Download Effects of rotating night shifts: literature review

INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES
Effects of rotating night shifts: literature review
Sandy Muecke
BN GradDipNurs RN
PhD Student, Department of Critical Care Medical, Flinders University, Adelaide, South Australia, Australia
Accepted for publication 17 September 2004
Correspondence:
Sandy Muecke,
Department of Critical Care Medicine,
Level 3,
Flinders Medical Centre,
Flinders Drive,
Bedford Park,
South Australia 5042 Australia.
E-mail: [email protected]
M U E C K E S . ( 2 0 0 5 ) Journal of Advanced Nursing 50(4), 433–439
Effects of rotating night shifts: literature review
Aim. This paper reports a review examining the concept of sleep and its antithesis
of fatigue, and considers the evidence on nurses’ ability to cope with the demands of
continually changing hours of work, their safety, and the impact any manifestations
of sleep disruption may have on the care of their patients. While many aspects of this
paper may apply to nursing in general, special consideration is given to nurses in the
critical care environment.
Background. Night duty rotations are common practice in nursing, and particularly
in specialist units. It is essential that nurses working in these environments are able
to maintain careful and astute observation of their vulnerable patients, and concern
arises when they may be unable to do so. Research suggests that fatigue can negatively affect nurses’ health, quality of performance, safety and thus patient care,
and that the effects of fatigue may be exacerbated for nurses over 40 years of age.
Method. The literature was examined for the 10-year period up to December 2003.
The databases searched were Ovid, Proquest, Blackwell Science, EBSCO Online,
Australian Health Review and WebSPIRS, using the keywords of, shiftwork, rosters,
intensive care, fatigue, sleep deprivation and sleep studies.
Findings. There is consensus amongst researchers on the adverse psychological and
physiological effects of night rotations on nurses when compared with their permanent night duty peers, particularly for those over 40 years of age. Evidence also
suggests that the effects of fatigue on nurse performance may negatively affect the
quality of patient care.
Conclusions. The literature reinforces concerns about the adverse relationship
between fatigue and performance in the workplace. Optimal standards for patient
care may be difficult to achieve for more mature nurses, who may suffer from sleep
deprivation and health problems associated with rotational night work and disrupted physiological rhythms.
Keywords: nursing, shiftwork, fatigue, sleep deprivation, literature review
Introduction
Night duty rotations are common practice in nursing. This
review shows how poor daytime sleeping may affect normal
homeostatic body mechanisms and how fatigue can negatively affect nurse health, quality of performance, safety and
thus patient care. Insufficient restorative daytime sleep and
inadequate recovery time from nightwork, as described in
many studies, may lead to sleep deprivation that may affect
2005 Blackwell Publishing Ltd
nurses’ abilities to provide the high standard of care that
nurses aspire to give to their patients.
Compelling evidence is found in the literature about the
relationship between fatigue and performance in the workplace, both from a nursing perspective and that of other 7-day
rostered occupations. Although nursing and occupational
health and safety aspects are acknowledged in the literature,
there is little focus on the specific characteristics of some
nurses that may make them more susceptible to the adverse
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S. Muecke
health effects of night duty rotations and hence put at risk
patient care and safety. Thus far, however, little research has
explored issues of competency, quality of performance and
emergent patient and nurse safety issues during night duty
rotations, particularly within a critical care setting. Indeed,
Poissonnet and Veron (2000) concede that little information
exists on the effects of shiftwork on health care professionals.
After investigating the concepts of sleep and its antithesis
fatigue, consideration is given to the evidence on nurses’
abilities to cope with the demands of continually changing
hours of work, the safety of these nurses and the impact of
these issues on patient care. As the literature demonstrates,
disruption of circadian rhythms is exacerbated for those over
40 years of age, and so the bodily responses to fatigue on this
group of nurses are the focus of this review.
