Performance and sleepiness in nurses working 12-h day shifts or night shifts in a community hospital

The predictive role of resilience and the ethical climate of hospital in the fatigue of surgical technologists working in operating rooms

BACKGROUND

Fatigue in surgical technologists is of paramount importance and is known as a priority because it can be regarded as a threat to the nurse's health and patient's safety. The fatigue level of healthcare workers can be affected by some factors, while the role of part of these factors is less known. This study aimed to determine the predictive role of resilience and the hospital ethical climate in the fatigue of surgical technologists working in operating rooms (ORs).

METHODS

This is a cross-sectional study conducted on 217 surgical technologists working in ORs of hospitals affiliated with Shiraz University of Medical Sciences. Data were collected using Connor-Davidson's Resilience scale, Olson's Hospital Ethical Climate Survey, and the Multidimensional Fatigue Inventory, and then analyzed using Pearson's correlation coefficient and multiple regression analysis.

RESULTS

87.1% and 12.9% of surgical technologists reported low and high fatigue, respectively. All fatigue subscales had significant and negative relationships with resilience (p < 0.05). Moreover, the relationship between fatigue and ethical climate was significant (p = 0.02). The multiple linear regression model showed the predictive role of resilience in fatigue (β=-0.29, P < 0.001). According to the model, 10% of the change of fatigue was related to resilience and ethical climate.

CONCLUSION

The present study demonstrated the relationship between resilience and ethical climate with fatigue. Moreover, resilience was a predictor of the surgical technologists' fatigue, so that their fatigue decreased with increasing resilience. However, future studies are recommended to determine other factors influencing fatigue in surgical technologists.

Feasibility of application-based psychomotor vigilance testing to assess fatigue in doctors working night shifts and correlation with smartwatch assessed shift intensity

OBJECTIVES

To assess: (1) the feasibility of novel data collection methods (wearable technology and an application-based psychomotor vigilance test (PVT)), (2) the impact of night shift working on fatigue, both objective and perceived, for doctors working night shifts in acute hospital specialties and (3) the effects of shift intensity and naps obtained on participant fatigue.

METHODS

We adopted an innovative, multimodal approach to data collection allowing assessment of objective and perceived measures of fatigue, in addition to markers of shift intensity. This comprised 5 min PVT for objective quantification of fatigue (via the validated, smartphone-based NASA PVT+ application), wearable electronic devices (Fitbit Versa2) for assessment of shift intensity (step counts and active minutes) and questionnaires to elicit perceptions of fatigue and shift intensity.

RESULTS

Data was collected from 25 participants for a total of 145 night shifts. Objective fatigue (assessed by PVT performance) was significantly increased post night shift, with a PVT mean reaction time 257 ms pre shift versus 283 ms post shift (p<0.0001). However, differences in PVT pre and post shift were not affected by night shift intensity, nor breaks or naps taken on shift. Differences in psychomotor performance between doctors working in different specialties were also observed.

CONCLUSIONS

The data collection methods used were found to be feasible with good participant engagement. Findings support existing evidence that night shift working in healthcare workers is associated with fatigue, with psychomotor impairment observed post shift. Lower shift intensity and napping did not appear to mitigate this effect.

Factors affecting the psychomotor vigilance of nurses working night shift

BACKGROUND

Shifts and long working hours decrease the psychomotor vigilance of healthcare workers especially when working night shifts. Working night shifts adversely affects nurses' health and impacts patient safety.

AIM

The purpose of this study is to identify factors affecting the psychomotor vigilance of nurses working night shift.

METHODS

This descriptive cross-sectional study was carried out with 83 nurses who were working in a private hospital in Istanbul and voluntarily participated in this study between April 25 and May 30, 2022. Data were collected using "Descriptive Characteristics Form," "Psychomotor Vigilance Task," "Pittsburgh Sleep Quality Index," and "Epworth Sleepiness Scale." The "STROBE checklist" for cross-sectional studies was utilized in order to report the findings of the study.

RESULTS

When time-dependent variation of the nurses' psychomotor vigilance task performances on the night shift was examined, it was observed that the nurses' mean reaction time and number of lapses increased at the end of the night shift. Age, smoking, physical activity, daily water consumption, daytime sleepiness, and sleep quality were found as the factors affecting nurses' psychomotor vigilance.

CONCLUSION

The psychomotor vigilance task performances of nurses working night shift are affected by age and a variety of behavioral factors.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Suggestions for nursing policy include the implementation of workplace health promotion programs in order to increase the attention level of nurses in order to ensure employee and patient health and safety and create a healthy working environment.

Influence of the work environment of nurses on the 30-day mortality of patients hospitalized in Polish hospitals. cross-sectional studies

BACKGROUND

An optimal work environment for nurses is characterized primarily by appropriate staffing, good team relations, and support from the management staff. These factors are consistently associated with a positive assessment of patient safety by a hospital's employees and a reduction in hospital mortality rates.

AIM

To understand the relationships between the work environment as perceived by nurses on the 30-day mortality of patients treated in Polish hospitals.

BACKGROUND

An optimal work environment for nurses is characterized primarily by appropriate staffing, good team relations, and support from the management staff. These factors are consistently associated with a positive assessment of patient safety by a hospital's employees and a reduction in hospital mortality rates.

MATERIAL AND METHODS

The analysis used discharge data from 108,284 patients hospitalized in internal medicine and surgery departments in 21 hospitals (with 24/7 operations) in Poland. Administrative data included coded data to estimate 30-day mortality. A Nurses' satisfaction questionnaire, including the PES-NWI scale and the SAQ questionnaire, was used to assess the work environment of nurses (n = 1,929). Correlations between variables were assessed using the Pearson coefficient. The analysis used a Poisson regression model, which belongs to the class of generalized linear models.

RESULTS

A lower 30-day mortality rate amongst patients was found among those treated in hospitals where the personnel feel that they may question the decisions or actions of their superiors regarding the care provided (r = - 0.50); nurses are informed about changes introduced on the basis of reports about negligence and mistakes (r = - 0.50); the ward nurse is a good manager (r = - 0.41); nurses receive timely information from the head of the department that may have an impact on their work (r = - 0.41).

CONCLUSIONS

Factors related to care during hospital stay such as the organization of care at the ward level, analysis of care errors, the number of staff providing direct patient care, informing nurses about mistakes without punishment, and the possibility of nurses challenging the decisions or actions of superiors, which concerns care providing, affect the 30-day mortality of patients after the end of hospitalization in Polish hospitals.

