Nurses struggle with night-shift sleepiness

1 in 4 stay awake 24 hours or more

Half of all health care workers who work the night shift get less than six hours of sleep a day.1 They drink caffeine to stay alert, but many still struggle to keep from involuntarily dozing. And one in four night shift nurses resort to staying awake for at least 24 hours to adjust to changing schedules.2

Although night shift is a necessary and longstanding part of hospital work, these findings indicate that nurses have not adapted well to an overnight schedule, says Karen Gamble, PhD, assistant professor of behavioral neurobiology at the University of Alabama at Birmingham. They are at risk for a condition known as shift work sleep disorder.

Employers should give employees information on the best strategies to cope with night shift and should be aware of fatigue-related risk, Gamble says.

“No matter what we do, hospitals are going to have to have people who work at night. It’s unavoidable,” she says. “But I really hope that we can find a better way [to cope], whether it’s a different shift system or providing strategies for people to adapt to it.”

Televised pharmaceutical ads about shift work sleep disorder have helped raise awareness of this problem. The American Nurses Association recently launched an educational campaign, with a webinar and tips on improving alertness.

“Shift work sleep disorders are under diagnosed and untreated,” says Jaime Murphy Dawson, MPH, senior policy analyst in the Department for Health, Safety and Wellness at the ANA in Silver Spring, MD.

Lark or owl? Neither does well on nights

Shift work sleep disorder is more than just sleepiness after a long night (or day) of work. Not everyone working night shift has a disorder. But fatigue-related problems are common for night shift workers.

In a 2011 ANA health and safety survey of 4,614 nurses, one in 10 said they have had a car accident that they believe is related to fatigue or shift work.2

Gamble and colleagues studied shift work sleep strategies and chronotype, or the genetic propensity to wake early (larks) or stay up late (owls). She found that overall, night shift workers were not well-adapted to their schedule.

One in four night shift workers used a sleep deprivation strategy to shift from sleeping during the day to during the night, or vice versa; they stayed up for 24 hours or more, a time period that encompassed their shifts. Older, more experienced nurses and nurses with children at home were more likely to use this strategy.

That lack of sleep has lingering effects, says Gamble. “With the no-sleep nurses, even when they go to sleep the next day, they’re still carrying that sleep debt with them for a few days,” she says. “That sleep deprivation is going to stay with them for a while.”

The most common strategy was the “switch sleeper,” in which nurses slept extra hours in the 24 hours preceding their night shift to store up sleep. “They have one day in which they sleep a whole lot,” Gamble says. “They wake up, then take a nap before they go to their shift. When they get off, they sleep a little bit and then try to go to bed at a normal social time.”

Only 3% of the nurses stayed on the nocturnal schedule even on their days off. “Our data really explains the idea of social jet lag,” says Gamble. “It’s a discrepancy between your biological time and your social time.”

Gamble also found that the 7-to-7 shift doesn’t work well even for many people on day shift. Larks, or those who biologically are more likely to wake early, are well-adapted to the day shift, but owls are not, she says.

Take a break to reduce fatigue

It’s exhausting. Gaining weight. I miss daylight. No energy, inability to eat at regular intervals.

Tired all the time.

Those are some of the comments Gamble has collected from night shift workers in an ongoing study. They illustrate some of the problems created by the schedule.

It’s not yet clear what would be the optimal schedule that would promote alertness but still enable hospitals to cover the overnight responsibilities. Eight-hour shifts are generally considered to be healthier, says Gamble, but research hasn’t yet established whether that schedule allows nurses to adapt better to the switch between day and night.

Yet there are some strategies that help reduce fatigue:

• Encourage breaks and, if possible, short naps. Nurses report that they are unable to take breaks or even mealtime because of staffing concerns, says Dawson. Hospitals should allow sufficient staffing to make sure that nurses can take a break.

• Rotate shifts clockwise. Gradually rotating shifts rather than abruptly shifting from day to night may allow for better adjustment, says Dawson.

• Use strategies to adjust the circadian rhythm. Our bodies have a wake-sleep cycle that responds to light and dark. On the way home from a night shift, nurses can wear sunglasses to dim the bright sunlight. While at work, bright light has an alerting effect.

References

1. Centers for Disease Control and Prevention. Short sleep duration among workers — United States, 2010. MMWR 2012;61:281-285.

2. Gamble KL, Motsinger-Reif AA, Hida A, et al. Shift work in nurses: Contribution of phenotypes and genotypes to adaptation. PLoS ONE 2011;6(4):e18395. doi:10.1371/journal.pone.0018395.

Symptoms, interventions for shift sleep disorder

According to the National Sleep Foundation, symptoms of shift work sleep disorder include:

• Excessive sleepiness

• Insomnia

• Disrupted sleep schedules

• Reduced performance

• Difficulties with personal relationships

• Irritability or depressed mood

Consider these issues to help workers

According to the National Institute for Occupational Safety and Health, employers should consider the following issues to help employees cope with shift work woes:

Regular Rest: Establish at least 10 consecutive hours per day of protected time off-duty in order for workers to obtain 7-8 hours of sleep.

Rest Breaks: Frequent brief rest breaks (every 1-2 hours) during demanding work are more effective against fatigue than a few longer breaks. Allow longer breaks for meals.

Shift Lengths: Five 8-hour shifts or four 10-hour shifts per week are usually tolerable. Depending on the workload, twelve-hour days may be tolerable with more frequent interspersed rest days. Shorter shifts (8 hours), during the evening and night, are better tolerated than longer shifts.

Workload: Examine work demands with respect to shift length. Twelve-hour shifts are more tolerable for “lighter” tasks (such as desk work).

Rest Days: Plan one or two full days of rest to follow five consecutive 8-hour shifts or four 10-hour shifts. Consider two rest days after three consecutive 12-hour shifts.

Training: Provide training to make sure that workers are aware of the ups and downs of shift-work and that they know what resources are available to them to help with any difficulties they are having with the work schedule.

Incident Analysis: Examine near misses and incidents to determine the role, if any, of fatigue as a root cause or contributing cause to the incident.