Heather A. Straight, RN, BScN Student Number: V001526916
Unhealthy Healthcare?
A Project Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Nursing at the University of Victoria.
Supervisory Committee
Dr. Carol McDonald,
University of Victoria School of Nursing Associate Professor, Supervisor
Dr. Lynne Young,
University of Victoria School of Nursing Associate Professor
Abstract
British Columbian nurses are experiencing alarmingly high rates of sick-time, injury claims and long-term disability claims. Compared to 47 categories of occupation, nurses have the highest rates of illness and injury-related absenteeism. Ironically, these injuries and illnesses occur while nurses are ‘caring’ for others. Is it time we ‘cared’ for nurses? The purpose of this paper is to discover what is known about the ‘health and safety’ implications for nurses working shift work and what strategies can be used to prepare and support nurses in their practice settings? The topic is addressed at three levels; 1) micro which focuses on the individual nurse; 2) meso which addresses environmental and organizational factors; and 3) the macro level which refers to organizations influencing nursing such as governments or national organizations.
Shift workers are known to experience a higher incidence of sleep distrubances, disrupted eating patterns and work-home conflict. Fatigue, a common complaint of shift workers, can negatively impact nurses’ lives both on and off the job. In addition, shift workers may suffer social isolation as their shifts are misaligned as compared with that of their friends or familes.
The findings of this paper conclude there is a lack of shift worker education, both in the academic and practice sectors in nursing. Although there has been a lot of research conducted about shift work, there has been very little resultant action in the practice setting. Nurses must work shift work to provide 24-hour care for their patients so a greater commitment from every level, micro, meso and macro is needed to support nurses to safely work shift work.
Acknowledgements
I would like to acknowledge and thank my supervisor Dr. Carol McDonald for her wisdom, calm demeanor and continuous support, Dr. Lynne Young for inviting me to reflect deeper, and for sharing her contagious passion for nursing education and to their colleagues at the University of Victoria for providing a rich learning experience.
Maintaining balance has always been an essential part of my life. Therefore, I would like to acknowledge and thank those who have helped keep my life in ‘balance’; my running partners’ Maria Jauristo and her dog Ruby, and my dog Crewe; to Michele Watters and her dog Isabella for our weekend walks in the forest; and Jayne Loutit for our stress-relieving swims, workout sessions and Friday night yoga. Many thanks to Darlene Stewart who deserves an honorary degree for proofreading my papers and listening to me talk about discourses and ideologies. Thanks to my parents Margaret and Walter McKenzie who continue to be an inspiration. And finally Meghan, Angus and Ron, thank you for your understanding, support and encouragement.
Table of Contents Supervisory Committee ii Abstract iii Acknowledgments iv Table of Contents v Chapter 1. Introduction 1 Research Question 2 Background 2 Search Methods 4 2. Literature Search 5 Fatigue 5 Health 9 Health Habits 11 Nurse Safety 13 Shift Schedules 14 Historical View 16 Patient Safety 16 3. Critical Analysis 17
Advanced Nursing Practice 17
Educational Theory 19
Literature Findings 20
Discourses 21
Health Versus Safety 21
Lifestyle Choices 22
Napping 22
Patients’ Versus Nurses’ Needs 23
Micro Level 23
Shift Work Education 23
Meso Level 27
Macro Level 29
An Ethical Lens 30
4. Recommendations 31
Micro Level Recommendations 31
Meso Level Recommendations 32
Macro Level Recommendations 34
Research Recommendations 35
Summary 37
References 38
Chapter One Introduction
I began critically examining shift work in 2005 when I became the project coordinator of the ‘Shifting to Wellness in Healthcare’ research project. Initially, I thought I had the knowledge and experience to inform others about shift work. After all, my husband and I had raised a family while both working shift work, while remaining healthy and being an integral part of our children’s lives. Through trial and error we had learned to ‘cope’ or ‘ignore’ the negative side effects of working shift work, instead choosing to embrace the advantages shift work afforded us like the ability to ski mid-week at Whistler, pick up our children from school, and experience traveling for extended periods of time. As I delved more deeply into the literature, I quickly realized how little I knew about the ‘health and safety’ risks to myself, my family or the motorists with whom I shared the roads. For example, how safe was it to drive from Vancouver to Whistler after a busy nightshift? This ‘aha’ moment was shocking to me. I understood how my fatigue could impact patient safety by making medication or charting errors, but I had not associated my fatigue with risking my ‘health or safety’. I began to question why nurses did not receive educational strategies to prepare them to undertake shift work with a view to minimizing ‘health and safety’ risks.
In this paper I describe the problem, provide background information about the significance of the topic within the healthcare sector and summarize findings from a literature review. Following an analysis of the issues, I will identify the gaps and provide recommendations.
For the purpose of this paper, the term shift work will refer to work done outside of daytime hours, incuding evenings, weekends and nights, overtime and extended work hours (Costa, 2003; Samaha, Lal, Samaha & Wyndham, 2007; Trinkoff, Le, Geiger-Brown & Lipscomb, 2005). The expression ‘variable shift’ and more recently ‘non-standard’ working hours have also been used to describe shift work (Costa, 2003). Research Question
What is known about the ‘health and safety’ implications for nurses working shift work and what strategies can be used to prepare and support nurses in their practice settings?
It is important to appreciate that this project will not address patient safety but rather, focus on the ‘health and safety’ risks for nurses. This in no way diminishes the importance of, or concern for, patient safety but instead is intended to illuminate the implications to nurses’ well-being.
Background
Nursing is known as the ‘caring’ profession (Brilowski & Wendler, 2005; Rolfe, 2008). To provide ‘care’ for clients, their families, or their communities, nurses
continually advocate for safe, ethical and appropriate practice environments (College of Registered Nurses Association of British Columbia, 2008). It is therefore ironic to have discovered that these ‘safe’ practice environments can, paradoxically, be unsafe for the very people who work so hard to provide a high level of care. Nurses experience alarmingly high rates of sick time, injury claims and long-term disability claims. The Canadian Nurses Association (2006) reports, that nurses working in publically funded
health care sytems have the “highest rates of illness and injury-related absenteeism” compared to 47 categories of occupation (p. 1). From a provincial lens, over $12 million dollars is paid annually in time loss claims for injured or ill British Columbian nurses. Musculoskeletal injuries (MSI) account for the largest category, with 55% of the WorksafeBC claims (WorksafeBC, 2009).
Nurses’ practice environments have changed significantly over the past few decades with patient acuity, workload, nurses’ absenteeism and sick time increasing (Canadian Nurses Association, 2006). There is a global nursing shortage causing
employers to compete to recruit and retain both local and international nurses (Dendaas, 2004; Macfarlane & O’Brien-Pallas, 2004; Peter & Hinshaw, 2006). Nurses are often asked to work long-hours plus overtime in an attempt to ‘care’ for their patients and support their colleagues. The Canadian Federation of Nurses Unions (2008) reports, “in 2005, RNs worked an estimated 18.2 million hours annually in paid and unpaid overtime-the equivalent of 10,054 full-time positions” (p. 1). These long working hours have been linked to both decreased patient safety and nurses’ ‘health and safety’ (Trinkoff, Geiger-Brown & Lipscomb, 2007; Rogers, Hwang, Scott, Aiken & Dinges, 2004). To complicate an already fragile healthcare system, the nursing profession is aging, with the average age of a registered nurse (RN) being 47.6 years (Canadian Nurses Association, 2006).