Effects of a simulated maritime shift schedule on vigilance, sleep, and sleepiness

Shift work is associated with circadian misalignment, which causes sleep loss, impairs performance, and increases the risk of accidents. Shorter, more frequently shifting watch schedules, widely used in industries such as maritime operation, defense, and mining, may mitigate these risks by reducing shift length and providing sleep opportunities for all workers across the biological night. However, the effects of frequently shifting work on sleep and performance still need to be clarified. The current study investigated the vigilance, sleepiness, and sleep patterns of fifteen participants who lived in a controlled and confined laboratory that mimicked a maritime environment for 14 d following a simulating frequent shift schedule. The results of psychomotor vigilance tasks (PVT) suggest that this shift schedule may lead to an accumulation of vigilance detrimental across watch days, with both reaction speed impairment and error growth. Furthermore, the circadian phase significantly affects PVT performance, with the afternoon shift section showing relatively better performance. Overall, more working hours per day resulted in poorer PVT performance. As the shift progressed, total sleep duration reduced slightly, and wake after sleep onset (WASO) increased. Sleep during the biological night was generally longer than sleep in the daytime. Less on-watch time was linked to longer overall sleep duration. Additionally, although the subjective sleepiness obtained by the Karolinska Sleepiness Scale (KSS) varied insignificantly across days, the KSS score was negatively correlated with PVT performance. This research can serve as a foundation for developing countermeasures to mitigate frequently shifting schedules' potentially detrimental effects and safety risks.

Time-of-day effects on speed and accuracy performance during simulated shiftwork

Performance on tasks involving speed and accuracy fluctuate throughout the 24-h day negatively affecting shift workers and organizations. Two simulated work shifts common in occupational settings were used to assess performance on a vigilance and math task. In study 1, 33 sleep-deprived participants completed a nightshift. In study 2, 32 partially sleep-deprived participants completed a dayshift. These studies found that performance differed between the type of task and the type of simulated shift where performance during the nightshift was worse than during the dayshift. In addition, collapsing speed and accuracy on the math task into inverse efficiency scores provided a unique measure that captured the impact of circadian rhythms during shiftwork. The current study also indicated that participants adopted cognitive strategies including speed-accuracy tradeoff and regulatory foci regarding work motivation (prevention focus and promotion focus) when completing the tasks depending on time-of-day, type of shift, circadian rhythms, and amount of sleep deprivation. This suggests that researchers and organizations should consider cognitive strategies in addition to the physiological components of sleep deprivation and circadian rhythms when investigating and documenting the impact of time-of-day due to different types of shiftwork conditions on performance and safety.

Impact of sleep-wake features on fatigue among female shift work nurses

BACKGROUND

Sleep disturbance and fatigue are prevalent in nurses. Little is known about the characteristics of shift work nurses' sleep-wake features and their subsequent impact on work performance. The study aimed to describe the characteristics of the sleep-wake index, reaction time, saliva cortisol level, and fatigue severity among female shift work nurses.

METHODS

This is a cross-sectional exploratory study. A convenience sample of 152 female nurses (8-hour day-evening-night, n = 70; 12-hour day-night, n = 82) participated in this study from nine intensive care units (ICUs) from two teaching hospitals in Beijing, China. A consecutive 7-day actigraphy data were used to analyse sleep-wake indexes, including total sleep time (TST) and circadian activity rhythms (CAR). Before and after shifts, the following data were collected, psychomotor vigilance task for reaction time, saliva cortisol for the level of alertness, and self-reported fatigue severity with the Lee Fatigue Scale-Short Form.

RESULTS

All nurses reported clinically significant fatigue severity. Compared with the 8-hour shift nurses, the 12-hour shift nurses had significantly more TST (456 vs. 364 min), higher saliva cortisol levels before the day shift (0.54 vs. 0.31), but longer reaction time before the night shift (286 vs. 277 ms). In both shifts, those with better CAR had significantly longer TST.

CONCLUSION

Female nurses experienced fatigue and desynchronized CAR, especially nurses on a 12-hour shift. The CAR-friendly shift work schedule is needed to minimize the health and safety impacts of circadian misalignment for nurses.Key messagesThis is the first use of consecutive 7-day actigraphy data to explore the link between sleep disturbances as a stressor to CAR, salivary cortisol, and reaction time among clinical nurses.CAR may be a helpful indicator for overworked nurses, and it can serve as a modifiable target for interventions to enhance nurses' well-being.

Consecutive Shifts: A Repeated Measure Study to Evaluate Stress, Biomarkers, Social Support, and Fatigue in Medical/Surgical Nurses

Nurses report that they are required to work during their scheduled breaks and generally experience extended work times and heavy workloads due to staffing shortages. This study aimed to examine changes in personal, work-related, and overall stress, as well as biological responses and fatigue experienced by nurses during three consecutive 12 h workdays (i.e., the typical "three-twelves" schedule). We also considered the moderating effects of social resources. This prospective study of 81 medical/surgical nurses who completed questionnaires and provided saliva samples at four designated intervals (i.e., pre-shift and post-shift on workdays 1 and 3). Fatigue reported by night shift nurses increased significantly over three consecutive workdays (p = 0.001). Day shift nurses said they encountered more social support than those on the night shift (p = 0.05). Social support moderated the relationship between work-related stress at baseline and reported fatigue on day 3.

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.

Endogenous Diurnal Patterns of Adrenal and Gonadal Hormones During a 24-Hour Constant Routine After Simulated Shift Work

Context

Night-shift work causes circadian misalignment, predicts the development of metabolic diseases, and complicates the interpretation of hormone measurements.

Objective

To investigate endogenous circadian rhythms, dissociated from behavioral and environmental confounds, in adrenal and gonadal steroids after simulated shift work.

Methods

Fourteen healthy adults (ages 25.8 ± 3.2 years) were randomized to 3 days of night or day (control) shift work followed by a constant routine protocol designed to experimentally unveil rhythms driven endogenously by the central circadian pacemaker. Blood was sampled every 3 hours for 24 hours during the constant routine to concurrently obtain 16 Δ4 steroid profiles by mass spectrometry. Cosinor analyses of these profiles provided mesor (mean abundance), amplitude (oscillation magnitude), and acrophase (peak timing).

Results

Night-shift work marginally increased cortisol by 1 μg/dL (P = 0.039), and inactive/weak derivatives cortisone (P = 0.003) and 18-hydroxycortisol (P < 0.001), but did not alter the mesor of potent androgens testosterone and 11-ketotestosterone. Adrenal-derived steroids, including 11-ketotestosterone (P < 0.01), showed robust circadian rhythmicity after either day- or night-shift work. In contrast, testosterone and progesterone showed no circadian pattern after both shift work conditions. Night-shift work did not alter the amplitude or acrophase of any of the steroid profiles.

Conclusion

Experimental circadian misalignment had minimal effects on steroidogenesis. Adrenal steroids, but not gonadal hormones, showed endogenous circadian regulation robust to prior shift schedule. This dichotomy may predispose night-shift workers to metabolic ill health. Furthermore, adrenal steroids, including cortisol and the main adrenal androgen 11-ketostosterone, should always be evaluated during the biological morning whereas assessment of gonadal steroids, particularly testosterone, is dependent on the shift-work schedule.

Self-reported work-related accumulative fatigue of nurses: A cross-sectional study in public hospitals in China

Objectives

Work-related fatigue is a serious safety risk to nurses and their patients. This study aimed to assess self-reported work-related accumulative fatigue of nurses and its associated factors.

