation, etc.
Night shift nurses are sometimes referred to as the forgotten nurses. Most patients in hospitals (if they are lucky) sleep through most of the night and never really remember the nurses who check on them in the wee hours of the morning. Nursing leadership and the rest of hospital administration acknowledges their essential function, but rarely actually see them. Working night shift is often considered a career stall if not an outright career killer, because of the invisibility to daytime administration. It’s also sometimes looked down upon as the ‘easy shift’ since not as much is going on during the night—no tests or surgeries being scheduled for patients. The hard part of night shift nursing is the pesky sleep issue for nurses, so it still comes with a pay differential.
Early in my career when I worked as a hospital nurse on a spinal/brain injury rehab unit, I chose to work evening shift. This was when they still had three 8-hr hospital nursing shifts instead of the more common 12-hour shifts they have now. I liked evening shift because it wasn’t as hectic as daytime shift with its PT/OT/procedures, so I got to spend more time one-on-one with my patients, as well as with their families. When I worked in a nursing home as a nurses’ aid I sometimes was asked to work an evening and a night shift back-to-back when they were understaffed. I remember stumbling home after those double shifts as if I were drunk. Indeed, sleep deprivation can be as bad as alcohol intoxication for basic brain functioning. Not safe for driving home after work and not safe for patient care duties.
Research shows that night shift nurses have higher “sleep debt,” worse circadian rhythm disorders (think chronic jet lag), higher risk of obesity (poor eating options at night plus hormonal/metabolic imbalances from night duty), and higher rates of certain types of cancers (especially colon cancer). Lack of adequate sleep and working too many consecutive hours is linked to higher risk of serious patient adverse events. This is why there have been significant changes by accrediting bodies limiting hours of medical residents (to 80 hours/week). This is similar to aviation rules mandating maximum number of hours that pilots and flight attendants can work. The aviation rules are better enforced since it is a federal mandate through FAA. Limits to medical resident hours are voluntary and rely on self-report.
Ann Rogers, who is Associate Professor at the University of Pennsylvania School of Nursing is an expert on the issue of night shift nursing, health and patient safety. In Patient Safety and Quality: An Evidence-based Handbook for Nurses (AHRQ, 2008) she has a chapter entitled “The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety.” There’s a handy algorithm for nurses to use in assessing risk due to sleep deprivation/disruption. It starts with “Have you had at least 7 hours of sleep in the 24 hours prior to starting your shift? It includes “fatigue management” strategies, including naps and caffeine use. Seemingly not endorsed by Starbucks, she writes, “Caffeine should be used therapeutically. Caffeine should not be consumed on a regular basis or when alert.” (p 11)—then “Do not consume caffeine outside of work.” (p. 12) This does not seem to be very practical advice. The short naps strategy can work, but only if supported by colleagues and administration. Many nurses do not even get to take uninterrupted scheduled lunch breaks—which is when sanctioned naptimes could occur.
Hospitals provide 24/7 nursing care, so night shift nursing is an essential—if forgotten, overlooked, or undervalued—part of heath care. I raise a toast (of my double-tall vanilla soy latte) to all you dedicated if sleep-deprived night nurses out there!