Problems associated with lack of sleep have been classified
by Barton (1994) and Reid et al. (1997) into three groups,
encompassing disturbance of circadian rhythm, physical and
psychological problems because of fatigue, and problems
associated with a disruption to family life. This categorization is well supported by the literature (Dingley 1996,
Learhart 2000). However, because of the complex nature of
sleep deprivation, the review will concentrate on the first two
of these manifestations, with emphasis on the circadian cycle
and the physiological disharmony resulting from fatigue,
although psychological disturbances will be briefly acknowledged.
Search methods
The English language literature was reviewed in early 2002
and late 2003 for papers published from 1992 onwards. The
databases searched were Ovid, Proquest, Blackwell Science,
EBSCO Online, Australian Health Review and WebSPIRS.
The keywords used were shiftwork, rosters, intensive care,
fatigue, sleep deprivation and sleep studies.
Papers were selected based on their content, relevancy,
author, and research validity or rigour. Papers published
within the past 10 years were sought, and some were found
by searching for specific authors considered by peers to be
experts within this domain of knowledge. Other papers were
identified from citations and reference lists of already
accessed professional literature.
Results
Sleep
In an excellent and comprehensive review of sleep–wake
cycles citing experiments and theories that evolved from the
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turn of the 20th century, Lavie (2001) describes the physiological processes of sleep as accepted today. It was not until
the 1970s that scientists first noted that sleep propensity
seemed to occur in a cyclic fashion that appeared to be
controlled by endogenous mechanisms in conjunction with
exogenous factors, rather than being solely controlled by
environmental factors as previously believed. This cyclical
pattern involves a major drive for sleep in the evenings and a
lesser drive in the middle of the day. Initially, scientists
believed the endogenous cycle had a period of 25 hours, but
Lavie (2001) describes recent research showing that this
period is almost exactly 24 hours, with only a few minutes’
deviation. This 24-hour cycle is known as the circadian
rhythm, from the Latin circa meaning ‘about’ and dies
meaning ‘day’.
Many authors (Grossman 1997, Humm 1997, Reid et al.
1997, Fox 1999, Lavie 2001, Turek et al. 2001) state that
sleep is controlled by the hypothalamus in the brain. Within
the hypothalamus lies the suprachiasmatic nuclei (SCN) that
directly communicate with the retina of the eye through the
retinohypothalamic nerve pathway. Significantly, Turek et al.
(2001) reveal that in 1997 the discovery of the circadian
clock gene Clock in mice occurred, linking the gene to SCN
diurnal homeostasis in these animals, although the presence
of this gene is as yet unproven in humans.
The hormone melatonin is very important in relaying
environmental information to the brain. Secreted by the
pineal gland only during times of environmental darkness,
melatonin has receptors located in the SCN and, when
injected into the body, it causes drowsiness and inhibits
several endocrine functions (Fox 1999, Perkins 2001).
Conversely, the cyclical release of the hormone cortisol, a
glucocorticoid, helps with day waking. Cortisol, which
regulates metabolism and is released in response to stress, is
released primarily in the morning and has low levels in the
evening (Reid et al. 1997, Perkins 2001). Thus, the pattern of
day and night is very important in regulating the circadian
clock and sleep–wake mechanisms, as normal sleep–wake
patterns rely on the recognition of day and night by the
retina.
In a comprehensive synopsis of many studies, Fox (1999)
details that during sleep the metabolic rate is lowered, as are
the heart rate, respiratory rate and blood pressure as the
brain’s cortical activity is depressed. Likewise, depressed
muscle tone and reflexes also occur. The importance of sleep
is further detailed by Fox (1999), who notes that protein
synthesis, growth hormone release and cognitive restoration
all occur during sleep.
Lavie (2001) reviewed the association of normal cyclical
temperature changes within the body and circadian rhythms.
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(4), 433–439
Integrative literature reviews and meta-analyses
Normally, people experience a temperature peak in the late
afternoon or early evening and a temperature low during the
early morning. Experiments reviewed by Lavie (2001)
showed a marked correlation between temperature and
ability to sleep in that, if sleep commences at about the
temperature peak (i.e. in the evening) rather than at the
temperature low (i.e. early morning), sleep times almost
double. Likewise, performance generally peaks around the
time of the evening temperature peak, between 16:00 and
18:00 hours. Therefore, the desire for sleep is at its lowest in
the morning as the core temperature begins to rise. Reid et al.