Methods

A questionnaire survey of 2,918 clinical nurses conveniently sampled from 48 public hospitals across six provinces in China was conducted. The "Self-diagnosis Checklist for Assessment of Workers' Accumulated Fatigue" was adopted to assess the level of work-related accumulative fatigue of the study participants. Chi-square tests and ordinal regression analyses were performed to determine the sociodemographic characteristics associated with work-related accumulative fatigue.

Results

About one third of respondents reported low work-related accumulative fatigue, compared with 23.1% reporting high and 24.6% reporting very high levels of work-related accumulative fatigue. Higher levels of work-related accumulative fatigue were associated with female gender (AOR = 0.614 for male relative to female, p = 0.005), age between 30 and 40 years (AOR = 1.346 relative to >40 years, p = 0.034), 5-10 years of work experience (AOR = 1.277 relative to >10 years, p = 0.034), and bachelor or above degree qualifications (AOR = 0.806 for associate degree relative to bachelor or above degree, p = 0.007). Those who worked in rural county hospitals (AOR = 0.816 for metropolitan relative to rural county hospitals, p = 0.006) and resided in central China (AOR = 1.276 relative to western China, p = 0.004) had higher odds of reporting higher levels of work-related accumulative fatigue.

Conclusion

High levels of work-related accumulative fatigue are evident in nurses of public hospitals in China. The problem is more serious in the female nurses in their mid-career and those who worked in the central region and rural setting.

Nurses' perceptions of night shifts: A qualitative study

AIM

To describe the experiences and perceptions of emergency nurses regarding the shortening of night shifts and identify aspects of nurses' preferences for night shifts.

BACKGROUND

Shift work can be associated with distinct physical and psychological disadvantages for nurses, especially night nurses. Knowledge regarding the factors influencing their perceptions of night shifts is limited.

METHODS

A qualitative description design. Fifteen nurses from the emergency setting with 6 to 14 years of work experience participated in interviews. Semistructured interviews were conducted between November 2018 and March 2019. A thematic analysis was performed for the data analysis.

FINDINGS

The following three themes emerged: (1) maintaining quality within quantity, (2) maintaining comfort within busyness, and (3) buffering the gap between ideal and reality.

CONCLUSIONS

Considering work intensity and patient safety, nurses believe that an 8 h night shift is the most suitable length for the emergency department. Long shifts are probably more suitable for other departments with lower night workloads.

Effects of 90 Min Napping on Fatigue and Associated Environmental Factors among Nurses Working Long Night Shifts: A Longitudinal Observational Study

For nurses working long night shifts, it is imperative that they have the ability to take naps to reduce fatigue, and that an appropriate environment is prepared where such naps can be taken. We verified the effects of 90 min napping on fatigue and the associated factors among nurses working 16-h night shifts. We investigated 196-night shifts among 49 nurses for one month. Wearable devices, data logging devices, and questionnaires were used to assess nap parameters, fatigue, and environmental factors such as the napping environment, ways of spending breaks, and working environment. Nurses who nap at least 90 min on most night shifts had more nursing experience. Multivariable logistic regression analysis showed that the environmental factors significantly associated with total nap duration (TND) ≥ 90 min were noise, time spent on electronic devices such as cellphones and tablets during breaks, and nap break duration. The night shifts with TND ≥ 90 min showed lower drowsiness after nap breaks and less fatigue at the end of night shift compared to those with TND < 90 min. Nurses and nursing managers should recognize the importance of napping and make adjustments to nap for at least 90 min during long night shifts.

Because they're worth it? A discussion paper on the value of 12-h shifts for hospital nursing

The organisation of the 24-h day for hospital nurses in two 12-h shifts has been introduced with value propositions of reduced staffing costs, better quality of care, more efficient work organisation, and increased nurse recruitment and retention. While existing reviews consider the impact of 12-h shifts on nurses' wellbeing and performance, this discussion paper aims to specifically shed light on whether the current evidence supports the value propositions around 12-h shifts. We found little evidence of the value propositions being realised. Staffing costs are not reduced with 12-h shifts, and outcomes related to productivity and efficiency, including sickness absence and missed nursing care are negatively affected. Nurses working 12-h shifts do not perform more safely than their counterparts working shorter shifts, with evidence pointing to a likely negative effect on safe care due to increased fatigue and sleepiness. In addition, nurses working 12-h shifts may have access to fewer educational opportunities than nurses working shorter shifts. Despite some nurses preferring 12-h shifts, the literature does not indicate that this shift pattern leads to increased recruitment, with studies reporting that nurses working long shifts are more likely to express intention to leave their job. In conclusion, there is little if any support for the value propositions that were advanced when 12-h shifts were introduced. While 12-h shifts might be here to stay, it is important that the limitations, including reduced productivity and efficiency, are recognised and accepted by those in charge of implementing schedules for hospital nurses.

Sleep, alertness and performance across a first and a second night shift in mining haul truck drivers

This study examined the impact of first and second night shift work on sleep and performance in mining haul truck drivers. Sleep-wake patterns were monitored using wrist actigraphy. The Karolinska Sleepiness Scale (KSS), Psychomotor Vigilance Test (PVT) and a truck simulator were administered at the start and end of the first (N1) or second (N2) night shift (19:00-07:00 h). Participants were categorised into those who demonstrated a decline in performance (increase of one or more PVT lapses [reaction time >500 msec] from the start to the end of shift) or those who did not demonstrate a decline in performance (no increase in lapses) from the start to the end of shift. Total sleep time (TST) was longer in the 24 h prior to N1 (9.05 ± 1.49 h) compared to N2 (5.38 ± 1.32 h). PVT lapses and the slowest 10% of reaction times were similar at the start and end of N1, while greater impairments on these outcomes were observed at the end of N2 compared to the end of N1 (p < .05). In contrast, subjective sleepiness was equally impaired at the end of both night shifts. PVT performance (lapses and slowest 10% of reaction times) and drive violations demonstrated a similar direction of change on N1 and N2. Participants who demonstrated a decline in performance showed reduced TST in the 48 h prior to shifts compared to those who demonstrated no decline in performance across the shift. Likely due to short sleep prior, the end of N2 was associated with pronounced performance impairments on the PVT and drive violations compared to the start of the shift. The findings suggest that drive violations may be more sensitive to sleep loss compared to the other driving measures examined in this study. This study also emphasizes the need for adequate recovery sleep between night shifts.

Working around the Clock: Is a Person’s Endogenous Circadian Timing for Optimal Neurobehavioral Functioning Inherently Task-Dependent?

