Shift Work and Heart Rate Variability Coherence: Pilot Study Among Nurses

The impact of working night shifts on cardiac autonomic nervous regulation during the six-minute walk test in nurses

BACKGROUND

Clinical nurses frequently face the necessity of working night shifts, often with insufficient opportunities for timely sleep recovery, which may negatively impact autonomic nervous system regulation. The aim of this study was to evaluate changes in heart rate variability (HRV) after the six-minute walk test (6MWT) in nurses post-night shift and to explore the impact of night shift work on cardiac autonomic regulation.

METHODS

Thirty-five female nurses, with a mean age of 28.7 years (range 21.0-37.0 years), participated in this study. On the first and second mornings after a night shift, the nurses performed the 6MWT. During the test, electrocardiogram (ECG) signals, blood pressure, and walking distance were recorded simultaneously.

RESULTS

Compared with the second postshift morning, on the first postshift morning, nurses presented higher ratings of perceived exertion (RPE), higher Borg scale scores, and a slower pulse rate before and after the 6MWT but covered a shorter walking distance. Additionally, HRV indicators such as the SDNN, RMSSD, pNN50, TP, VLF, LF, and HF were all higher on the first postshift morning. Regarding the amplitude of cardiac autonomic nervous regulation, variations in the RMSSD and pNN50 were both greater during the 6MWT on the first postshift morning, although there was no significant difference in post-6MWT recovery.

CONCLUSIONS

Night shifts appear to increase the activity of the autonomic nervous system in nurses on the first postshift morning and exert a greater inhibitory effect on parasympathetic activity during the 6MWT. Therefore, it is important to ensure timely recovery sleep and improve autonomic regulation after working night shifts.

KEYWORDS

Heart rate variability; Night shift; Autonomic nervous system; Six-minute walk test; Nurses.

TRIAL REGISTRATION

This study was retrospectively registered in the Clinicaltrials.gov. Registration Date: August 1, 2024.

CLINICALTRIALS

gov ID: NCT06542510.

Influence of shift work on sleep quality and circadian patterns of heart rate variability among nurses

Background

Shift work implementation is essential for providing continuous patient care in hospitals. However, working in shifts on a routine basis may disrupt the circadian pattern and alter the sleep-wakefulness cycle in nurses. Stress due to shift work can influence the adaptability of the cardiovascular system, produce psychophysiological strain and deteriorate work performance in female nurses.

Objective

This study investigated the effect of morning and night shift work on sleep quality and circadian patterns governing heart rate variability (HRV) in female nurses working in a tertiary care hospital.

Methods

Thirty-eight healthy female nurses were recruited. Frequency and time domain parameters of HRV were recorded as markers of cardiac autonomic function. A student t-test was used to investigate differences in HRV between morning and night shift workers. Mann-Whitney non-parametric test was applied for the difference between Pittsburgh Sleep Quality Index (PSQI) scores in the two groups.

Results

Standard deviation of the normal-to-normal interval (SDNN) (msec), total power (ms2) and high-frequency (HF) band power (ms2) were significantly reduced in night shift nurses than in morning shift nurses. The low-frequency (LF)/HF ratio was significantly increased in night shift nurses. The differences in standard deviation of the averages of NN intervals (SDaNN) (msec), root mean square of successive differences between adjacent NN intervals (RMSSD), mean NN, very low-frequency (VLF) band power (ms2) and LF band power (ms2) were not statistically significant. The global PSQI score was significantly higher among night shift workers than in morning shifts.

Conclusion

Inadequate sleep can disrupt the body's ability to regulate heart rhythm and increase the risk of cardiovascular diseases and mortality. The research suggests a propensity for autonomic imbalance in night shift workers when compared to their counterparts on morning shifts.

Consequences of Shift Work and Night Work: A Literature Review

Nonstandard work schedules such as shift work and night work tend to trigger problems for workers in different areas. To illustrate the diversity of areas affected and the relative interest of the scientific community, we conducted a literature review of the effects of shift work and night work on workers. In particular, we intended to identify the main variables addressed in the field of health, the family sphere, and the organizational context. The literature review was carried out using the Web of Science with the following terms: "shift work", "rotating shifts", and "night work". Inclusion criteria incorporated empirical studies and articles written in Portuguese or English published in 2019. We selected 129 of the 619 articles identified. Regarding the impacts of shift work and night work, there existed a high discrepancy of focus between the three defined areas: health, family life, and organizational context. Specifically, health-related variables were the most studied (83.4%), followed by organizational variables (9.2%), and, lastly, family variables (7.4%). Based on these results, it is essential to extend the study of the two underrepresented impacts to other crucial areas, not only for the worker but also for organizations.