(1997) summarize this relationship by stating that:
Sleep is of short duration if it starts at the body temperature’s low
point; sleep is longer if it starts near the peak of the body temperature
rhythm, with wake time 2–3 hours after the subsequent minima in
core temperature. (p. 442)
This is supported by Perkins (2001), who concludes that
people who sleep during the day obtain about 4 hours less
sleep than night sleepers. Thus, temperature cycles in the
body also affect the sleep–wake cycle.
The circadian-driven propensity for sleep is therefore
strongest at night. Night workers must work during the
nocturnal release of melatonin and sleep during the day
without it, and also against the cortisol-induced desire for
morning wakefulness (Perkins 2001, Lamond et al. 2003).
Fletcher and Dawson (1997) state that ‘sleep that occurs
during times when an individual is biologically driven to be
awake tends to be shorter and of decreased quality’ (p. 474).
Many sleep studies have shown that night sleep is the most
restful and restorative.
Nightworkers are therefore subject to two types of sleep
deprivation, as described by Fletcher and Dawson (1997).
The first, experienced as a night shift progresses and normal
night-time sleep is omitted, is continuous sleep deprivation.
The second is cumulative sleep deprivation that occurs over
successive days and nights because of shortened sleep times
during circadian wake times. Perkins (2001) also discusses
this notion of a cumulative sleep debt. Given that day
sleeps are often 1–4 hours shorter than night sleeps, night
nurses may accumulate a significant number of hours sleep
debt even in just 1 week, contributing to long-term
exhaustion.
Fatigue can therefore be described as a function of the
amount of sleep obtained and the time of day when it is
received. Although the longer a person works, the more they
will tire, it is also vital to relate work to the time of day at
which it is performed as, according to Fletcher and Dawson
(1997), fatigue accumulates faster during nightwork compared with daywork. Indeed, Fletcher and Dawson (1997,
Effects of rotating night shifts
p. 475) contend that ‘no more than two or three night shifts
should be worked consecutively in any work block’.
Fatigue
The literature links some of the world’s worst disasters with
fatigue. Rogers et al. (1997) and Harrington (2001) are just
some of many authors who attest that the Chernobyl nuclear
reactor catastrophe, which occurred at 01:35 hours, was
because of human error as a result of nightwork. The
environmental disaster of the Exxon Valdez oil spill is also
linked to human error and fatigue in many publications,
including that of Rogers et al. (1997).
Reinforcing these undesirable consequences of sleep deprivation is research by Dawson, an eminent researcher of sleep
disorders, and Reid et al. (1997). Their frequently-cited,
quantitative experiment compared psychomotor performance
of 40 people who were deprived of sleep for 28 hours and
then at a later time were asked to consume 10–15 g of
alcohol. Both groups’ performance deteriorated significantly
and, after 17 hours of wakefulness, performance was equivalent to that of a blood alcohol level of 0Æ05% and after
24 hours without sleep, performance was equivalent to that
of a blood alcohol level of 0Æ10%. Transferring these findings
to nursing practice, would suggest that, 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 0Æ10%.
Many studies note that staff who work permanent night
duty are less likely to suffer sleep-deprivation effects with
such acute severity. Dingley (1996) attributed this to the
ability of the cycle to adjust itself if given sufficient time. In a
comparative study of two groups of nurses, one group
working permanent nights and the other rotational nights,
Dingley (1996) asked them to assess their levels of alertness
using a visual analogue scale and a reaction time test using a
computer, over four consecutive nights. Although only a
small sample size was used (10 nurses in each group) and the
nurses worked in different clinical areas, results clearly
showed that alertness improved up to the fourth night as
the number of nights progressed, reinforcing the notion of
circadian rhythm shifts and adaptation. Not surprisingly, test
performance was better at the start of the night shift than at
the end, as fatigue progressed.