Neurobehavioral task performance is modulated by the circadian and homeostatic processes of sleep/wake regulation. Biomathematical modeling of the temporal dynamics of these processes and their interaction allows for prospective prediction of performance impairment in shift-workers and provides a basis for fatigue risk management in 24/7 operations. It has been reported, however, that the impact of the circadian rhythm—and in particular its timing—is inherently task-dependent, which would have profound implications for our understanding of the temporal dynamics of neurobehavioral functioning and the accuracy of biomathematical model predictions. We investigated this issue in a laboratory study designed to unambiguously dissociate the influences of the circadian and homeostatic processes on neurobehavioral performance, as measured during a constant routine protocol preceded by three days on either a simulated night shift or a simulated day shift schedule. Neurobehavioral functions were measured every 3 h using three functionally distinct assays: a digit symbol substitution test, a psychomotor vigilance test, and the Karolinska Sleepiness Scale. After dissociating the circadian and homeostatic influences and accounting for inter-individual variability, peak circadian performance occurred in the late biological afternoon (in the “wake maintenance zone”) for all three neurobehavioral assays. Our results are incongruent with the idea of inherent task-dependent differences in the endogenous circadian impact on performance. Rather, our results suggest that neurobehavioral functions are under top-down circadian control, consistent with the way they are accounted for in extant biomathematical models.

Effect of sleep on alertness at work among fixed night shift nurses: A prospective observational study

AIMS

To identify patterns of declining alertness at work among fixed night shift nurses using an objective measure and to determine the effect of sleep parameters on the decline in alertness at work.

DESIGN

A prospective observational study.

METHODS

Data were collected from 65 fixed night shift nurses who provided direct nursing care for patients in Korean hospitals between September 2020 and March 2021. Participants wore an actigraph for 14 days on their non-dominant hand to measure sleep parameters and predict their hourly alertness scores. They completed an online survey to provide their demographic information. Mixed-effect models were employed to determine the association between sleep parameters and the decline in alertness.

RESULTS

The alertness scores of fixed night shift nurses constantly dropped every working hour. Scores dropped below 20% after 4 h from the beginning of the shift and below 30% after 6 h. Increased minutes in bed, minutes asleep and sleep efficiency reduced the risk of decreased alertness scores below 70. Increased sleep latency was associated with an increased risk of alertness scores dropping below 70.

CONCLUSION

The alertness of fixed night shift nurses drops steeply during regular hours and remains low during overtime. Sleep parameters contribute to the decline in alertness at work among fixed night shift nurses.

IMPACT

This study identified patterns of decline in alertness among fixed night shift nurses and the contributing factors for this decline, using an objective measure. The findings have important implications for the development of future interventions to improve the sleep hygiene of fixed night shift nurses to enhance their alertness at work.

Test-retest reliability of the 5-minute psychomotor vigilance task in working-aged females

BACKGROUND

The psychomotor vigilance task (PVT) is a commonly used test that effectively assesses neurobehavioral alertness. The originally developed PVT is 10 minutes in duration, which presents practical and logistical issues, particularly when administered to large samples or on a repetitive basis. More recently the PVT has been used in both 3- and 5-minute formats. While both of these durations have been shown to be field sensitive to identify impairments from sleep- and fatigue-related interventions, the 5-minute version has been suggested to be more valid than the 3-minute. However, while these have shown field-validity in a number of working populations, there is a paucity of data reporting the test-retest reliability statistics of the 5-minute PVT, particularly in working-aged females. The purpose of the study was to examine the test-retest reliability of a comprehensive set of PVT variables for the 5-minute PVT in a population of working-aged females (20-63 years).

NEW METHOD

Participants reported to the laboratory on two separate days and performed a 5-minute PVT on each occasion. Outcome measures included the mean reaction time (MRT), fastest and slowest 10% of reaction times (F10RT% and S10RT%, respectively), standard deviation of reaction times (SDRT) as well as error-based metrics including major and minor lapses, anticipations, and false starts. In addition, total errors (ERR) were computed as a composite of all types of errors. Reliability statistics were reported as intraclass correlation coefficients (ICCs), standard error of measurement (SEM, SEM%), and minimal difference to be considered real (MD, MD%). Systematic error was also evaluated between sessions.

RESULTS

Overall high reliability was shown for the MRT (ICC = 0.79, SEM% = 4.14%) and F10RT% (ICC = 0.83, SEM% = 4.43%) variables, with moderate relative reliability (based on ICCs) for the false starts, ERR, and sleepiness scale (ICC = 0.50 - 0.70) variables but these all exhibited poor absolute reliability (based on SEM% values of 32.60 - 168.69%). Poor relative reliability was found for the SDRT and S10RT% variables (ICCs < 0.50) but the S10RT% variable had good absolute reliability (SEM% = 7.12%). The minor and major lapses and anticipations variables had too few of event occurrences for a confident determination of the reliability.

CONCLUSIONS

The finding that the MRT variable displayed systematic error (P = 0.01) indicating that a learning curve may have been present, but the F10RT% did not show systematic error, suggests the F10RT% may be the most reliable PVT variable in a 5-minute duration test. These findings provide researchers and practitioners with reliability statistics that may help in determining which variable(s) to use, and which to avoid when specifically conducting 5-minute PVT assessments, particularly in a population of working-aged females. These results suggest that the 5-minute PVT can be used in place of the 10-minute version, if used appropriately.

Disturbance of the Circadian System in Shift Work and Its Health Impact

The various non-standard schedules required of shift workers force abrupt changes in the timing of sleep and light-dark exposure. These changes result in disturbances of the endogenous circadian system and its misalignment with the environment. Simulated night-shift experiments and field-based studies with shift workers both indicate that the circadian system is resistant to adaptation from a day- to a night-oriented schedule, as determined by a lack of substantial phase shifts over multiple days in centrally controlled rhythms, such as those of melatonin and cortisol. There is evidence that disruption of the circadian system caused by night-shift work results not only in a misalignment between the circadian system and the external light-dark cycle, but also in a state of internal desynchronization between various levels of the circadian system. This is the case between rhythms controlled by the central circadian pacemaker and clock genes expression in tissues such as peripheral blood mononuclear cells, hair follicle cells, and oral mucosa cells. The disruptive effects of atypical work schedules extend beyond the expression profile of canonical circadian clock genes and affects other transcripts of the human genome. In general, after several days of living at night, most rhythmic transcripts in the human genome remain adjusted to a day-oriented schedule, with dampened group amplitudes. In contrast to circadian clock genes and rhythmic transcripts, metabolomics studies revealed that most metabolites shift by several hours when working nights, thus leading to their misalignment with the circadian system. Altogether, these circadian and sleep-wake disturbances emphasize the all-encompassing impact of night-shift work, and can contribute to the increased risk of various medical conditions. Here, we review the latest scientific evidence regarding the effects of atypical work schedules on the circadian system, sleep and alertness of shift-working populations, and discuss their potential clinical impacts.

Alertness during working hours among eight-hour rotating-shift nurses: An observational study

PURPOSE

The aim of this study was to identify the patterns of the decline in the alertness of rotating-shift nurses during working hours across different shift types (day, evening, and night) using an objective measure.

DESIGN

An observational study using ReadiBand wrist actigraphs was conducted.

METHODS

Data were collected from June 2019 to February 2020. Participants were rotating-shift nurses (N = 82) who provided direct nursing care for patients in acute care hospitals in South Korea. Nurses wore actigraphs continuously for 14 days on their non-dominant hand to identify sleep-wake cycles and predict their alertness scores hourly. All participants completed a sleep diary.