The effect of extended shift work on autonomic function in occupational settings: A systematic review and meta-analysis

OBJECTIVE

To examine the effect of 24-h shift work on autonomic nervous system function via heart rate variability (HRV) methodologies.

METHODS

Electronic databases (indexed in either PubMed, MEDLINE, CINAHL, SPORTDiscus, or OpenDissertations) were searched from January 1964 to March 2023. A modified Downs and Black checklist was used for assessing methodological quality and the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Study design, study population, study sample, shift work description, and assessment of HRV metrics and methods were extracted from each study.

FINDINGS

A total of 58 478 study articles were identified, of which 12 articles met inclusion criteria. Sample sizes varied from eight to 60 participants, with the ratio of low- to high-frequency HRV (LF/HF) as the most common frequency-domain variable reported. Of the nine included studies that observed LF/HF, three (33.3%) demonstrated a significant increase after 24-h shift work. Moreover, of the five studies that reported HF, two (40%) noted a significant decrease after 24-h shift work. When observing risk of bias, two (16.6%) studies were low quality, five (41.7%) were moderate quality, and five (41.7%) were high quality.

INTERPRETATION

There were inconsistent findings demonstrating an effect of 24-h shift work on autonomic function, with a suggested shift away from parasympathetic dominance. Discrepancies in HRV methodologies, such as the duration of recordings and hardware used for measurement, may have contributed to the disparity in findings. In addition, differences in roles and responsibilities across occupations may explain the incongruence in findings across studies.

Copper-induced diurnal hepatic toxicity is associated with Cry2 and Per1 in mice

BACKGROUND

This study aimed to investigate diurnal variations in copper-induced hepatic toxicity and the molecular mechanisms underlying this chronotoxicity.

METHODS

Male C57BL/6J mice were intraperitoneally injected with copper chloride (CuCl2) at zeitgeber time 2 (ZT2) or 14 (ZT14), twice per week for 5 or 8 weeks. Seventy-two hours after the final CuCl2 injection, the mice were euthanized, and plasma samples were collected. The livers and kidneys were collected and weighed. In vitro experiments were performed to assess cell viability and fluctuations in clock gene expression levels in Hepa1-6 cells after CuCl2 treatment. We examined copper homeostasis- and apoptosis-related genes under clock genes overexpression.

RESULTS

Repeated CuCl2 administration for 8 weeks resulted in more severe toxicity at ZT14 compared to ZT2. CuCl2 administration at ZT14 elevated plasma aspartate aminotransferase, hepatic tumor necrosis factor-α, and interleukin-6 for 5 weeks, whereas the toxic effects of CuCl2 administration at ZT2 were weaker. Moreover, CuCl2 treatment inhibited Hepa1-6 cell viability in a dose-dependent manner. We observed increased expression of three clock genes (Ciart, Cry2, and Per1) after CuCl2 treatment. Among them, overexpression of Cry2 and Per1 accelerated CuCl2-induced inhibition of Hepa1-6 cell viability. Moreover, we found that the overexpression of Cry2 and Per1 regulates cleaved caspase-3 by modulating the copper transporter genes ATP7B and CTR1.

CONCLUSION

These results suggest that CuCl2-induced diurnal toxicity is associated with Cry2 and Per1 expression through the regulation of copper transporter genes in mice.

Following the Rhythm of the Heart: HeartMath Institute's Path to HRV Biofeedback

This paper outlines the early history and contributions our laboratory, along with our close advisors and collaborators, has made to the field of heart rate variability and heart rate variability coherence biofeedback. In addition to the many health and wellness benefits of HRV feedback for facilitating skill acquisition of self-regulation techniques for stress reduction and performance enhancement, its applications for increasing social coherence and physiological synchronization among groups is also discussed. Future research directions and applications are also suggested.

