Night Shift Nursing: A Policy Proposal
Submitted by Skip Morelock PhD, RN, NEA-BC
Nurses who work on the night shift often reap enhanced financial incentives including higher shift differentials and a generous pay structure. Unfortunately, these positive financial incentives may come at a very high cost in personal time, restriction in pleasurable social activities and in physical and psychological health problems. There may also be a cost to patients in the form of increased clinical errors by the very people who are trained to advocate for their patient’s health and well being. Fatigue and errors have been studied extensively and there is a small but growing body of evidence that connects fatigue with an increased risk of committing clinical errors. There is also mounting evidence that due to the unusual circumstances of shift work and associated problems, these nurses qualify as a group with health disparities and unique healthcare needs. New policies which will help ensure the safety and maximize the well-being of these nurses and may also benefit the patients that they are caring for. This investigation will attempt to increase the information on this line of policy research and posit possible solutions to the problem of the fatigued nurse.
Unfortunately, there are no extant policies at the Federal, State or local levels that uniformly address nursing as it relates to the identified issues. The best course of action is to spur development of new policies that adequately addresses these disparities in nurses.
Since there is little guidance in local, state, or national policy regarding the nurses that work the overnight shifts, this paper will focus on the development and hypothetical operational implementation of such a policy at the state level. There are valid rationales for choosing to formulate a state policy and not a federal one. State policy is inherently easier to implement simply because of the number of relevant actors are far less at the state than at the federal level (Tableman, 2005). In addition, the complexity and vagaries of laws, which can vary widely, make it near impossible to implement any kind of cohesive policy on the federal level. It is also easier at the state level to introduce small tests of change which can then be evaluated for more widespread application. Simply stated, if it works in Texas, then the policy might work in other states as well. Before considering a policy which would affect nurses working overnight shifts, it is prudent to consider existing policies and guidelines in other industries in which there are overnight workers.
Night Shift Workers: Nursing and Beyond
While it is tempting to think that night shift workers enjoy enhanced benefits for working overnights, that belief is in error in most states. In fact, there is no federal statute that requires or compels an employer, in either a government or private sector entity, to offer additional pay for working what are considered undesirable schedules (Wage and Hour Division, 2010). There are also no federal provisions for employees who work overnight shifts or who work extended/unusual shifts (Occupational Safety and Health Administration, 2012).
There are however some guidelines regarding the length of individual shifts in certain occupations such as long-haul/interstate trucking, and the airline industry. Long-haul truck drivers by law may only drive for fourteen consecutive hours and this must be followed by ten consecutive hours of non-drive time (Federal Motor Carrier Safety Administration, 2011). Nurse practice, to a large extent, are guided by position papers from the individual boards of nursing and individual states’ Nurse Practice Acts. The following example is from the Texas Board of Nursing which issued a position paper in 2011 which states in part “the nurse has a duty to recognize when he or she is unfit to practice secondary to physical, mental, and or emotional fatigue. Nursing judgment and provision of nursing care may be impaired if a nurse is physically, mentally or emotionally exhausted, which could lead to nursing errors” (Texas BON Position Statement, 2011). Note that unlike the policies governing certain transportation and airline workers, Board-issued position statements do not have the force of law and are only recommendations for improving safety in nursing practice. The Nurse Practice Act, at least in Texas, does not address overnight shifts or health considerations from working these shifts. It is of interest that other fields such as aviation and trucking have policies and guidelines governing their workers ostensibly because these workers might be dangerous if they became excessively fatigued, yet nurses are not viewed as a danger even though they may be working without adequate sleep and are responsible for calculating and administering potentially dangerous medications. What is needed is a comprehensive policy at the state level that addresses health irregularities as well as other consequences of fatigue which plague the night shift nurse.
Brief Primer on Policy Development at the State Level
Developing a policy which would encompass nurses as a whole is complicated since competing interests will often seek to sabotage efforts seen as encroaching on their turf (Vinz, Foreman, and Cummings, 2010). Broadly speaking, those tasked with writing new policies must engage the front line staff in order to achieve the all important buy in. There must be opportunities for front line staff to participate in the research process and to recommend changes and revisions to any proposed policies. Once a policy is agreed upon, the vetting process can be extensive and time-consuming. Specialty groups who are impacted must be given an opportunity to voice concerns. Hospital administration personnel would certainly have strong opinions about any new policy which affects nursing productivity and even nurses in different settings, rural versus urban, might have widely varying ideas about how to implement changes. The final approval would have to come from the Board of Nursing whose primary task is to protect the citizens.
Stakeholder is defined for the purposes of this article are those who have an active and abiding interest in any aspect of the proposed policy including the person(s) who design the policy, state-sponsored health organizations who will be testing and vetting the policy, and the end user who will use the policy to drive other measures that address this group of nurses.
The primary stakeholders are the affected nurses. In order for changes to be effective there must be a groundswell of support for such changes. This should occur at the staff nurse level and they should then drive the change upward and outward. Unfortunately, in many cases of policy change, the opposite occurs...a group of elites formulate policy and then advocate for its buy in (Hoffman, 2003). This type of change can and should be generated at the staff level in order to increase buy in. Nurses, as a collective body, can potential wield much political and economic power (Newland, 2010). The problem is translating and then harnessing this potential power into meaningful and measureable change.
Other stakeholders in this process are the hospitals and any entities which employ nurses on a 24 hour basis. Patients also must be considered a stakeholder. They are at the recipient end of any change and the effect that the change has on direct on bedside care may prove to be the ultimate arbiter of whether an implemented policy succeeds or fails.