FINDINGS

Nurses working during night shifts had lower average alertness scores (mean = 77.12) than nurses working during day (mean = 79.05) and evening (mean = 91.21). Overall, alertness showed a declining trend and the specific patterns of decline differed across shifts. Participants with alertness scores less than 70 or 80 demonstrated a significant decline in alertness across all shifts.

CONCLUSIONS

Distinct patterns of decline in alertness per nursing shift were revealed. Each shift feature should be considered when developing interventions to increase nurses' alertness, promote high-quality care provision, and ensure patient safety.

CLINICAL RELEVANCE

The implementation of interventions to increase alertness among shift nurses is needed at the organizational level, and the cooperation of nursing managers and administrators is required.

Psychometric Evaluation of the Creighton Competency Evaluation Instrument in a Population of Working Nurses

BACKGROUND AND PURPOSE

This study explored the psychometric properties of the Creighton Competency Evaluation Instrument (C-CEI), previously validated for use with nursing students, to assess simulation performance among registered nurses working 12-hour shifts. Valid and reliable measurements are needed to test clinical and simulation competencies and characterize the effects of fatigue on nursing performance.

METHODS

Trained raters scored nurses' patient care performance in simulation scenarios using the C-CEI. We analyzed the instrument's principal components, internal reliability, and construct validity.

RESULTS

Internal reliability of the C-CEI aggregate score and the Clinical Decision-making component were high (>.70). The latter robustly correlated with predicted cognitive effectiveness, a measure of fatigue.

CONCLUSIONS

The C-CEI is a reliable measure for use among registered nurses and its further development will be important for testing performance of working nurses and fatigue-mitigation innovations.

The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: A quasi-experimental study

BACKGROUND

Healthcare systems have widely adopted consecutive 12 h day and night shifts for nurses, but the effects of these shifts on cognition, sleepiness, and nursing performance remains understudied.

OBJECTIVE

To determine the extent of changes in cognition and sleepiness in nurses working three consecutive 12 h shifts, quantify the respective impacts of these changes on different aspects of nursing performance, and investigate individual differences in all measures.

DESIGN

A quasi-experimental, between-within design collected data from nurses between November 2018 and March 2020. The between-groups component was comprised of day shift nurses vs. night shift nurses, while the within-groups component was comprised of two separate test sessions for each nurse: one immediately following a third consecutive shift (fatigued) and one after three consecutive days off work (rested).

SETTING

Participants were tested in a northwestern US university's nursing simulation laboratory.

PARTICIPANTS

A volunteer sample of 94 registered nurses involved in direct patient care working 12 h shifts were recruited from two local hospitals.

METHODS

Simulated nursing performance was measured in seven separate domains and an aggregate score from the Creighton Competence and Evaluation Inventory, covering both lower- and higher-level constructs like procedural skills, assessment, decision-making, etc. Cognition and sleepiness were assessed through measures of sustained attention, predicted cognitive effectiveness, and subjective sleepiness.

RESULTS

In our 94 nurses, individual differences in all our measures varied from trivial to extensive. For six domains of performance and the aggregate score there were no significant differences in means across groups or conditions. For the seventh, Communication skills were lower for night nurses than day nurses, but this effect was small. After three consecutive shifts, sustained attention and predicted cognitive effectiveness decreased, and subjective sleepiness increased. Predicted cognitive effectiveness was particularly low for fatigued night nurses relative to other conditions and was positively correlated with Communication while controlling for other predictors.

CONCLUSIONS AND RELEVANCE

Nurses maintained their levels of performance for all domains after three consecutive shifts. Individual differences in predicted cognitive effectiveness could account for variation in performance by shift type for Communication skills but for no other domain of performance. Communication skills and predicted cognitive effectiveness may interest researchers in the development of fatigue-mitigation strategies for night nurses, but our findings also suggest that more sensitive measures of performance may be necessary to capture other meaningful effects of long, consecutive shifts-if any-on patient care. Tweetable abstract: The effects of three consecutive 12 h shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: A quasi-experimental study.

Sleep, fatigue and alertness during working hours among rotating-shift nurses in Korea: An observational study

AIMS

To determine the effects of sleep parameters and fatigue on the decline in alertness of nurses across shifts.

BACKGROUND

Shift work can lead to nurse fatigue owing to insufficient sleep and inadequate recovery time between shifts. Nurse fatigue has adverse effects on alertness and can affect provision of quality care.

METHODS

An observational study using wrist actigraphs was conducted from 2019 to 2020. Participants were 82 rotating-shift nurses who provided direct nursing care in acute hospitals in South Korea. They wore actigraphs for 14 days to measure sleep parameters and predict hourly alertness and reported subjective fatigue before and after every shift.

RESULTS

Nurses demonstrated shorter sleep hours, lower sleep efficiency and longer sleep latency before night shifts compared with other shifts. Fatigue was the highest before day shifts. Sleep parameters and fatigue significantly affected the steep decline in alertness in participants with alertness scores below 70.

CONCLUSIONS

Sleep parameters and fatigue level contributed to the differences in decline in alertness across shifts.

IMPLICATION FOR NURSING MANAGEMENT

Findings inform nurse managers, administrators to develop interventions to reduce fatigue, improve sleep quantity and quality and increase alertness among rotating-shift nurses. Management, institutional and individual factors should be considered when developing interventions.

Differential effect of sleep deprivation on place cell representations, sleep architecture, and memory in young and old mice

Poor sleep quality is associated with age-related cognitive decline, and whether reversal of these alterations is possible is unknown. In this study, we report how sleep deprivation (SD) affects hippocampal representations, sleep patterns, and memory in young and old mice. After training in a hippocampus-dependent object-place recognition (OPR) task, control animals sleep ad libitum, although experimental animals undergo 5 h of SD, followed by recovery sleep. Young controls and old SD mice exhibit successful OPR memory, whereas young SD and old control mice are impaired. Successful performance is associated with two cellular phenotypes: (1) "context" cells, which remain stable throughout training and testing, and (2) "object configuration" cells, which remap when objects are introduced to the context and during testing. Additionally, effective memory correlates with spindle counts during non-rapid eye movement (NREM)/rapid eye movement (REM) sigma transitions. These results suggest SD may serve to ameliorate age-related memory deficits and allow hippocampal representations to adapt to changing environments.

Sleep-Related Problems in Night Shift Nurses: Towards an Individualized Interventional Practice

Rotating shifts (mostly 8- or 12-h) are common among nurses to ensure continuity of care. This scheduling system encompasses several adverse health and performance consequences. One of the most injurious effects of night-time shift work is the deterioration of sleep patterns due to both circadian rhythm disruption and increased sleep homeostatic pressure. Sleep problems lead to secondary effects on other aspects of wellbeing and cognitive functioning, increasing the risk of errors and workplace accidents. A wide range of interventions has been proposed to improve the sleep quality of nurses and promote an increase in attention levels. In recent years, particular attention has been paid to individual and environmental factors mediating the subjective ability to cope with sleep deprivation during the night shift. Given the predictive role of these factors on the negative impact of a night shift, an individualized intervention could represent an effective countermeasure by ensuring suitable management of shift schedules. Therefore, the aims of this mini-review are to: (a) provide an updated overview of the literature on sleep problems in night shift nurses and their adverse consequences; and (b) critically analyze the psychosocial factors that mediate the negative impact of shift work with the ultimate goal of defining an effective countermeasure based on an individualized approach.