Furthermore, unlike other sectors that have implemented shift work purely for economic reasons, to increase productivity, the healthcare sector has a professional obligation to provide patient/resident care 24-hours a day, seven days a week (Folkard & Tucker, 2003). This means nurses must work shift work.
Before delving into the topic of shift work, it is important to reflect on the ‘context’ in which nurses are working. Could there be a correlation between nurses’ increased injuries and illnesses and the nursing practice environments that include shift work? Or is working shift work an isolated risk factor? Shift workers are found to have a higher incidence of health concerns such as; 1) cardiovascular disease, 2) gastro-intestinal problems, 3) depression and 4) sleep disturbances (Berger & Hobbs, 2006; Costa, 2003; Muecke, 2005). Nurses working shift work are challenged to fit regular family, social and leisure time activities around irregular work schedules. In addition, shiftworkers have an increase in negative health habits including smoking, alcohol consumption, poor dietary practices, and a lack of regular exercise. These adverse health habits contribute to chronic health concerns such as obesity and diabetes mellitus, often resulting in the ‘caregivers’ requiring care themselves (Zhao & Turner, 2008).
Search methods
The databases utilized for the literature search included the Medical Literature Analysis and Retrieval System (Medline), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Educational Resources Information Center (ERIC). CINAHL provides access to nursing journals from 1982 and includes books, conference proceedings and dissertations. Medline/PubMed “covers approximately 3,200 journals world-wide” and has an international, evidence and research-based focus (Timmins & McCabe, 2005, p. 45). The ERIC database provided an educational perspective, with access to an on-line library with “education literature to support the use of educational research and information to improve practice in learning, teaching, educational
decision-making and research” (Educational Resources Information Center, 2009). The ERIC database provided access to educational literature that I had not successfully retrieved using the other databases, for example, what educational materials are available for shift workers? The librarians at the College of Registered Nurses Association (CRNABC) helped focus the search by using two key words ‘shift work’ and ‘nursing’. Using an advanced search, nursing was truncated and the relevant words were added. For instance: fatigue, safety, sleep, sleep deprivation, depression and education. Additionally, I found some informative articles by examining the reference list of articles that I had retrieved. Another resource I used was grey literature, which includes studies with limited
distributions, dissertations, or un-published reports (Polit & Beck, 2008). Although as I discovered, grey literature has limitations such as author bias and it is not peer-reviewed.
Chapter Two: Literature Search
The literature search section is presented in themes to help identify the many threads associated with the ‘health and safety’ risks for nurses working shift work. Fatigue
Fatigue impacts nurses’ personal well-being and their ability to provide effective patient care, in a deleterious way (Lockley, Barger, Ayas, Rothchild, Czeisler &
Landrigan, 2007; Muecke, 2005; Rogers et al., 2004). Interestingly, there is no agreed-upon definition of fatigue in the literature, but there are common threads (Samaha, Lal, Samaha & Wyndham, 2007; Shen, Botly, Chung, Gibbs, Sabanadzovic & Shapiro, 2006). Therefore, I am using fatigue in this paper to mean drowsiness, weakness and depleted energy that can result in ‘nodding off’, including micro-pauses, ‘night shift paralysis’ when the worker is conscious but temporarily unaware of the surroundings and
‘automatic behavior’ (Vancouver Coastal Health, Providence Health Care & Keyano College, 2007).
Fatigue can be further described as acute sleep deprivation or chronic partial sleep deprivation (Lockley et al., 2007). Acute fatigue or acute sleep deprivation can occur when a nurse has continuously been awake for greater than 17 hours. At this point, deterioration in performance has been noted in many studies (Fitzpatrick, While & Roberts, 1999; Rogers et al., 2004; Trinkoff et al. 2007). The effects of acute sleep deprivation can be reversed with a good night’s sleep, as opposed to chronic partial sleep deprivation which is more severe. Chronic partial sleep deprivation or chronic fatigue builds up over long periods of time, weeks or months. If a nurse continually fails to get a sufficient amount of sleep, a cummulative effect can lead to persistent tiredness and decreased performance (Samaha, Lal, Samaha & Wyndham, 2007). Lockley et al. (2007) assert “performance continues to decline during several weeks of chronic partial sleep deprivation, subjective ratings level off, making self-assessment of fatigue and
performance unreliable, much in the same way that occurs following alcohol
consumption” (p. 8). Blachowicz and Letizia (2006) agree, “Fatigue is a subjective state that cannot be measured objectively: in fact, the person experiencing fatigue may not be fully aware of it.” (p. 274). Shen et al. (2006) report “there is no ‘gold-standard’ test for fatigue” (p. 1). What are the ramifications of chronic partial sleep deprivation in the workplace? How does chronic fatigue impact the individual nurse’s health and his/her ability to interact socially?
Humans are regulated by internal circadian rhythms to be alert during the day and sleep during the night. In addition to sleep, this 24-hour internal clock regulates alertness and other physiological and behavioural processes, including the digestive system and body temperature. Circadian rhythms are strongly influenced by environmental cues such as natural light, meal times and clock time (Horrocks & Pounder, 2006). Circadian misalignment can cause night workers to feel like they are experiencing ‘jet lag’ and disorientation as their body attempts to adjust to being ‘awake and alert’ at night or asleep during the day (Lee, 2003; Lockley et al., 2007; Shen et al., 2006). This disruption in circadian rhythm, also referred to as ‘shift-lag syndrome’, “is characterized by feelings of fatigue, sleepiness, insomnia, disorientation, digestive troubles, irritability, poorer mental agility and reduced performance efficiency” (Costa, 2003, p. 84). An integrative literature review and meta-analysis by Muecke (2005) concludes night workers often suffer from sleep disturbances due to insufficient restorative daytime sleep (between night shifts) and disrupted circadian rhythms causing body ‘disharmony’. “Given that day sleeps are often one to four hours shorter than night sleeps, night nurses may accumulate a significant number of hours of sleep debt even in just 1 [sic] week, contributing to long-term exhaustion.” (Muecke, 2005, p. 435).