Hospitals in particular would be sensitive to any policy which might elicit changes in the way work rules are generated or personnel are managed. Yet hospitals should pay very close attention to the disparities in night shift nurses and the effect that working overnight hours has on them. Dawson and Reid (2007) discovered in their research that when an individual has been up for seventeen consecutive hours, their cognitive and psychomotor performance deteriorates to the level of an individual with a blood alcohol level of 0.05. After 24 hours of no sleep, the cognitive impairment increases to a blood alcohol level equivalent of 0.10. The potential for negative consequences is great especially if these nurses are driving home after their shifts.
There are three research strategies that should be employed as a first step toward formulating a cohesive and comprehensive policy which addresses the overnight shift worker. The first would be to earmark funds to generate and support studies which examine this issue. This research should be nurse-driven and the results from the proposed study would be used to support policy development. The second research strategy would be designed to gauge the support of a new policy on frontline nursing staff. Getting universal buy in for such a comprehensive policy is not possible, but one would surmise at least a plurality of nurses would have to be supportive of the research efforts. A corollary of this research would be educating the nurses who work overnight shifts about the apparent risks. The third research strategy must involve hospital administrators and director/managers of the individual nursing units which employ nurses 24 hours a day. Research would need to focus on the fiscal impacts that a policy would have. There would also need to be a focus on institutional liability since nurses who may meet criteria for being impaired, are leaving the hospital and driving home. There are studies which are examining hospital liability and nurses who are judged to be impaired from sleepiness and fatigue (Rogers, 2008) and (Institute of Medicine, 2004).
The policy would identify, confirm, and recognize that night shift nursing can, quite literally, be hazardous to one’s health. Resources would need to be allocated to fund research to further develop information regarding the possible dangers of sustained night shift work and sleep deprivation as well as research into possible remedies or strategies to at least partially offset the negative effects of night shift work. The policy would require nursing school instruction about night shift nursing and the effects that it can have. This is especially important since at least in the experience of this author, many new registered nurse graduates must initially work the night shift.
Recommendations for Nursing Organizations
Nursing organizations on both state and national levels should be paying close attention to this issue and be prepared to mobilize their membership in order to catalyze the policy development process. This will not be an easy task as any sort of state policy might have the effect of restricting the nurses working hours in order to reduce the harmful effects of fatigue. There could also be unintended consequences of amending either the Nurse Practice Act or enacting/enforcing new policies. Some nurses will likely not be supportive of any policy which interferes with their right to work as many hours as they would like. It is a complex situation, yet must be addressed and managed in a way that does not alienate the nursing base to the extent that no action is taken.
Nursing organizations should also be prepared to disseminate the latest peer-reviewed research to their members and be prepared to take a decisive stand on the issues. These are problems which should be addressed not only for the continued health of the overnight workforce, but also for the patients who are receiving this care.
Reading List for the Identified Policy Issue
For those unfamiliar with the plight of the night shift nurse, the following resources are submitted for your reading. They delve into the basics of the subject as well as touch on the many physical and psychological issues that are associated with night shift nursing.
- Help Me Make It Through the Night (Shift) by Laura Stokowski RN. Written in a folksy yet professional tone, this is an excellent primer about how night shift nurses effectively and sometimes very creatively manage working the ‘graveyard’ shift. It is available in the March/April 2012 issue of the Ohio Nurses Association. Weblink is www.ohnurses.org
- Surviving Shift Work – this is a short article from the Texas Nurses Association (TNA) which describes strategies for managing working the night shift. Direct link is http://www.texasnurses.org/displaycommoncfm?an=1subarticlenbr=235
- Institutes of Medicine (IOM) write up on sleep disorders and sleep deprivation. The IOM site (www.iom.edu) is a particularly good resource for learning about issues which affect patient safety. Night shifts and shift work are two key terms which can be used in the search engine and it will generate several interesting and informative articles.
It must be said that nurses will continue to care for patients throughout the day and night. This means that for the foreseeable future, nursing staff will be required to work during the overnight hours to ensure the safety and well being of patients. While night shift work cannot be eliminated, this research may open up new avenues of exploration into the issues that can occur when working long overnight hours and possibly yield new and more effective strategies for managing night shift work so that the negative impacts to both patient and nurse are lessened. A cogent and cohesive policy regarding the night shift nurse should be researched and developed and will hopefully serve to benefit nurse and patient.
- Dawson, D. & Reid, K. (1997). Fatigue, alcohol and performance impairment. Nature, 56(2), 235-242.
- Federal Motor Carrier Safety Administration (2011). Maximum driving time for property-carrying vehicles. Rule 395.3. United States Department of Health and Human Services.
- Hoffman, B. (2003). Health care reform and social movements in the United States. American Journal of Public Health, 93(1), 75-85.
- Institute of Medicine (2004). Keeping patients safe: transforming the work environment of nurses.
- Newland, J. (2010). Our sphere of influence: are we doing all we can? The Nurse Practitioner, 35(5), 6-9.
- Occupational Safety and Health Administration (2012). Position on extended or unusual work shifts. United States Department of Labor.
- Rogers, A. (2008). The effects of fatigue and sleepiness on nurse performance and patient safety. Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Hughes, R. (Ed.) Rockville, MD.
- Tablemann, B. (2005). How governmental policy is made. Best Practice Briefs, 34, 1-7.
- Texas Board of Nursing (2011). Position statement 15.14 regarding overtime shifts and consecutive shifts.
- Vinz, C., Foreman, J. & Cummings, K. (2010). An integrated approach to developing health care guidelines and measures. Agency for Healthcare Research and Quality. United States Department of Health and Human Services.
- Wage and Hour Division (2010), Frequently Asked Questions Regarding Pay Practices. United States Department of Labor.