Fatigue and the Female Nurse: A Narrative Review of the Current State of Research and Future Directions

Background: The female nurse exhibits a multitude of personal and environmental characteristics that renders this population especially prone to fatigue. The consequences of fatigue in nurses are widespread and impactful at the personal, organizational, and societal levels. These include high injury rates and burnout in the nurse and poor patient and organizational outcomes. Objective: This article discusses the implications of fatigue in female nurses, including the impacts of fatigue across multiple entities (e.g., worker, patient, organization). It also reviews the current state of the research, including recent work on nurse fatigue and work schedule characteristics, and key areas for future work that would help empirically establish approaches to counter the detrimental and widespread effects of fatigue. Method: A narrative literature review was conducted resulting from an analysis of the literature limited to peer-reviewed studies. Results: A confluence of factors combines to elevate the prevalence and risk of fatigue in the female nurse. Numerous measures have established that performance-based fatigue results from nursing work schedules in nurses. Data also demonstrate that fatigue accumulates across successive shifts. Recent evidence supports the use of objective fatigue measures, including psychomotor reaction time and muscle function-related variables. Current gaps in the literature are delineated in the text. Conclusions: Strategic and well-designed research studies, as well as recent technological advances in fatigue tracking tools have the potential to help workers, administrators, and organizations develop fatigue management programs that could reduce the heavy burdens of fatigue on a multitude of health, safety, and economical outcomes.

The impact of shift work schedules on PVT performance in naturalistic settings: a systematic review

OBJECTIVE

The Psychomotor Vigilance Test (PVT) is considered the gold standard for detecting sleep loss and circadian misalignment related changes in performance in laboratory and field settings. This short 3-, 5- or 10-min test appraises an individual's sustained vigilant attention on a visual stimulus through reaction time, false starts and performance lapses. The PVT has been widely used as a measure to assess vigilant attention among shift workers, but information evaluating the application and performance of this test in different naturalistic shift work settings is limited. The purpose of this review is to synthesise and evaluate existing literature which has used the PVT to assess and monitor psychomotor performance in response to shift work schedules and rosters performed in real-world settings.

METHODS

A systematic search of studies examining PVT performance in response to 24/7 shift work schedules (e.g., day, afternoon, evening and night shifts) performed under naturalistic conditions was conducted. Articles were identified by searching Medline, Embase, CINHAL and PsycINFO databases in April 2020.

RESULTS

The search yielded 135 results, of which 16 publications were suitable to be included in this review. Articles were grouped according to when the PVT was applied to a research cohort, which included (a) multiple instances per shift, (b) commencement and cessation of shift and (c) other varying times.

CONCLUSIONS

This review suggests PVT performance is typically congruent across studies when the test is applied at generally consistent time intervals. The lack of research concerning the use of the PVT during extended duty shifts (e.g., shifts and on call work > 30 h) is an area for future research.

Impact of 12-hr shifts in general hospitals: Study conducted in two intensive care units

AIM

To evaluate the impact of 12-hr shifts on health status, working conditions and satisfaction among nurses and healthcare auxiliaries in medical and surgical intensive care units in a general hospital.

DESIGN

This study was a descriptive and prospective questionnaire study of personnel involved in the organization of 12-hr shifts.

METHODS

The EVREST questionnaire was used, with the addition of two questions on respondents' health status and five questions on their job satisfaction. The study consisted of a first phase immediately before work was organized in 12-hr shifts and a second within 7-9 months of application of this organization.

RESULTS

Positive effects were found among day nurses including decreased periods of pressure during the working day and improved work-life balance. Conversely, night nurses, who are not in favour of 12-hr shifts, reported dissatisfaction caused by a deterioration both in working conditions and in work-life balance.

The association between eating frequency with alertness and gastrointestinal complaints in nurses during the night shift

We investigated the association of the number of eating occasions and energy intake with alertness and gastrointestinal (GI) complaints in nurses during their night shift. During this observational study we collected data on anthropometrics and demographics, eating frequency, energy intake, alertness and GI complaints in 118 healthy female nurses, aged 20 to 61 years. Nurses completed an alertness test (psychomotor vigilance task) during the night shift and a 24‐hr dietary recall and a questionnaire about GI complaints after the night shift. This was repeated three times, always on the first night shift in a night shift series. The number of eating occasions during the night shift was negatively associated with reaction times (β = −4.81 ms, 95% confidence interval [CI] −9.14 to −0.48; p = .030), and number of lapses (β = −0.04, 95% CI −0.07 to −0.00; p = .030). However, the number of eating occasions was not associated with subjective alertness and GI complaints. Energy intake during the night shift was not associated with objective or subjective alertness or with GI complaints. These associations were independent of caffeine intake, age, body mass index and dependence among the repeated measurements. The present study showed that eating frequency was positively associated with objectively measured alertness levels in female nurses during the night shift. The results need to be confirmed in an intervention study, where also timing, size and composition of the meal will be taken into account. In practice, optimising nutritional guidelines on these aspects could lead to faster responses, less (medical) errors, and a better wellbeing of night shift workers.

Effect of shift work on fatigue and sleep in neonatal registrars

OBJECTIVE

We aimed to study fatigue and sleep in registrars working 12-hour rotating shifts in our tertiary neonatal intensive unit.

METHODS AND PARTICIPANTS

This study involved neonatal registrar's working day (08:00-21:00) and night (20:30-08:30) shifts. Participants maintained a sleep diary, answered a self-reported sleepiness questionnaire assessing subjective sleepiness, and performed a 10-minute psychomotor vigilance task (PVT) at the start and end of each shift. Primary outcomes: (1) Fatigue at the (i) "start vs end" of day and night shifts, (ii) end of the "day vs night" shifts, and (iii) end of "first vs last shift" in block of day and night shifts. (2) Duration and quality of sleep before the "day vs night" shifts. Mean reaction time (RTM), relative coefficient of variation (RTCV), and lapses (reaction time > 500ms) were used as measures of fatigue on PVT. Secondary outcome: Subjective sleepiness (self-reported sleepiness questionnaire) at the 'start vs end" of day and night shifts.

RESULTS

Fifteen registrars completed the study. Acuity was comparable for all shifts. (1) Psychomotor responses were impaired at the end vs start of day shifts [RTM (p = 0.014), lapses (p = 0.001)], end vs start of night shifts [RTM (p = 0.007), RTCV (p = 0.003), lapses (p<0.001)] and end of night vs day shifts [RTM (p = 0.007), RTCV (p = 0.046), lapses (p = 0.001)]. Only lapses were significantly increased at the end of the last (p = 0.013) vs first shift (p = 0.009) in a block of day and night shifts. (2) Duration of sleep before the night (p = 0.019) and consecutive night shifts was decreased significantly (p = 0.034). Subjective sleepiness worsened after day (p = 0.014) and night shifts (p<0.001).