In an attempt to quantify the risks associated with fatigue, Dawson and Reid (1997) studied the effects of both alcohol and fatigue related to participants performance impairment. Although published in 1997, this study is still widely cited. Forty
participants enrolled in the counterbalanced experiments in which the participants in the first experiment stayed awake for 28 hours from 8:00 in the morning until 12:00 noon the following day. The second experiment had participants consume a specific amount of
alcohol at 30 minute intervals until their blood alcohol concentration (BAC) reached 0.10%. A computer-administered test of hand-eye coordination was administered at different intervals in an attempt to measure cognitive psychomotor performance. After 17 hours of being ‘awake’ cognitive psychomotor performance was found to be equivalent to a BAC of 0.05% and after 24 hours was equivalent to 0.10% (Dawson & Reid, 1997). To put this into perspective, in most countries a driver is considered legally impaired with a BAC of 0.05% although it is 0.08% in Canada (Paciocco, 2002). Muecke (2005) linked these research finding to nursing practice and suggests:
if a nurse was to get up at 07:00 hours on the first day of a period of night duty, 24 hours later that nurse would be completing the night shift with performance levels equivalent to those associated with a blood alcohol level of 0.10%. (p. 435)
Based on my experience, I believe that Muecke’s link to healthcare workers is pertinent. I have been told anecdotally by many nurses that they get up with their children in the morning, are busy all day with home and family activities, and then go to work for their first night shift. If they can not nap on the night shift, they will have been awake for over 24-hours. Interestingly, the State of New Jersey (2003) passed a law allowing prosecuters to charge motorists with vehicular homicide if proven to have been driving while fatigued. Fatigue as defined in this law means “having been without sleep for a period in excess of 24 consecutive hours” (210th Legislature, New Jersey State, p. 2). If convicted the crime is punishable by up to ten years in prison and a $100,000 fine. This law is named after a college student Maggie McDonnell who was killed in 1997 by a drowsy driver who admitted to being awake for more than 30 consecutive hours (Stayed,
2009). How many nurses are driving in this state and are potentially unaware of the devastating consequences of their actions?
Health
An analysis of four large studies concluded, “Research now suggests a link
between exposure to light during the hours of darkness, as occurs with night workers, and an increased incidence of cancer, particularily breast cancer” (Hume, 2005, p. 20). Davis, Marick and Stevens (2001) reported a 60% increase in the incidence of breast cancer amongst the 800 participants working night shifts. In addition to breast cancer, the Nurses’ Health Study, an on-going study started in 1976 and expanded in 1989 with over 230,000 American nurses participating, recently reported nurses working rotating night shifts “had a 35% increased risk of colorectal cancer and a 47% greater risk of
endometrial cancer” (Nurses’ Health Study, 2008, p. 5)
In 2007 the International Agency for Research on Cancer (IARC), the cancer agency of the World Health Organization (WHO), re-classified shift work from a ‘possible’ to a ‘probable’ human carcinogenic (Group 2A). At the time of writing this paper the final report from IARC regarding shift work was ‘pending’. It is thought that being exposed to light at night disrupts circadian rhythms, which contributes to chronic sleep deprivation and suppression of the production of melatonin (International Agency for Research on Cancer, 2009). Melatonin is a “hormone that helps reduce the risk of cancer” (McCarthy, 2009, p.10). Denmark has compensated 40 nurses and flight attendants after classifying breast cancer as an occupational disease. Breast cancer “is associated with raised concentrations of estrogen, which is overproduced under artificial light and suppressess melatonin production” (Lancet, 2009, p. 1054). To be eligible for
compensation, a woman must have worked at least one night shift a week for over 20 years and have no other known risk factors associated with breast cancer.
“Nurses have one of the highest rates of musculoskeletal injuries of any
occupational group” (Killien, 2004, p. 19). The likelihood of sustaining a musculoskeletal injury (MSI) has been associated with working long-hours and shift work (Sveinsdottir, 2006; Trinkoff, Rong Le, Geiger-Brown, Lipscomb & Lang, 2006). Trinkoff and colleagues surveyed 2, 617 registered nurses, 95% women with an average age of 45, about their work schedules, actual hours worked and psychological and physical
demands. A higher rate of shoulder injuries correlated to working overtime and ‘on-call’. Working schedules “(hours/day, working 13+ hours/day, non dayshifts, weekends, working with less than 10 hours off) and working on time off (working while sick, on days off, instead of taking breaks) were significantly related to neck, shouder and back MSI” (Trinkoff et al., 2006, p. 967).
A small study with 66 participants examined the association between working shift work and menstrual function, infertility and adverse pregnancy outcomes. Of the participants, 53% had reported a change in menstrual cycle function, including the length, flow and increased pain while working shift work (Labyak, Lava, Turek & Zee, 2002). These findings were consistant with earlier studies. The same 53% reported more sleep related issues such as sleep disturbances and problems concentrating. The numbers of participants that experienced infertility or a miscarriage was less or equal to the national average. There are many references throughout the literature about the circadian rhythms controling the body temperature, pulse rate and gastrointestinal systems, but very little research attention has been given to the reproductive system and how it is effected by
shift work. For example, “Menopausal women are twice as inclined as pre-menopausal women are to use sleeping pills, as they sleep less and suffer more often from insomnia symptoms.” (Canadian Sleep Society, 2005). How does working shift work impact menopausal women, generally between ages 45 to 55, who may already be experiencing sleep difficulties (Canadian Sleep Society, 2005)?
Health habits
In a study of 689 Finnish nurses, 506 shift workers and 183 day workers, shift workers were found to have higher rates of smoking and being overweight (Kivimaki, Paivikuisma, Virtanen & Elovainio, 2001). These rates gradually increased with age. In a review of published scientific literature studying the link between shift work and people’s daily health habits, Zhao and Turner (2008) found similar findings such as higher body mass index and an increased prevalence of smoking. In addition, “despite various research on the diverse aspects of diet, most of the results indicated that shift work affected nutritional intake in a negative way” (Zhao & Turner, 2008, p. 21).
Costa (2003) reports that individuals respond differently to shift work citing many variables that affect tolerance levels, including the individual’s age, family support and over-all health and ability to sleep. “Ageing [sic] may be associated with a progressive intolerance to shiftwork [sic] due to reduced psycho-physical fitness, the decreased restorative properties of sleep, and a higher proneness to internal desynchronization of circadian rhythms.” (Costa, 2003, p. 86). Muecke (2005) cites studies that suggest that older workers, between 40- 50 years of age, have a decreased capacity to adjust to
rotating shift patterns. As people age, the normal sleep/wake cycles change and the body becomes more accustomed to early rising and less to being nocturnal. Young people can
also have difficulty adjusting to shift work because of the social isolation and the inability to regularly participate in group activities (Costa, 2003).
