Running head: SHIFT WORK

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.

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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

Shift work iii

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.

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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.

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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

Nursing Theory 18

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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

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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.

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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

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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.

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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-

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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

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‘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?

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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

Shift work 8

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,

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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

Shift work 10

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 11

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

Shift work 12

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

Shift work 13

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

Shift work 14

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

Shift work 15

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

Shift work 16

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

Shift work 17

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,

Shift work 18

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

Shift work 19

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).

Shift work 20

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.

Shift work 21

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

between the newly hired ‘claims advisors’ who have an alliance to the employer and with

Shift work 22

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

Shift work 23

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

Shift work 24

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,

Shift work 25

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,

Shift work 26

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”

Shift work 27

(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.

Currently, nurses sleep wherever they can, including nurses and patient lounges. This is

Shift work 28

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

Shift work 29

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)

Shift work 30

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

Shift work 31

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

Shift work 32

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

Shift work 33

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

Shift work 34

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?

Shift work 35

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?

Shift work 36

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

Shift work 37

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.

Shift work 38

References

Association of Canadian Ergonomists. What is ergonomics and who are ergonomists??

Retrieved July 22, 2009, from http://www.ace-

ergocanada.ca/index.php?contentid=142

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