CONCLUSION

Fatigue worsened after the 12-hour day and night shifts with a greater change after night shifts. Lapses increased after block of day and night shifts. Sleep was decreased before night shifts. Our findings need to be confirmed in larger studies.

Vigilance and sleepiness in nurses working 12-hr shifts and their coping strategies

AIM

To describe the progression of vigilance and sleepiness over the shift and the coping strategies of nurses working 12-hr day or night shifts.

BACKGROUND

The spread of 12-hr shift work in nursing raises the question of whether sufficient vigilance can be maintained to ensure quality of care.

METHOD

18 nurses working 12-hr shifts filled out a Karolinska Sleepiness Scale questionnaire and a Brief Psychomotor Vigilance Test, at the beginning of the shift and then every 3 hr. Coping strategies and quality of care were assessed on self-administered questionnaires, filled out at 3 hr, 6 hr, 9 hr and 12 hr after the start of the shift.

RESULTS

The present investigation did not show significantly excessive sleepiness or vigilance impairment or poor self-perception of quality of work during 12-hr nursing work shifts, although Psychomotor Vigilance Test results gradually deteriorated slightly over duty time (from start to end of shift). Certain coping strategies were preferred such as 'having a nap' later in the night shift.

CONCLUSION

Attention needs to be paid to the health status of nurses working 12-hr shifts, with regular medical monitoring by the occupational health service.

IMPLICATIONS FOR NURSING MANAGEMENT

Coping strategies to maintain sufficient vigilance to ensure quality of care should be facilitated.

Nurses and Night Shifts: Poor Sleep Quality Exacerbates Psychomotor Performance

In Europe, 40% of health-care employees are involved in shift work. The altered sleep/wake rhythm of night-shift nurses is also associated with deteriorated cognitive efficiency. In this study, we examine the effects of the night shift on psychomotor performance, sleepiness, and tiredness in a large sample of shift-working nurses and evaluated if poor sleep quality, sex, age, or years on the job could impact on a better adaptation to shift work. Eighty-six nurses with 8-h-rapidly-rotating-shifts were evaluated at the end of three shifts (morning/afternoon/night) for sleepiness and tiredness. Sleepiness, as measured by the Karolinska Sleepiness Scale, and tiredness, as measured by the Tiredness Symptoms Scale, were more pronounced after the night shift. These increases were paralleled by lower attentional performance on the psychomotor vigilance task (PVT) after the night shift. While sex, age, and years on the job did not affect PVT performance after the night shift, lower sleep quality (Pittsburgh Sleep Quality, PSQI > 5) was associated with decreased performance. The high prevalence of altered sleep quality showed that nurses, and shift workers in general, are at risk for a poor sleep quality. The evaluation of sleep quality through PSQI could represent a rapid, inexpensive tool to assess health-care workers assigned to rotating night shifts or to evaluate nurses who coped poorly with night-shift work.

Melatonin Is a Feasible, Safe, and Acceptable Intervention in Doctors and Nurses Working Nightshifts: The MIDNIGHT Trial

Nightshift working is associated with sleep deprivation, fatigue and attention/concentration deficits which, in healthcare workers, may impact on patient safety. Clinical staff in the UK routinely work several 12 h nightshifts in a row at about 1-3 month intervals. We investigated the feasibility and acceptability of a crossover trial of melatonin administration in clinical staff working nightshifts with an exploration of effects on sleep measures and attention/concentration tasks. This was a pilot, double-blinded, randomized, placebo-controlled crossover feasibility trial in doctors and nurses working 3 consecutive nightshifts at a tertiary referral hospital in the UK. Twenty five male and female subjects were randomized to receive either 6mg Circadin™ slow release melatonin or placebo before sleep after each consecutive nightshift, followed by a washout period, before crossing over to the other experimental arm. We used actigraphy for objective assessment of sleep parameters. The trial design was feasible and acceptable to participants with negligible side effects, but elevated melatonin levels were prolonged during the active arm (P=0.016). Double digit addition testing, a concentration/attention task, improved with melatonin treatment (P<0.0001). Lapses of vigilance or judgement while doctors or nurses are working nightshifts could impact on patient safety and melatonin may be a useful intervention. This study supports the conclusion that a larger definitive trial of this design is both feasible and safe. Clinical Trial Registration: identifier ISRCTN15529655. https://www.isrctn.com/.

One-year trial of 12-hour shifts in a non-intensive care unit and an intensive care unit in a public hospital: a qualitative study of 24 nurses' experiences

OBJECTIVES

The aim of this study was to provide recommendations to hospital owners and employee unions about developing efficient, sustainable and safe work-hour agreements. Employees at two clinics of a hospital, one a non-intensive care and the other a newborn intensive care unit (ICU), trialled 12-hour shifts on weekends for 1 year.

METHODS

We systematically recorded the experiences of 24 nurses' working 12-hour shifts, 16 in the medical unit and 8 in the ICU for 1 year. All were interviewed before, during and at the end of the trial period. The interview material was recorded, transcribed to text and coded systematically.

RESULTS

The experiences of working 12-hour shifts differed considerably between participants, especially those in the ICU. Their individual experiences differed in terms of health consequences, effects on their family, appreciation of extra weekends off, perceived effects on patients and perceived work task flexibility.

CONCLUSIONS

The results indicate that individual preference for working 12-hour shifts is a function of own health situation, family situation, work load tolerance, degree of sleep problems, personality and other factors. If the goal is to recruit and retain nurses, nurses should be free to choose to work 12-hour shifts.

Decreased psychomotor vigilance of female shift workers after working night shifts

Background

We compared psychomotor vigilance in female shift workers of the Bergmannsheil University Hospital in Bochum, Germany (N = 74, 94% nurses) after day and night shifts.

Methods

Participants performed a 3-minute Psychomotor Vigilance Task (PVT) test bout at the end of two consecutive day and three consecutive night shifts, respectively. Psychomotor vigilance was analyzed with respect to mean reaction time, percentage of lapses and false starts, and throughput as an overall performance score, combining reaction time and error frequencies. We also determined the reaction time coefficient of variation (RTCV) to assess relative reaction time variability after day and night shifts. Further, we examined the influence of shift type (night vs. day) by mixed linear models with associated 95% confidence intervals (CI), adjusted for age, chronotype, study day, season, and the presence of obstructive sleep apnea (OSA).

Results

At the end of a night shift, reaction times were increased (β = 7.64; 95% CI 0.94; 14.35) and the number of lapses higher compared to day shifts (exp(β) = 1.55; 95% CI 1.16–2.08). By contrast, we did not observe differences in the number of false starts between day and night shifts. Throughput was reduced after night shifts (β = -15.52; 95% CI -27.49; -3.46). Reaction times improved across consecutive day and night shifts, whereas the frequency of lapses decreased after the third night. RTCV remained unaffected by both, night shifts and consecutive shift blocks.

