Disparities in Healthcare: Night Shift Nurses
Submitted by Skip Morelock PhD, RN, NEA-BC
When one thinks of health disparities, the profession of nursing might not immediately come to mind. In fact, with the increase in the social and economic stature of the nurse has come some measure of economic stability. Some nursing specialties are now highly compensated and on par with other professionals with similar levels of education. There is a subset of nurses that are suffering from health disparities…the night shift nurse. Research over the past twenty years has led to the increasing conclusion that working night shifts for as little as eight shifts a month is associated with an increased likelihood to develop metabolic syndrome, a four-fold increase in the incidence of vascular events, and an increased chance of developing certain cancers. (Borugian, Gallagher, Friesen, Switzer, and Aronson, 2005) and (Su, Lin, Baker, Schnall, and Chen, 2008). The working of night shifts over an extended period of time also carries implications for one’s psychosocial health. By nature, night shift work tends to be rigid in its application thus making it more difficult to attend to last minute emergencies that can crop up. It can also prevent or at least make more problematic the spontaneous scheduling of activities with family and friends. Willis, O’Connor, and Smith (2008) examined social and psychological adjustment of night shift nurses. Their research showed that these nurses suffered more negative psychological effects such as disenfranchisement, work anger, and anxiety as well as physical effects such as impaired alertness and cognition when required to work during the evening or night times.
Historical Precedents and Referents
All hospitals employ some kind of shift system for their frontline nurses. The history of shift work in health care can be traced back to 16th century Catholic religious orders when nuns would continuously minister to the sick. In the early 19th Century there were almshouses where the ill and the mentally unstable went to convalesce (Wall, 1998). The almshouses were also places of shelter for the homeless and for children without parents. These entities were often religious-based and became the forerunners to today’s hospitals.The conditions which these early night shift nurses used to observe their patients must have been rudimentary at best with candlelight as the only practical means of illumination. With the emergence of modern American hospitals beginning in the latter part of the 19th Century, there was an increase in the demand for workers to care for the sick during the night. Following the invention and widespread application of the light bulb, there became a way to simulate day conditions around the clock thus making it easier for workers to stay awake during the times that most were sleeping. While this had obvious manufacturing implications related to increased production volumes and productivity, there were healthcare implications as well in that patients could now be cared for around the clock with the distinct advantage of a lighted work environment. Thus was the genesis of the night shift and the attendant culture which slowly evolved over the next century.
Social Determinants and Analysis
The National Institute on Minority Health and Health Disparities (NIMHD) in 2009 listed ten conditions which were determined to be the most powerful determinants of poor health. These were derived from work done in the 1970’s by Sir Michael Marmot, a London-based physician and epidemiologist. The ten conditions are low social status, relentless stress, adversity in early life, social exclusion, stress at work, unemployment, absence of social support, addiction, poor nutrition, and an environment that promotes inactivity (NIMHD, 2009). Night shift nurses fit five of these criteria very well.
Nursing is stressful. Caring for individuals while managing and finessing the required regulatory elements that hospitals demand would be taxing for any nurse. The night shift nurse may have to accomplish this without the resources that would normally be available during standard working hours. Social exclusion is perhaps difficult to quantify, yet it would seem fairly clear that if you are working twelve-hour shifts during the night, which is a time of lower social imperative, then one might be missing out on many social opportunities because of the need for restorative sleep on the days after working. Kunert, King, and Kolkhorst (2007) found that night shift nurses often report being unable to participate in activities because they are either working or because they would have to miss needed sleep in order to be physically ready for the next shift. The same cohort also reported difficulty in the spontaneous scheduling of activities which they had enjoyed prior to working overnights and many engaged in less than desirable means of staying awake such as the excessive consumption of caffeine supplements or a split sleeping regimen.Since nurses have to be available continuously to provide patient care, this can come at a significant cost to the nurses’ personal life. West, Aham, Byrnes, andKwanten (2007) discovered that while most new night shift nurses eventually adapt successfully to shift work, many suffer varying degrees of social dysfunction for as long as they work the night shift. This can be especially problematic with young mothers who often have to adopt very creative strategies to manage pre-school children and still get the required sleep prior to working a shift.
Another criteria mentioned by the NIMHD was poor nutrition. Atkinson, Fullick, Grindey, and Maclaren (2008) found that night shift workers on average were more likely to consume calorie dense food and in larger amounts and also found that night shift workers used vending machines more than day shifters. This would not be an unanticipated finding since many facilities do not have food service available during the night shifts thus leaving vending machines as an option. This could also possibly explain the nexus found in the research between nurses that worked the night shift and the increase in the incidence of developing metabolic syndrome (Admi, Tzischinsky, Epstein, Herer, and Lavie, 2008).
Inactivity is another criteria and this is also associated with the night shift culture. There are few practical opportunities for nurses to consistently exercise during a shift and many nurses do not feel like exercising immediately prior to a shift. In many cases after working consecutive twelve hour shifts, the nurse may not feel like getting up early (and interrupting sleep) in order to exercise prior to the beginning of the next shift.
While addiction is hopefully not typical of most night shift nurses, studies have found that approximately 10.5% of registered nurses meet the intake criteria for drug addiction including alcoholism (Kunyk and Austin, 2011) and another author reports that episodic substance abuse among nurses may be as high as 32% (Tariman, 2007). While the nexus between drug abuse and the night shift may be somewhat nebulous, there are valid reasons why many State Boards of Nursing and peer assistance programs do not permit nurses in recovery to initially work the night shift. Drugs are believed to be more readily available on the night shift and there are fewer supervisors to detect potential diversion. Another researcher has even included the desire to work exclusively night shifts as one of the items on a “how to recognize an impaired colleague” checklist (Copp, 2009). Whether there is a higher incidence of drug use on the night shift versus the day shift remains to be seen and there will most certainly be more research into this.