Evaluation of the Heart Rhythm Coherence Ratio During Sleep: A Pilot Study With Polysomnography

The psychophysiological coherence model proposes that a heart rhythm pattern, known as heart rhythm coherence (HRC), is associated with dominant parasympathetic activity and the entrainment of respiratory function, blood pressure, and heart rhythms. Although the HRC pattern has primarily been assessed during wakefulness, changes in cardiac and autonomic activity that occur during sleep stages can also be associated with the HRC pattern. The objective of this study was to examine whether any differences in the HRC pattern could be detected among various sleep stages. Eighteen healthy young individuals participated in this study. Two consecutive polysomnographic (PSG) recordings were obtained from each participant, several segments of cardiac activity were obtained from the second PSG. The HRC pattern was quantitatively evaluated by calculating the HRC ratio (HRCR). The highest peaks in the coherence band (Coher-Peak), 0.1-Hz index, respiratory sinus arrhythmia (RSA), and heart rate (HR) were evaluated. A Friedman test showed significant differences among sleep stages in the Coher-Peak, 0.1-Hz index, RSA, and HR; the Coher-Peak and RSA values were lower in rapid eye movement (REM) sleep, while the 0.1-Hz and HR values were higher in REM sleep. Post hoc analyses identified significant differences between the N2 and REM sleep stages. Among the various sleep stages, HR and RSA measurements behaved independently of the HRC pattern, and the HRC pattern did not appear to be associated with the 0.1 Hz frequency. Further studies are required to identify the characteristics of the HRC pattern during sleep.

Neurocognitive impairment in night and shift workers: a meta-analysis of observational studies

OBJECTIVE

Shift work is an essential element of modern labour, ensuring ideal conditions of service for today's economy and society. Despite the beneficial properties, its impact on the neurobehavioural performance of exposed subjects remains controversial. This meta-analysis aimed to provide the first summarising effects regarding the association between shift work exposure and different cognitive functions.

METHODS

A literature search was performed using the databases PubMed, PsyINFO, PsyARTICLES, MedLine, PsycNET and Scopus including eligible studies up to April 2021 that compared shift workers with non-shift workers regarding neurobehavioural performance tests. We carried out a random-effects model using Hedges' g as a meta-analytical effect size with a restricted likelihood estimator to summarise the mean differences between the exposure group and controls. Positive effect sizes indicate higher performance for non-shift workers. The heterogeneity of effect sizes was addressed by sensitivity analysis using funnel plots, Egger's tests, p-curve analysis, meta-regressions and subgroup analysis.

RESULTS

We included 18 studies resulting in a total sample of 18 802 participants and 37 effect sizes concerning six different neurobehavioural outcomes. Our results showed significantly worse performance in shift workers compared with non-shift workers in the following cognitive functions with g (95% CI): processing speed 0.16 (0.02 to 0.30), working memory 0.28 (0.51 to 0.50), psychomotor vigilance 0.21 (0.05 to 0.37), cognitive control 0.86 (0.45 to 1.27) and visual attention 0.19 (0.11 to 0.26).

CONCLUSIONS

We provide the first meta-analytical findings that associate shift work with decreased cognitive performance in processing speed, working memory, psychomotor vigilance, cognitive control and visual attention.

Effects of High-Intensity Interval Exercise and Acute Partial Sleep Deprivation on Cardiac Autonomic Modulation

Sleep deprivation in healthy adults has been associated with disrupted autonomic nervous system function, which in turn has been linked to cardiovascular health. High-intensity interval exercise (HIIE) may affect both sleep and cardiac autonomic modulation. Purpose: To investigate the impact of acute partial sleep deprivation on autonomic cardiac regulation before and after an acute bout of HIIE and the length of time for the autonomic system to return to resting levels. Methods: Fifteen healthy males with body mass index (BMI) of 25.8 ± 2.7 kg·m^-2 and age 31 ± 5 y participated in a reference sleep (~9.5 hr) with no HIIE (RS), a reference sleep with HIIE (RSX), and an acute partial sleep deprivation (~3.5 hr) with HIIE (SDX). HIIE was performed in 3:2 intervals at 90% and 40% of VO₂ reserve. Autonomic regulation through HRV selected time and frequency domain indices were recorded the night before, the morning of the next day, 1 hr-, 2 hr-, 4hr-, and 6-hr post-exercise. Results: HIIE performed in a 3:2 W:R ratio decreased the HRV (p < .05) at 1-hr post exercise and it took up to 4 hr to return to baseline levels. Parasympathetic related HRV indices increased the morning of the next day for SDX (p < .05). Acute partial sleep deprivation and HIIE did not modify the HRV responses compared to reference sleep and HIIE. Conclusion: HRV disturbance typically seen in responses to an acute episode of HIIE is not influenced by acute partial sleep deprivation.