This circadian adaptation is also supported by Lamond
et al. (2003), who propose that circadian adjustment is very
slow, may take several days or weeks, and may never achieve
completion. The Dingley (1996) and Lamond et al. (2003)
findings thus undermine the case for rotating night shifts, as
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(4), 433–439
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S. Muecke
they highlight the fact that circadian adaptation to nightwork
often occurs just in time to return to the day roster.
Barton (1994), reviewing several previous studies, noted
the fact that permanent night workers choosing rather than
being obliged to work at night, in combination with differing
personality types, greatly influenced the ability to cope with
night duty. This interesting observation could be attributed to
the fact that not everyone has the same timing in their
circadian clock (Reid et al. 1997, Poissonnet & Veron 2000).
Some people appear to have circadian rhythm periods of
longer than 24 hours and may have a longer time period
between temperature peaks and troughs. Those with such
cycles may find that they are more able to cope with
nightwork, because of a natural preference for either mornings or evenings (Reid et al. 1997, Learhart 2000). A morning
person gets up early, has an active morning and an early
night. The ‘night owl’ sleeps later, is more active in the
evening, cannot get to sleep at night and may be more suited
to nightwork.
When sleep is deprived, the natural circadian rhythm is
disrupted and sleep is craved. Perkins (2001) describes the
phenomena of micro-sleep, because of continuous or cumulative sleep deprivation when a person may uncontrollably
experience altered states of consciousness for periods up to
30 seconds. During this time, there is loss of concentration
and no response to environmental stimuli, and this can
happen during any activity and becomes more frequent as
sleep deprivation continues.
Effects of fatigue on health
Physiological effects
The literature has conclusively identified a relationship
between biological body rhythms and the natural propensity
for night-time sleep and day-time wakefulness. The power of
the circadian pacemaker is best seen when the sleep–wake
cycle is disrupted and other rhythms of the body become
chaotic (Turek et al. 2001). Many cyclical hormone releases
in the body are aligned to the circadian sleep cycle, such as
those of melatonin and cortisol. Given that nightwork and in
particular rotational night work is disruptive to the circadian
drive, inter-dependent rhythms of the body are likely to suffer
similar physiological upheaval.
Higher rates of sick leave are noted amongst rotational
shiftworkers (Panton & Eitzen 1997, Reid et al. 1997).
Cardiovascular status and haemodynamic functions influence
renal perfusion and urine production, digestive tract function,
reproductive hormone release and red and white blood cell
production. Immune response, too, is diminished in proportion to the amount of sleep debt accumulated (Perkins 2001).
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Digestive enzymes are secreted in a cyclical fashion, and
the unusual eating and fasting times of nightwork are in
disharmony with this cycle. Specifically, some of the health
problems experienced by shiftworkers because of disrupted
biological synchronism include obesity with associated
cardiovascular disease and a sixfold increase in the incidence
of gastrointestinal disorders such as peptic ulcers, indigestion,
nausea, diarrhoea and constipation (Reid et al. 1997,
Learhart 2000, Perkins 2001).
The circadian pattern of lowering of blood pressure and
heart rate at night may result in a higher incidence of
ischaemic heart disease in nightworkers. Harrington (2001)
concurs and describes Scandinavian studies that support this
observation. These studies suggest that the propensity for
cardiovascular pathology amongst shiftworkers is not only
related to circadian disruption, but also to stress and a poor
diet and exercise regime that may be associated with the
social upheaval linked with irregular working hours.
A higher risk of miscarriage and premature labour is noted
amongst shiftworkers (Reid et al. 1997, Perkins 2001).
Commonly, menstrual problems (another biological cycle)
are also noted among these workers. Perkins (2001) proposes
that nurses who suffer from diabetes, heart disease, and some
gastro-intestinal disorders, such as Crohn’s, disease should
avoid night shifts. Asthmatics may also suffer more on nights
as, according to Perkins (2001), respiratory irritation is most
likely to occur between 04:00 and 07:00 hours.