Clissold, Smith, Accutt and Di Milla (2002) found that nurses with partners and parental responsibilities obtained almost one hour less sleep in a 24-hour period than their single colleagues. Most significant was their inability to repay their sleep debt by
sleeping in prior to an afternoon shift or being able to nap in the afternoon on their days off. Although the sample size was small with 12 participants, the findings validated the anecdotal stories I heard when teaching ‘Shifting to Wellness’. Barnett and Gareis (2007) enrolled 55 dual-earner families in a study to look at the relationship between shift work, parenting behaviors and children’s socioemotional well-being. This study was limited to ‘traditional heterosexual families’with the mother being a nurse who worked evenings, no nights, and the children ranged from ages eight-14 years of age. Mothers working
evening shifts were found to “compensate for their time at work during the after-school and evening hours by spending more time with their children before school and on days when they are not at work” (Barnett & Gareis, 2007, p. 742). Does this lead to chronic fatigue? On a positive note, fathers spent more time with their children, knew more about the children’s activities and received more disclosures from their children. In another study shift workers were found to experience higher rates of work-family conflict and social isolation while working shifts that are out of sync with family and friends (Haines, Marchand, Rousseau & Demers, 2008). Although there is not a direct link between working shift work and depression, there is an “association between work demands and employee well being” (Haines, Marchand, Rousseau & Demers, 2008, p. 351). Taking a different perspective, McLaughlin, Bowman, Bradley and Mistlberger (2008) explored
the seasonal variation in shift work tolerance and found a significant increase in
depressive symptoms in the winter season. Although the summer season was associated with less depressive symptoms, participants complained of less hours of sleep.
Nurse Safety
Shift workers were one of three populations identified as high risk for drowsy driving crashes in a report sponsored by the National Center on Sleep Disorders Research (NCSDR) of the National Heart, Lung, and Blood Institute of the National Institutes of Health, and the National Traffic Safety Administration (NHTSA) (1998). A more recent study by Scott, Hwang, Rogers, Nysse, Dean and Dinges (2007) found that nurses who work extended hours will likely experience a drowsy driving episode and have an increased risk of being involved in a motor vehicle accident (MVA). The participants consisted of 895 randomly selected full-time hospital staff nurses who completed log books for a four week period. Information was self-recorded about work hours, sleep patterns, and episodes of sleepiness at work and while driving. Of the nurses involved, 67% reported at least one episode of drowsy driving and 30 nurses reported experiencing drowsy driving after every shift. Although nurses reported experiencing drowsy driving after 8.5 hour shifts, the risk for experiencing drowsy driving doubled when working 12.5 or more consecutive hours. Working at night also significantly added to the risk with 79% of night nurses reporting at least one episode of drowsy driving and almost 16% of the nurses recording a near-miss or a motor vehicle accident. Additionally, 57 nurses reported two or more accidents within the four-week period. Self-reporting data could be considered a limitation of this study but the authors noted their results were consistent with previous studies. Although this study was conducted in the United States, the
participants’ demographics and work environments were similar to what we would find in Canada. For example, the participants were predominately Caucasian women, in their mid-40s, who were working full-time for an average of 18 years in medium (100-300 beds) or large (greater than 300 bed) hospitals and with an average commute time of 22 minutes (Scott et al., 2007).
Trinkoff et al. (2005) conducted a three-wave longitudinal survey with 2, 624 registered nurses, in which they evaluated the relationship between working hours and needle stick injuries. They found “long working hours and working nonday shifts and weekends, significantly increased the risk of needle stick injury.” (Trinkoff et al., 2005, p.161). Specifically, shifts greater than 13-hours were associated with increased risk. In a national survey of the work and health of nurses, 12 % of B.C. nurses reported they had “occasionally or frequently been injured on the job in the past year” (Shields & Wilkins, 2006, p. 23). This was the highest proportion reported in the country, with the national average being 9% (Shields & Wilkins, 2006).
Shift schedules
Developing shift patterns to meet the many needs of an organization,
patients/residents and nurses is very challenging (Sveinsdottir, 2006). What is best for the organization may not be best for the individual worker. The literature addressing 12-hour shifts was contradictory as there are both benefits and challenges (Josten, Ng-A-Tham & Thierry, 2003; McGettrick and O’Neill, 2006; Rossen & Fegan, 2009). Extended
workdays affords nurses more time off, more weekends off, and theoretically could improve continuity of patient care. However, the fatigue levels are higher and patient care could be negatively impacted (Josten, Ng-A-Tham & Thierry, 2003). Poissonnet and
Vernon (2000) reviewed scientific literature addressing the health implications for shift working healthcare professionals between 1969 to 1998 and found there is “no conclusive evidence found to favour any particular work system, although there is evidence that extended workdays (9- 12h) should be avoided as much as possible” (p. 13).
‘Rotators’ is a common term coined by early researchers to describe shift workers who work night shifts in addition to either extended days or evening shifts (Gold et al., 1992). Gold et al’s. (1992) study evaluating the impact of nurses’ work schedule on accident rates, sleepiness and sleep schedules is still widely cited in the current literature. The findings illuminated that “rotators and night nurses reported fewer hours of sleep than day/evening nurses” (p.1012). Interestingly, 92.2% of the day/evening nurses were able to obtain ‘anchor sleep’ regularly throughout the month, where only 6.3% of night nurses and none of the rotators achieved this. Anchor sleep is used here to mean “at least four hours of sleep obtained regularly during the same clock hours every night, both during work days and days off” (Gold et al., 1992, p. 1011). The quality and quantity of sleeping during the day is decreased, often being one to four hours shorter than night sleep. Sleep debt can quickly accumulate into chronic fatigue. In addition, “rotators had 3.9 times the odds and night nurses had 3.6 times the odds of nodding off while driving to or from work” compared with day/evening nurses (Gold et al., 1992, p.1012).
Nicol and Botterill (2004) reviewed 16 articles pertaining to being ‘on-call’ as part of a work schedule, of which only four articles referred to healthcare. Being ‘on-call’ can add hours to a nurse’s work day/week, contributing to the cycle of fatigue (Garrett, 2008). On-call is understood to be “a designated period of time, outside of designated hours of operation” when nurses are available to respond to a work need (Association of
peri-Operative Registered Nurses, 2005). In addition to increasing worker stress, being on-call can “decrease the quality and quantity of sleep for workers and can leave people feeling fatigued for periods after their on-call work” (Nicol & Botterill, 2004, p. 5). A huge problem for on-call nurses is the expectation to report for duty after a night on-call. The authors noted a lack of research attention devoted to this issue.
Historical view
The negative aspects associated with shift work in the social, psychological and physiological domains were documented in the literature over 30 years ago (Gordon, Cleary, Parker and Czeisler, 1986; Skipper, Jung and Coffey, 1990; Jamal, 1981). However the specific ‘health and safety’ hazards to nurses has not received equal research attention as compared with patient safety, nor has this early research been widely questioned or acknowledged within the healthcare sector. Who has benefited from silencing this information and who has been disadvantaged?
Patient safety
As aforementioned, this paper focuses on the the relationship between shift work and the ‘health and safety’ implications for nurses. However, it is worth noting that throughout the literature patient safety and nurses’ well-being are often discussed concurrently. Much research has occurred and is currently underway examining the association between healthcare-worker-sleep-deprivation, caused by shift work, and work performance. Rogers, Hwang, Scott, Aiken and Dinges (2004) completed a ‘landmark’ study involving 393 nurses, all members of the American Nurses Association. Findings suggest the risk of making a mistake and negatively impacting patient safety increased significantly following a 12.5 hour shift and continued to increase with the number of
hours of overtime worked. This is consistent with the research about nurses’ ‘health and safety’.