Exploring the Association between Sleep Quality and Heart Rate Variability among Female Nurses

The quality of nurses' work has a direct effect on patient health, and poor sleep has been positively associated with nurses' medical errors. The aim of this study was to investigate the relationship between quality of sleep and heart rate variability (HRV) among female nurses. A descriptive cross-sectional correlational study design was used in January 2014 to study female nurses (n = 393) employed in a medical center in Taiwan. Data were obtained from several questionnaires. HRV was analyzed with five-minute recordings of heart rate signals obtained using a Heart Rater SA-3000P. Approximately 96% of the participants self-reported a poor quality of sleep. Compared to non-shift nurses, significant decreases were found in total power (TP) and low-frequency HRV among shift-work nurses. However, negative correlations were found between sleep quality and HRV, including total power, low frequency, and the low frequency/high frequency ratio (r = -0.425, p < 0.05; r = -0.269, -0.266, p < 0.05). In a stepwise multiple regression analysis, 23.1% of variance in quality of sleep can be explained by TP and heart rate. The sleep quality of female nurses was poor and this affected their autonomic nervous system, which can contribute unfavorable consequences for their health.

Indexes of cardiac autonomic profile detected with short term Holter ECG in health care shift workers: a cross sectional study

Background:

The assessment of early effect of shift work-related circadian rhythms desynchronization and work-related stress in health care workers has gained a primary role among the duties of the occupational physician.

Objectives:

Aim of our study was to assess the cardiac autonomic modulation through quantification of sinus rhythm variability, as an index of the adaptability to shift work of the cardiovascular system in healthcare shift workers.

Methods:

We measured Heart Rate Variability (HRV) by short-term (60 minutes) Holter Electrocardiography (ECG) during the regular duties in the respective department of 42 healthcare workers (31 nurses and 11 physicians) of an Italian Hospital (12 male and 30 females, aged 24-58 years), working on 3 shifts with a forward fast rotation with rest at the end of the night shift (7 am - 2 pm; 2 pm - 10 pm; 10 pm - 7 am) or in a fixed daytime shift (8 am - 2 pm). Measurements were all performed between 9 am and 12 am for fixed day workers and between 9 am and 12 pm or between 10 pm and 1 am for shift workers. The following HRV parameters were compared between the subgroups of shift workers and daytime workers: mean heart rate (HR), standard deviation of all normal RR (NN) intervals (SDNN), standard deviation of the averages of NN intervals in all 5-minute segments of a recording (SDaNN) and the triangular index (the integral of the density distribution divided by the maximum of the density distribution). We used parametric tests for independent series to compare HRV parameters by subgroups within the study subjects. We also tested correlation between the variables of interest and the association between HRV and shift work modality, along with other covariates, by means of a multiple linear regression analysis.

Results:

We found significantly lower values of SDaNN in shift workers compared with workers engaged solely on day shifts (50.80 ms vs 66.71 ms; p=0,014). The mean heart rate did not show any significant difference between day workers and shift workers (85.78 bmp vs 85.53 bpm respectively). Multivariate analysis showed a significant association between SDNN and female gender and age, while no significant associations were found between HRV and shift work.

Discussion:

The autonomic control of the heart rhythm could be disrupted by desynchronization of the biological rhythm secondary to the organization of shift work and night work. Shift work is an important factor of social and biological distress, influencing the adaptability of the cardiovascular system to stimuli and demands of work organization.

Shiftwork Association with Cardiovascular Diseases and Cancers Among Healthcare Workers: A Literature Review

The round-the-clock demands of healthcare services, coupled with the shortage of healthcare providers in many parts of the world, have made shiftwork widespread among healthcare workers. Understanding how to mitigate unfavourable effects of shiftwork on well-being is essential to improve health promotion, to prevent disease prevention, and to increase quality of life. This comprehensive review aims to present evidence linking shiftwork with cardiovascular diseases and cancers among healthcare workers. Several studies have demonstrated evidence indicating the relationship between long-term exposure to shiftwork tempo and a higher risk of cardiovascular diseases. Health workers are increasingly witnesing unfavourable effects of shiftwork on their health state. Shiftwork disturbs circadian rhythm and cardiopulmonary processes, leading to adverse health outcomes. Increasing prevalence of shiftwork in healthcare industries due to population expansion and public health threat of cancers call for investigation towards a better understanding of the underlying mechanism of shiftwork-induced diseases. The shift work period has been considered in different studies using various criteria, resulting in inconsistent definition of measurement criteria leading to misclassification of the study population. There is a need for a more considerable and holistic effort towards standardization of shiftwork definition and conduct an assessment to establish a more conveniently appliacable framework for intervention strategies.