Ageing and night shifts
The ability of the circadian cycle to adjust constantly to the
changing sleep patterns that must be endured by the rotational night nurse is diminished with age (Reid et al. 1997,
Learhart 2000, Poissonnet & Veron 2000, Reid & Dawson
2001, Lamond et al. 2003). This inability to tolerate shiftwork has also been attributed to the diminished ability of
older people to achieve sleep that is uninterrupted and of
sufficient length, even under optimal conditions. This is
typically seen at around 40–45 years of age and may be
exacerbated by other health problems.
Interestingly, it seems that even permanent night staff may
have difficulty with nocturnal schedules once they reach 40 or
50 years of age (Learhart 2000). Reilly et al. (1997) suggest
that there is a natural tendency for older people to become
morning people rather than night-owls which makes night
work difficult for mature permanent nightworkers, and may
contribute to their resignation from permanent nightwork.
Given that older nurses are often the most senior and
experienced, this has serious ramifications for efficient
hospital management, the general standard of patient care
and education of junior nurses.
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(4), 433–439
Integrative literature reviews and meta-analyses
Psychological effects of fatigue
Problems because of diurnal disruption are not solely physiological. Psychological imbalance can be experienced also
(Reid et al. 1997). Fatigue has been well-documented in the
literature. In the Maastricht Cohort Study that began in
1998, questionnaires were distributed to 26,978 employees,
of whom 12,161 returned the first of the eight questionnaires.
Of these respondents, 61Æ9% returned the eighth and final
questionnaire (n ¼ 7482) (Jansen et al. (2003). Forty-five
different workforce populations were represented and results
showed that fatigue may be an underlying cause of cessation
of shiftwork in favour of working during daylight hours.
Irritability and strain are also noted in the literature
(Lushington et al. 1997, Reid et al. 1997). Lushington et al.
(1997) also identified that nurses and their partners found
shiftwork to be disruptive to their family and social lives.
Poissonnet and Veron (2000) describe studies showing that
nurses on rotating schedules experienced less job satisfaction
and were more likely to leave, when compared with those
working fixed shifts.
Effects of fatigue on safety
The literature shows that sleep deprivation of 24 hours can
result in performance levels associated with those of blood
alcohol levels of 0Æ10% (Dawson & Reid 1997). Reid and
Dawson (2001) suggest that mature people will reach
performance levels equivalent to a blood alcohol level of
0Æ10% in less time than their younger workmates. This may
mean that a nurse may drive home from work in an unfit state
that is detrimental to both the well-being of the nurse and
other road users.
Hart et al. (2003) concludes that rotating shift workers,
probably because of the diminished performance associated
with circadian disruption, are at particular risk of having an
accident at work. In particular, Swaen et al. (2003) used the
Maastricht Cohort Study data to determine if prolonged
fatigue and inadequate recovery were precursors of occupational accidents. They found that, while the likelihood of
being injured varied amongst different groups of employees,
shiftwork (especially nightwork) was strongly linked to an
increase in workplace accidents. Participants who worked
nights were three times more likely to be injured in a work
related accident than day-time workers.
The evidence presented clearly describes working conditions that may be fatal. Indeed, Baker et al. (1997) assert that
‘shiftwork should be viewed and managed as a hazardous
place to work’ (p. 452), while Dawson (1997) declares that
‘there is clear scientific evidence that shiftwork is an identified
workplace hazard’ (p. 412).
Effects of rotating night shifts
Effects of fatigue on patient safety
A summary of the hazards of night work is given by Dingley
(1996), p. 1248), based on data gathered from many sleep
studies. She states:
… sleep loss, along with the need to work at the low point of
circadian cycle, increases the risk of night nurses being less alert than
would ideally be the case. This may impair the efficiency with which
they carry out their duties and in an extreme case could possibly
endanger the life of a patient.
Aspects of performance related to disrupted circadian
rhythms and deleterious to patient safety have been described
by Reid et al. (1997), and include ‘slowing reaction time;
delaying responses; failing to respond at the correct time;
giving false responses; and causing slowed thinking and
diminished memory’ (p. 442).