Chapter Three: Critical Analysis
To critically investigate this topic, I will be drawing from nursing and education theories, skills acquired from advanced nursing practice (ANP), the synthesis of the relevant literature, and reflecting on my lived experience and observations from the practice settings. Integration of all these ‘ways of knowing’ will inform this next section. As Chinn and Kramer (2006) assert, “best practices are those that arise from critical reflection and action to change what has been in the past and to create that which the practitioner imagines will improve the past” (p. 2). Through this process I will consider the interplay between the three levels in healthcare (e.g., micro, meso and macro). Micro refers to the individual nurse, meso addresses the environmental and/or organizational level including policies and programs, and the macro level looks at the supporting organizations such as governments or national organizations like Canadian Nurses Association (Storch, 2004). It would be remiss to assume that shift work education alone, could decrease the ‘health and safety’ risks to nurses without first considering their practice environments, and polices and procedures that guide their practice. Advanced Nursing Practice
Advanced Nursing Practice (ANP) is defined by the Canadian Nurses Association (2008) as,
an advanced level of clinical nursing practice that maximizes the use of graduate educational preparation, in-depth nursing knowledge and expertise in meeting the health needs of individuals, families, groups,
communities and populations. It involves analyzing and synthesizing knowledge; understanding, interpreting and applying nursing theory and research; and developing and advancing nursing knowledge and the profession as a whole. (p. 10).
Nursing theory
In choosing a nursing theory to guide my work, Jean Watson’s Caring Theory seemed like a natural fit. It aligns with my values and beliefs that nursing is a caring profession. In addition, Watson’s theory is one of the few to extend the art of caring beyond the patient to include the caregiver (Cara, 2003). This addresses two issues: (1) caring for self, and (2) caring for colleagues. I have been advocating that nurses practice caring for self for over a decade. However, it has been my observation that self-care is not universally valued or supported within my organization. For example, nurses routinely skip lunch breaks, forfeiting a mental break and an opportunity to stretch their bodies, citing too great a workload to look after their own health. I concur with Riley (2003) who states, “Self care [sic] is a matter of giving oneself permission to take the time, to make the commitment, and to negotiate the roadblocks” (p. 439).
Watson’s theory includes four major concepts: (a) ten ‘carative’ factors; (b) transpersonal caring relationship; and (c) caring occasion/moment and (d) caring modalities (Watson, 2006). The ten carative factors (e.g., promotion of transpersonal teaching-learning) were designed to distinguish nursing from medicine that valued ‘curative’ factors (Watson, 2006). The transpersonal caring relationship was another compelling argument for my choice of Watson’s theory. Attending to the ‘relationship’ is a core belief of mine as a nurse, educator or colleague. The term transpersonal means, “to
go beyond one’s own ego and the here and now, as it allows one to reach deeper spiritual connections in promoting the patient’s comfort and healing” (Cara, 2003, p. 53). This way of ‘being’ has been of assistance to me as I reflect on the issues surrounding shift work. I can ask questions of others in a respectful, curious way. I whole-heartedly agree with Watson (2002) who eloquently states, “When our Values are congruent with our actions, we are in harmony; we may even say we are healthy, we are whole” (p. 4). Educational Theory
Although I maintain that my nursing and educational practices are intertwined both influencing the other, I acknowledge they are underpinned by two very separate ‘bodies of knowledge’, nursing and education. This seemingly obvious relationship took me a long time to appreciate. I am both intrigued and humbled by the enormous depth and breadth of knowledge within the educational profession. My continued belief in ‘learner-centered’ teaching and learning, are aligned with the tenets of the constructivism theory. The broad concept of constructivism, as I use it here, “stresses that all knowledge is context bound, and that individuals make personal meaning of their learning
experiences” (Knowles, Holton III & Swanson, 2005, p. 192). Young and Maxwell (2007) further contend, “Constructivism holds that learning is a process of meaning making or knowledge building in which learners integrate new knowledge into a pre-existing network of understanding” (p. 9). Cognitive constructivism, influenced by the work of psychologists Jean Piaget and John Dewey, maintain that learners build on the knowledge that they bring to the experience of learning, while social constructivism, influenced by L. S. Vygotsky, claim students learn in social settings (Billings & Halstead, 2009).
In keeping with what constructivism posits, I have engaged nurses with narrative pedagogy. Narrative pedagogy, as it is understood here, “is an approach to teaching and learning, a community practice, and a way of thinking about what is possible and
problematic” (Ironside, P, 2003, p. 510). By using a narrative pedagogy I was privileged to hear the nurse’s ‘stories’ and together we were able to ‘unpack’ (critique and
deconstruct) the assumptions, the rhetoric and taken-for-granted values and beliefs associated with shift work. I will continue to use this valuable pedagogy as I move forward with this work.
Literature findings
As I reviewed the literature, I found it to be fragmented. For instance, the research primarily focused on the relationship between shift work and one of the following: (a) depression; (b) obesity; (c) physical health; (d) family relations; (e) patient safety; or (f) nurses’ safety. This failed to afford me an appreciation of how they all influenced each other; how they were interconnected. In addition, there is a dearth of research
investigating the ‘context’ in which the nurses’ work and live. “These contexts include the material, social and discursive realities that surround and construct the experiences of a life.” (McDonald & McIntyre, 2002, p. 261). I argue that it would behoove the nursing profession to use a holistic approach to thoroughly examine the interplay between shift work, nurses’ ‘health and safety’, and the practice settings within which they work.
Discourses
Health versus safety
Being able to recognize and name the ‘discourses at work’ has enabled me to critically analyze the issues surrounding shift work and nurses’ ‘health and safety’. By discourse I am referring to “interconnected systems or patterns of language, symbols, and human communications that create meaning and behavior” (Chinn & Kramer, 2008, p. 296). For example, although I had worked in the Health and Safety Department (renamed Worksafe and Wellness) for ten years, I had never recognized the competing discourses of health and safety within the name of the department. Allender, Colquhoun & Kelly (2006) explains opposing discourses in workplace health as “health as safety discourse, supported by legislation; and, health as lifestyle discourse supported by broader social understanding of impact of lifestyle on disease” (p. 76.) Understanding how ‘health’ is conceptualized within my organization and in others such as the academic setting and organizations like WorksafeBC, has helped me appreciate how and why the financial and human resources are distributed the way they are. For example, if health is understood as ‘safety’, the largest part of the department budget will be dedicated to ‘complying’ with safety regulations as mandated by WorksafeBC. Further, the majority of employees will be safety personnel rather than health care professionals. I agree with Allender,
Colquhoun and Kelly (2006) who contend, “Each professional standpoint brings a different set of understandings, methods, and expectations to the idea of workplace health. These perspectives may often be competing, and some dominate while others are marginalized” (p. 77). I imagine there are competing beliefs, values and alliances
the small number of remaining occupational health nurses who use a holistic approach to advocate for employees. Is the ‘health as wellness’ discourse marginalized by not being legislated? For the purpose of this paper, I am using health to mean, “much more than the measurements of death, disease and disability, it also encompasses mental and social well-being, quality of life, life satisfaction and happiness” (Hancock, Labonte & Edwards, 1999, p. 22).