There is a significant amount of information related to the practice of nursing on the night shift and the various challenges that nurses on the night shift experience. Hospitals are typically designed to operate as a quasi-business entity with most staff and ancillary support services available during typical business hours...usually beginning around 7-8 AM and ending around 5 PM. After that time, there are usually far fewer resources available to the nurse and what resources are available are typically pooled for productivity reasons. What this translates to are that nurses must accomplish many of the same tasks, but with fewer resources to guide them. Exacerbating this situation are that in many cases the night shift nurse may be a novice nurse with less than two years of experience. Night shift nurses can also be distinguished from their dayshift counterparts by an increase in the likelihood of developing certain diseases especially if night shift work lasts for an extended period. The body of literature is ripe with clinical evidence that nurses who work the night shift are at a significantly higher risk of developing metabolic syndrome (Szosland, 2010), certain cancers (Straif, Baan, and Grosse, 2007), and ischemic brain and heart disease (Brown, Fesk, Sanchez, Rexrode, and Schernhammer, 2009).
What also must be considered when addressing health disparities in this cohort of nurses are any possible correlations between night shift work, ethnicity, and gender. While the research is quite robust when addressing health issues stemming from night shift work, there is a paucity of research which compares the variables of ethnicity and gender. One study which was sponsored by the National Institutes of Health showed that healthcare workers who identified as Black were more likely than either Whites or Asians to be obese. This effect persisted after controlling for education and age (Chou & Johnson, 2008). This study however did not control for the shift worked so it is unknown whether this effect would be observed for night shift workers. We know that females comprise 94% of registered nurses in Texas (Texas Board of Nursing, 2013), but it does seem, at least anecdotally, that more men choose to work night shift than women. At least that is the experience from this author.
Regarding the quality of sleep in night shift nurses, there is evidence of disparity in the reported sleep of nurses of various ethnicities. Black and Caribbean immigrants report 64 minutes less sleep than their White counterparts. This effect persisted after controlling for gender and age. Ertel, Berkman, and Buxton (2011) postulate that possible reasons for these differences are the continuing socioeconomic challenges faced by this group as well as other occupational exposures. When controlling for education, the sleep gap lessened, but was still statistically significant.
Based on what has been discovered regarding the health of nurses working the night shift, there are several imperatives that should be implemented. The first of which is determining which nurses are best suited to working the night shift. Not everyone’s circadian rhythm is the same and some tolerate the night shift better than other. There is much research at this time being undertaken on the phenomenon of morningness and eveningness...two terms that characterize the body’s biological preference on being alert and active during specific times during the say. There is also evidence to show a genetic component to this and also evidence that supports letting the nurse have input into deciding what shift is worked (Korompeli, Sourtzi, Tzavara, and Velonakis, 2009) and (Barclay, Eley, Maughan, Rowe, and Gregory, 2011). It behooves nursing administrators, clinical and staffing managers to ensure that the night shift is being staffed with nurses who are physically able to engage and retain clinical competency and the ability to critically think during the overnight hours.
The second recommendation is to increase awareness of the physical issues surrounding working the night shift and potential sequelae. This includes the increased risk of vascular events, the development of metabolic syndrome, and certain cancers. The risk to the public must also be considered given the fact that many of these nurses are driving home after having been on a twelve hour shift with sometimes little to no sleep prior. One study has shown clearly the increase in automobile accidents which nurses were involved after having worked a twelve hour shift (Berryman and Lukes, 2009) and (Centers for Disease Control and Prevention, 2010). Related to this would be the risk to patients from fatigued nurses. While the research has not consistently shown a direct correlation between fatigue and nursing errors, it is known that on tests of psychomotor ability, scores on the test subjects who worked night shifts were significantly lower than their day shift counterparts(Johnson, Brown, and Weaver, 2010). Similar results were also found among military test subjects who were sleep deprived (Schnyer, Zeithamova, and Williams, 2009).
A third recommendation to alleviate some of these symptoms are plannedmicronaps during the shift. A micronap is a period of sleep not exceeding 10 minutes in length. Napping has been advocated by several researchers who noted that performance improved after a short nap (Rogers, 2008) and (Fallis, McMillan, and Edwards, 2011). While many hospitals still do not encourage napping, the potential benefits of this intervention cannot be dismissed and the growing body of evidence that shows this to be therapeutic should also be considered a call to action.
Hospitals have to operate continuously twenty-four hours a day. Because of this demand and the acuity and occasional immediateness of patient care, the staff attending the needs of the patients must be alert while they are on duty. This means that even in the middle of the night, when most of the community is sleeping, the ever vigilant nurse must be able to rapidly and accurately assess and intervene in all patient situations in which a nurses expertise is required. While much attention and research has been paid to patients and the effect of poor sleep has on patient satisfaction and patient outcomes, little attention has been paid to the nurses that deliver this care in the middle of the night at a time when their bodies may be craving sleep. The physical toll that this is exacting is still being researched, but there is little doubt that night shift nurses are suffering the effects of working long hours. Researchers’ primary task is now to find viable and workable solutions to the various issues surrounding the healthcare of this group. Hospitals must function at all times and this is not going to change. It is important for not only patients, but for the night shift nurses caring for them that they be given every opportunity to access health improving technologies and wellness programs in an effort to stave off the effects of working night shifts for extended periods.
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