The implications of fatigued nurses working in any patient
care area are undoubtedly important, but the effects of
impaired nurse performance in the critical care environment
may be more profound. Indeed, Rogers (2002), in a paper
addressing sleep deprivation in an emergency department,
suggests that small yet vital changes in a patient’s condition
or medication order errors may be overlooked by a sleepstarved nurse. Given that Bond and Dax (2000, p. 1914)
describe critical care nurses as ‘responsible for diagnosing
life-threatening conditions and instituting appropriate treatment…in an environment equipped for technically advanced
methods of assessing and managing patient problems’, the
necessity for an alert and focused patient care nurse is
obvious. This need for nurse astuteness is further supported
by the Confederation of Australian Critical Care Nurses Inc.
in their document outlining Competency Standards of
Specialist Critical Care Nurses. This organization defines a
critically ill patient as one ‘characterized by the presence of
actual and/or potential life threatening health problems’ and
that ‘the needs of these patients include the requirement for
continuous observation and intervention to prevent complications and restore health’ (Confederation of Australian
Critical Care Nurses Inc. 1996, p. viii).
A study by Lee et al. (2003) investigating the mortality rates
of babies admitted to a neonatal intensive care unit showed
that babies born between 24 and 32 weeks of gestation during
the study period were 60% (risk-adjusted) more likely to die if
born at night, when compared with those of the same
gestational age born during the day. That is, 29 extra deaths
per 1000 births of babies of less than 32 weeks gestation might
have been averted. Three possible reasons were given. First,
infants admitted at night were thought to be sicker than those
admitted during the day. Second, expert physician care was
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(4), 433–439
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S. Muecke
What is already known about this topic
• There is an adverse relationship between fatigue and
quality of performance.
• Older nurses, specifically those over 40 years of age,
may exhibit inferior performance skills compared with
those of younger night workers.
• Fatigue has been implicated in some of the world’s
worst disasters.
What this paper adds
• Disrupted body rhythms caused by shiftwork lead to
major physiological and psychological effects for nurses
that may affect patient safety and the quality of care
provided.
• These effects are greater in those over 40 years of age
and may be more profound in a critical care setting.
• The findings of the review raise important questions for
the organization and management of a 24-hour health
care service.
more readily available during the day. The third reason related
to the inferior levels of alertness and performance of medical
and nursing staff during nightshifts, linked to fatigue and
circadian dis-synchronism. This study clearly supports the
notion that patient safety may be at risk during nightshifts in
some instances.
Conclusion
Despite evidence in the literature describing the vital role
sleep plays in health maintenance and homeostasis, the
adverse consequences of sleep deprivation on nurses’ health
and patient safety have been poorly explored. Furthermore,
there is little on the implications of nurse fatigue in
specialized settings such as the critical care unit. The
literature has shown that fatigued nurses working rotating
night shifts, especially those over 40 years of age, may not
function at optimal performance levels during the latter hours
of a night shift or over successive night shifts as fatigue
accumulates. Thus, there are concerns about the health and
safety of nurses and the undesirable manifestations of fatigue
on the care and safety of patients, particularly in specialist
care settings.
As professionals in a caring vocation, nurses strive to give
safe and effective nursing interventions 24 hours a day, and
to treat and support patients in order to achieve the most
favourable outcomes. It is therefore essential that nurses,
438
both the young and not quite so young, are physically able to
administer the high standards of care that they are obliged
both personally and professionally to give. However, this
may not be achievable at all times, given that they may be
suffering the effects of sleep deprivation that may intensify as
they age.
The intimate and indivisible relationships between performance, fatigue, recovery, and age that have been shown in
this review to contribute decisively to the quality of care
during night shifts, and the possible implications of the
evidence presented are disturbing for both patients and
nurses, particularly in the critical care environment.
Acknowledgements
Construction of this paper follows the completion of a
Bachelor of Nursing Honours degree at the School of Nursing
and Midwifery, Flinders University, Adelaide. Special thanks
to Dr Lindy King, Senior Lecturer at Flinders University for
sharing her extensive research expertise, and particularly for
her assistance with drafts and the research process.
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