Lifestyle choice
Lifestyle modification used as a strategy to improve or maintain nurses’ ‘health and safety’, is a discourse associated with shift work. However, the notion that individual lifestyle modification used alone, as a shift work coping mechanism, is essentially
removing all responsibility from the employer. Instead, the “consequence of such philosophy is victim blaming, that is, blaming the person who becomes sick for her sickness” (Wuest & Berman, 2002, p. 796). In other words, “The rhetoric implicates the individual life-style choice as a cause of disease” (Lowenberg, 1995, p. 320). When I worked in the Wellness program we were all cognizant that the factors influencing the musculoskeletal injuries and sick time are multi-factoral. We realized that the workload and stresses placed on nurses could be so overwhelming that they were challenged to live a ‘healthy’ lifestyle.
Napping
In my experience, ‘operational napping’ is a controversial subject within the practice setting. ‘Operational napping’, is used here to mean naps that are “20-30 minutes in length and are taken on the job and during a scheduled break” (Vancouver Coastal Health, 2008). There appears to be two diametrically opposed camps, those who believe
in the benefits of napping, and those who do not. The predominant discourse, which seems to be brought about by personal bias and a lack of knowledge, is that nurses who nap at work are lazy, weak or unmotivated. A nursing leader recently told me although she is aware of the literature supporting napping in the workplace she is from the ‘old school’ where nurses did not nap as napping was viewed as unprofessional behavior. It is this lack of support and insight into shift fatigue, compounded by resistance to change that is troubling.
Patients’ versus nurses’ needs
Self-neglect is a common discourse impacting the ‘health and safety’ of nurses. In other words, nurses are willingly and consciously risking their own ‘health and safety’ to provide routine care to patients (Gabrielle, Jackson & Mannix, 2007). An example I witnessed all too often was nurses’ physically transferring dependant patients instead of using a mechanical lift. The nurses admitted to being at risk of sustaining an injury or re-injury but justified their behavior because the patient had requested to be manually transferred. Hidden in this discourse is the lack of value for self-care.
Micro Level
Shift worker education
Shift worker education for nurses, as used here, refers to education including: a) self-care b) circadian rhythms and sleep, c) fatigue and safety, d) stress, e) nutrition, f) physical activity, and g) strategies to mitigate fatigue (Vancouver Coastal Health, Providence Health Care and Keyano College, 2007). Mistlberger (2004) as part of a WorksafeBC funded project, surveyed 178 organizations employing shift workers across all sectors in BC to determine the variety of shift schedules and availability of shift
worker education programs. Although there were no specific details about healthcare, the finding supported my assumptions. For example, 82% of the employers did not provide any shift worker education and of the 32 organizations that did provide education it was limited to orientation or the odd safety talk. Five organizations provided employees with written information and only 1.9% hired a professional to design shift schedules. In addition few organizations provided facilities to enhance shift work adaptation such as exercise and napping facilities, and none provided childcare (Mistlberger, 2004). Mistlberger (2004) recommends further research to determine what kinds of education, and materials, would be most effective to mitigate the impact of shift work.
Searching on-line I found a number of private companies offering: a) shift worker education or strategies to mitigate fatigue; b) fatigue analysis using actigraphy or sleep watches; and c) shift work risk assessment. These companies work with all shift work populations, not just healthcare. To my knowledge, the only program specifically designed for healthcare workers is the ‘Shifting to Wellness in Healthcare’ program. VCH, Providence Health Care (PHC) and Keyano College partnered in 2005 to
customize the existing Shifting to Wellness program originally designed for the ‘oil and gas’ industry. The demographics, work environments and educational backgrounds of nurses, and healthcare workers in general, are significantly different than the employees in the male dominated, blue-collar ‘oil and gas’ sector. For example, over 90% of the nurses in British Columbia are female, nearly half are over 45 years of age, and one could assume all have received educated about health and lifestyle risk factors in their basic nursing programs (Canadian Nurses Association, 2006; WorkSafeBC, 2009). However,
being educated about the risks factors, and adopting healthy lifestyle practices to decrease the risk factors, is another issue beyond the scope of this paper.
When customizing the STW program we took into consideration the unique challenges of the healthcare setting including the frequent shortage of nurses, high stress work environments, and rotating schedules. Unlike other industries where employees can attend a two-day STW workshop, that luxury is not a reality in healthcare. We would be fortunate if a nurse could attend a 20-30 minute session during her workday. As well, there was no budget for nurses to attend education on their days off so the challenge became trying to incorporate an education session into their already busy, stressful days. We thought about how nurses working weekends and nights would access this education. In the end, we designed eight modules with the flexibility to be used in various ways (Vancouver Coastal Health, Providence Health Care, Keyano College, 2007). Each module has a power point presentation, expanded speakers notes to assist new facilitators, supporting handouts and a healthy recipe. The program was developed so that each facilitator could ‘engage’ learners in the way that makes sense to them. In other words, depending on what educational theory underpins their practice, they may select different ‘ways of being’ with students. For instance, I choose not to use the power point
presentation but instead engaged the students in different types of group work where they were invited to share their experiences and ideas about shift work. For nurses who were unable to attend one of the four sessions offered monthly, handouts and a resource list with relevant websites were displayed in the STW bulletin boards (see Figure 1). A video and take home booklets are also available to share with family members. Although face-to-face sessions at VCH are no longer available due to the current financial conditions,
STW is available on-line. However there is no record of how many nurses have accessed the site.
Figure 1. Bulletin board displaying handouts, reference list and a healthy recipe From my experience teaching ‘shift work education’, information about circadian rhythms, sleep, fatigue, napping and how it relates to ‘health and safety’ is new content for the majority of the nurses I encountered. This information is a gap within the practice setting. Operational napping has been identified in the literature as a strategy to mitigate the impact of fatigue (Kilpatrick & Lavoie-Tremblay, 2006; Smith-Coggins, Howard, Mac, Wang, Kwan, Rosekind, et al, 2006; Wilson, 2002). However, when napping is done incorrectly, it can become a patient safety issue referred to as ‘sleep inertia’. Sleep inertia is used here to mean, “impairment present immediately on awakening from sleep”
(Lockley, et al. 2007). If a nurse naps greater than 60-minutes he/she could wake up in a drowsy state and not be able to function properly (e.g., respond to an emergency) for up to an hour after (Vancouver Coastal Health, 2008). Therefore, nurses require the science to understand sleeping and napping in order to safely nap at work. Operational naps should be 20-40 minutes in length (Smith-Coggins et al., 2006; Vancouver Coastal Health, 2008).
I have come to appreciate the healthcare sector has three, sometimes four, generations of nurses working together. As Johnson and Romanello (2005) contend, “Understanding generational characteristics gives nurse educators insight into how students from different generations learn best” (p. 212). As I think about how to ‘engage’ learners in shift work education it is prudent to consider the diverse learners and learning styles. Perhaps the Millennials, who were born after 1982, would prefer joining a
Facebook group or another on-line way of connecting. I agree with Peate (2007) who contends nurses’ families should participate in shift worker education. Otherwise, is it realistic to expect families to support nurses if they do not understand how shift work impacts nurses’ physically, mentally, emotionally and spiritually? It behooves us to consider how to best ‘engage’ families?
Meso Level
There are limited designated safe napping locations in healthcare facilities where nurses may nap. Designated safe napping locations refers to a space used for napping at night that can be locked, darkened and is quiet. As healthcare facilities undergo
renovations, consideration should be given to providing safe napping locations.
another example of the interplay between the micro and meso level occurs. A nurse may do everything he/she can to mitigate the negative impacts of shift work such as eating healthfully, ensuring adequate time for sleep and participating in regular exercise, but if he/she is constantly being asked to work overtime, stay late and is unable to nap during a night shift how does that influence their health outcomes?
Healthful food options that are available 24-hours a day are becoming more plentiful in the healthcare facilities but usually obtained from a machine. Pop has been replaced with juice, milk or water, and chips are baked not fried. Few healthcare facilities have fitness equipment or designated exercise spaces accessible for use by night workers wanting to exercise to stay alert. Most facilities have bicycle racks and some have access to shower facilities. More importantly, nurses need to recognize the value of self-care (Saskatchewan Registered Nurses’ Association, 2009). If there is not a ‘culture’ of caring for yourself, it is irrelevant if there are healthy food options or supporting exercise or recreation facilitates. As mentioned, from my observations in practice, this is an area that needs further attention.
Ergonomic controls for mitigating fatigue including lighting, temperature controls and possibly alarms are not used within the practice setting. This is a gap that needs further research and partnership with the academic sector and biomedical engineering and ergonomic professionals. There is more research needed about manipulation of lighting in the workplace. Some studies suggest a link between increased cancer rates, especially breast cancer, and exposure to light at night (Hume, 2005). Mistlberger (2004) noted bright lights used at the end of a night shift, either at home or the workplace, merits further research as a “countermeasure for sleep and mood disruptions” (p. 1). It is this
type of research that we need to encourage. At the time of writing this report, information about the risk management and legal implications of working long hours or over-time was not available in my health authority. This is also an area that needs consideration given the research available today. To avoid institutional liability, Collins (2007)
suggests that lawyers become aware of the current research that “begins to scientifically quantify the relationship between nurses’ work environments and patient safety failures (p. 91). Although Collins is referring to patient safety, she highlights safety failures related to shift length and overtime. For example, does the healthcare organization monitor work hours and the relationship between hours worked and patient safety? These same indicators should also be monitored from the perspective of the nurses’ ‘health and safety’.
Macro Level
The level of interest, research, advocacy or action from the organizations influencing, governing or employing nurses has been perplexing. The Canadian Nurses Association, the British Columbia Nurses Union (BCNU), WorkSafeBC, the College of Registered Nurses Association of British Columbia (CRNABC), employers and our academic partners appear to have not acted upon existing research or insisted on further research.
I only recently discovered the Occupational Health and Safety regulations addresses fatigue under the “Impairment” section (WorkSafeBC, 2009). There are two sections included in “Impairment”, one addresses physical and mental impairment and the second addresses alcohol, drug or other substance. Fatigue is noted under the latter regulation (4.20)
In application of sections 4.19 and 4.20, workers and employers need to consider the effects of prescription and non-prescription drugs, and fatigue, as potential sources of impairment. There is a need for disclosure of potential impairment from any source, and for adequate supervision of work to ensure reported or observed impairment is effectively managed.
Although ‘fatigue’ is mentioned in the regulations (albeit once) I would argue it is ‘hidden’ and effectively not addressed within the practice setting. Additionally,
WorkSafeBC does not collect data specific to shift workers and/or fatigue (K.
Thipthorpe, personal communication, June 26th, 2009). How can we begin to appreciate the impact of shift work unless we start tracking it? It would be interesting to know if WorksafeBC followed through on the recommendations that officers received education about the “principles and practice of shiftwork [sic] adaptation” (Mistlberger, 2004, p. 21).
An ethical lens
The word ethics, as used in this paper, implies “relating to how individuals (and groups) make choices about how they ought to behave or act in situations” (Oberle & Raffin Bouchal, 2009, p. 3). Chinn and Kramer (2004) further contend that ethical knowing “involves confronting and resolving conflicting values, norms, interests, or principles” (p. 5). After critically analyzing the impact of shift work, I am surprised more ‘action’ has not been taken. As I mentioned before, the literature highlighted the health risks over thirty years ago. I wholeheartedly agree with Windle, Mamaril and Fossum (2008) who contend we have a “professional responsibility to disseminate the nursing
fatigue findings to prevent harm” (p. 167). This includes providing education, shift work strategies and translating fatigue research into concepts that nurses can relate to. A perfect example of this is the correlation between hours awake and being legally impaired. Given what we know, it is unethical to continue sending students and new employees into the workplace without an awareness of the associated risks and an understanding of how to mitigate them. The World Health Organization (WHO) has re-classified shift work from a ‘possible’ to a ‘probable’ human carcinogenic, is the nursing profession going to wait until it is re-classified again before action is taken?
Chapter Four: Recommendations
The following recommendations are not specific to Vancouver Coastal Health, but instead are generic recommendations intended for the reader to consider for their particular area of interest.
Micro Level Recommendations
Micro level recommendations are intended to benefit individual nurses. First and foremost shift work education should be an integral part of the basic nursing program and be readily available to practicing nurses and their families. A variety of methods are required to disseminate this information. For instance, articles, newsletters, conferences, and workshops would be useful tools to begin to convey shift work information.
However, considering the different generations, learning styles and the knowledge level of both student nurses and practicing nurses, I invite the reader to explore creative
strategies to engage nurses in innovative ways. Some learners may benefit from a face-to-face interaction, while others may find a blog or interactive website more constructive. A
benefit of computer-based education is it is accessible during weekends and nights, when traditional face-to-face educational sessions are not available.
Meso Level Recommendations
Meso level recommendations refer to environmental and organizational factors. It is imperative that the commitment to support shift workers is implemented at both the environmental and organizational levels. Decision makers at all levels of the organization need to be aware, and perhaps educated, about the ‘health and safety’ risks for nurses working shift work.
Employers should develop or, at the very least, endorse a ‘Fatigue Management Program’ including shift worker education, safe napping locations, practice guidelines addressing working hours, scheduling and overtime. Ongoing research about fatigue in the workplace would benefit both patients and nurses, which in turn could lead to retention of senior nurses.
Organizational representatives responsible for risk management, legal matters and human resources should be invited to a meeting to evaluate current policies and/or
guidelines regarding: a) the length of a shift; b) the number of consecutive shifts allowed to be worked in a row; c) the minimum hours off between shifts; and d) the maximum amount of over-time worked per shift and per pay period. This group should consider if the employer has any legal responsibilities regarding fatigue? What if a nurse was involved in a fatal motor vehicle accident on his/her way home from an overtime shift, could the employer be found liable?
Given there has been a dearth of education for shift workers in the past it will require the assistance of many internal stakeholders to quickly disseminate the
information to all shift working nurses. One way to address this concern would be to provide shift work materials and information to nursing educators, health and safety advisors, human resources and ergonomic advisors in the hope that they could weave this education into their existing curricula? Ergonomic advisors could describe how fatigue increases the risk of sustaining a back injury, and the Health and Safety advisors could share statistics illustrating how working long hours increases the chance of experiencing a needle stick injury. This being said, the stakeholders should be invited to participate in shift work education so they can truly understand the issues, and appreciate how their involvement and collaboration can lead to a safer work environment.
Both health and safety advisors and employee engagement/human resource staff have access to organizational data that could potentially provide valuable statistics to guide future decision-making about shift work design. A suggestion would be to modify the ‘Employee Event Report’ to include information about fatigue. For instance, did the employee incident/accident occur during a night shift, over-time shift or while the employee was working extended hours? Employee engagement could look for a correlation between shift workers and the amount of sick time they use, the amount of over-time worked and their musculoskeletal injury rates?
It is recommended an Ergonomist, specializing in fatigue management, be consulted to research, trial and implement strategies to mitigate fatigue and the negative side effects of shift work. Using a holistic view, “ergonomists contribute to the design and evaluation of tasks, jobs, products, environments and systems in order to make them compatible with the needs, abilities and limitations of people (Association of Canadian Ergonomists, 2009). Sleeping cots, couches or sleep pods for nurses to ‘operationally
nap’ should be trialed, taking into consideration the cost, storage, and related infection control issues. Additionally, could light therapy, alarms and temperature controls be used to help mitigate the negative impacts of shift work? Could actigraphs, also referred to as sleep watches, help inform researchers about nurses’ rest and energy patterns, and could knowing this information result in safer shift patterns? Could the use of exercise facilities or equipment, like a stationary bike, enhance alertness during the night shift?
Macro level recommendations
Is there an interest in, and commitment to, addressing the ‘health and safety’ of shift working nurses among the external staked holders in British Columbia (BC)? Examples of stakeholders include: (a) British Columbia Nurses Union; (b) College of Registered Nurses Association of British Columbia; (c) health authorities; (d) academic partners/researchers; (e) WorksafeBC; and (f) the Occupational Health and Safety Agency for Healthcare in BC. As a nursing profession we have an ethical responsibility to “question and intervene to address unsafe, non-compassionate, unethical or
incompetent practice or conditions that interfere with their ability to provide safe, compassionate, competent and ethical care” (Canadian Nurses Association, 2008, p. 9). Stakeholders ought to begin to address the concerns surrounding shift work and fatigue. What is currently happening in the province? How do we share our research and practice ideas? How do we engage our national partners including the Canadian Nurses
Association, the Canadian Federation of Nurses Unions, and the Canadian Institute of Health Information? Can we participate in the development of surveys regarding shift work, fatigue, self-care and work-life balance in collaboration with the Canadian Institute of Health Information?
Organizations influencing nursing must take a leadership role in addressing shift work ‘health and safety’ concerns by developing practice guidelines, advocating for the inclusion of shift work education and on-going research. One of the first priorities should be to determine who is responsible for providing shift work education for nurses,
including student nurses. Ethically we ought to be preparing nurses to safely work shift work, it is no longer acceptable to send ill-prepared students into the practice setting. They must understand the negative impact shift work can have on their performance and indeed on their own ‘health and safety’, and be introduced to strategies to help mitigate those risks.
Research recommendations
There has been enough research, over the past 30 years, addressing the ‘health and safety’ concerns for shift workers to ‘alarm’ us. Healthcare needs to put some recommendations into ‘action’ and begin to address this complex problem. The nursing profession is a unique shift worker population, consisting of primarily female workers, that deserves to be studied independently of other shift working industries that are predominately men and blue-collar workers.
Research is needed to evaluate the strategies used to mitigate fatigue in the workplace. For example, what strategies used by individual nurses are effective in decreasing their ‘health and safety’ risks? How can fatigue be assessed/measured in the workplace? Are there proven, universal tools to measure fatigue? Is light therapy indicated?
Given that over 90% of the nurses in BC are women, research focusing on women and shift work is indicated (Canadian Nurses Association, 2006). How can working shift work impact menopause, aging, menstrual cycles, heart health, breast cancer, and family dynamics? There have been research studies conducted about ‘women and sleep’, addressing hormonal changes, family responsibilities and the aging process, but not in relationship to working shift work. It is the inter-relational aspect of shift work that needs to be explored. For example, does fatigue contribute to depression and/or obesity? Is fatigue related to unhealthy lifestyle choices such as smoking, and increased caffeine and alcohol consumption? Does age impact how a worker adapts to shift work? Is there a cause-effect relationship between fatigue and exercise? Could regular exercise improve sleep and decrease depression in shift workers?
More research is required to determine what is the optimal length of shift for a nurse’s ‘health and safety’? Is it a 12-hour shift or an 8-hour shift? Or is there another choice? What is the best start time for a day shift? Recognizing that shifts must meet the needs of patients and the organization, can shifts be designed to be less disruptive to nurses’ circadian rhythms? Would a start time of eight or nine o’clock in the morning be less disruptive than seven? Should older nurses work shorter shifts or fewer night shifts? An example of adapting a shift pattern to reduce stress on circadian rhythms occurred at a local emergency department. Instead of working all night (7pm – 7am), the physicians divided the night shift in half with one physician working until 3 am (e.g., 7pm- 3am), and the relief starting at 3 am and working until 7am. Both shifts permitted the physicians to sleep in their own beds during part of the night resulting in less disruption of their sleep patterns. This shift change not only improved work performance but also had a
significant influence on the quality of their family life. Although this is an anecdotal example involving physicians it illustrates how an innovative shift schedule can have a positive impact on both the workplace and the individual workers.
How useful is shift work education? Once shift work education is started, it must be evaluated. What methods of engagement are most effective for nurses? Do they retain more information from on-line courses, printed materials or face-to-face sessions? Does shift work education decrease the risk for ‘health and safety’ concerns for nurses working shift work? Or does shift work education need to be supported by environmental and organizational factors to be effective?
Summary
In this paper I described the problem, provided background information about the significance of the topic within the healthcare sector and summarized the findings from a literature search. Following an analysis of the issues, I identify the gaps and provide recommendations. Hopefully, it is now apparent that working shift work can be dangerous to one’s ‘health and safety’. It would behoove the nursing profession to
seriously consider the recommendations not only for the long-term ‘health and safety’ for nurses but also to improve work performance, patient safety and retention of nurses within the healthcare system.
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