Discussion

Our results add to the growing body of literature demonstrating that night-shift work is associated with decreased psychomotor vigilance. As the analysis of RTCV suggests, performance deficits may selectively be driven by few slow reactions at the lower end of the reaction time distribution function. Comparing intra-individual PVT-performances over three consecutive night and two consecutive day shifts, we observed performance improvements after the third night shift. Although a training effect cannot be ruled out, this finding may suggest better adaptation to the night schedule if avoiding fast-changing shift schedules.

Fatigue and nurses' work patterns: An online questionnaire survey

BACKGROUND

Fatigue resulting from shift work and extended hours can compromise patient care and the safety and health of nurses, as well as increasing nursing turnover and health care costs.

OBJECTIVES

This research aimed to identify aspects of nurses' work patterns associated with increased risk of reporting fatigue-related outcomes.

DESIGN

A national survey of work patterns and fatigue-related outcomes in 6 practice areas expected to have high fatigue risk (child health including neonatology, cardiac care/intensive care, emergency and trauma, in-patient mental health, medical, and surgical nursing).

METHODS

The 5-page online questionnaire included questions addressing: demographics, usual work patterns, work in the previous two weeks, choice about shifts, and four fatigue-related outcomes - having a sleep problem for at least 6 months, sleepiness (Epworth Sleepiness Scale), recalling a fatigue-related error in clinical practice in the last 6 months, and feeling close to falling asleep at the wheel in the last 12 months. The target population was all registered and enrolled nurses employed to work in public hospitals at least 30 h/week in one of the 6 practice areas. Participation was voluntary and anonymous.

RESULTS

Respondents (n = 3133) were 89.8% women and 8% Māori (indigenous New Zealanders), median age 40 years, range 21-71 years (response rate 42.6%). Nurses were more likely than New Zealand adults in general to report chronic sleep problems (37.73% vs 25.09%, p < 0.0001) and excessive sleepiness (33.75% vs 14.9%, p < 0.0001). Fatigue-related error(s) in the last 6 months were recalled by 30.80% and 64.50% reported having felt sleepy at the wheel in the last 12 months. Logistic regression analyses indicated that fatigue-related outcomes were most consistently associated with shift timing and sleep. Risk increased with more night shifts and decreased with more nights with sleep between 11 p.m. and 7 a.m. and on which nurses had enough sleep to feel fully rested. Risk also increased with roster changes and more shift extensions greater than 30 min and decreased with more choice about shifts. Comparisons between intensive care/cardiac care and in-patient mental health nursing highlight that fatigue has different causes and consequences in different practice areas.

CONCLUSIONS

Findings confirm the need for a more comprehensive and adaptable approach to managing fatigue. We advocate an approach that integrates safety management and scientific principles with nursing and management expertise. It should be data-driven, risk-focused, adaptable, and resilient in the face of changes in the services required, the resources available, and the overall goals of the healthcare system.

Rotating Shifts Negatively Impacts Health and Wellness Among Intensive Care Nurses

The impact of shift work on sleep and health has been examined in the past, but most studies utilized cross-sectional designs relying on between-subject differences. The purpose this study was to examine the within-subject differences in self-report measures of health and wellness among a group of nurses engaged in rotating shifts. Patient-Reported Outcomes Measurement Information System (PROMIS) measures, collected post-day and post-night shift, were used to assess health, sleep disturbances and sleep-related impairment, fatigue, emotional distress (anger), satisfaction with social roles outside of work, and applied cognitive abilities. Among the sample of 23 White, mostly female (91.3%) nurses, all PROMIS measures were worse indicting lower health and wellness after working night shifts compare to after working day shifts ( p values from .167 to < .001). During both time points of assessment, sleep-related impairment was highly correlated with greater emotional distress, greater fatigue, and worse memory and concentration. Study findings support prior studies that shift work can negatively impact health and wellness.

The Impact of Shift Work on Sleep, Alertness and Performance in Healthcare Workers

Shift work is associated with impaired alertness and performance due to sleep loss and circadian misalignment. This study examined sleep between shift types (day, evening, night), and alertness and performance during day and night shifts in 52 intensive care workers. Sleep and wake duration between shifts were evaluated using wrist actigraphs and diaries. Subjective sleepiness (Karolinska Sleepiness Scale, KSS) and Psychomotor Vigilance Test (PVT) performance were examined during day shift, and on the first and subsequent night shifts (3^rd, 4^th or 5^th). Circadian phase was assessed using urinary 6-sulphatoxymelatonin rhythms. Sleep was most restricted between consecutive night shifts (5.74 ± 1.30 h), consecutive day shifts (5.83 ± 0.92 h) and between evening and day shifts (5.20 ± 0.90 h). KSS and PVT mean reaction times were higher at the end of the first and subsequent night shift compared to day shift, with KSS highest at the end of the first night. On nights, working during the circadian acrophase of the urinary melatonin rhythm led to poorer outcomes on the KSS and PVT. In rotating shift workers, early day shifts can be associated with similar sleep restriction to night shifts, particularly when scheduled immediately following an evening shift. Alertness and performance remain most impaired during night shifts given the lack of circadian adaptation to night work. Although healthcare workers perceive themselves to be less alert on the first night shift compared to subsequent night shifts, objective performance is equally impaired on subsequent nights.

Not only a Problem of Fatigue and Sleepiness: Changes in Psychomotor Performance in Italian Nurses across 8-h Rapidly Rotating Shifts

Although many studies have detailed the consequences of shift work in nurses concerning health, fatigue, sleepiness, or medical errors, no study has been carried out trying to disentangle the contribution of sleepiness and fatigue associated to shift work from the attentional performance. The aim of this pilot study is (A) to investigate the effects of an 8-h rapidly rotating shift on fatigue and sleepiness among staff nurses and (B) how these factors affect their psychomotor performance. Fourteen nurses were selected for a within-subject cross-sectional study according to this sequence of shifts: morning⁻afternoon⁻night, which were compared as function of tiredness, sleepiness, and performance at the Psychomotor Vigilance Task (PVT). Subsequently, a within-subject Analysis of Covariance (ANCOVA) evaluated if the observed differences between shifts persist when the contribution of sleepiness is controlled. Our results clearly indicate that night shifts are associated with significant greater sleepiness and tiredness, and worsened performance at the PVT. As hypothesized, ANCOVA showed that these differences disappear when the contribution of sleepiness is controlled. Results point to a lower psychomotor performance in night compared to day shifts that depends on sleepiness. Hence, interventions to minimize the consequences of the night shift should consider a reduction of sleepiness.

Association between sleep and fatigue in nurses who are engaged in 16 h night shifts in Japan: Assessment using actigraphy

AIM

To determine the association between sleep and fatigue in nurses who are working in a two-shift system, including 16 h night shifts.

METHODS

Sixty-one nurses were assessed on their sleeping and napping over 9 days, using actigraphy and a sleep diary. Work-related feelings of fatigue were measured by using the "Jikaku-sho shirabe" questionnaire and the Cumulative Fatigue Symptoms Index.

RESULTS

The main night-time sleep started after 00:00 hours in half of the participants and the average start and end times were significantly delayed among the participants in their 20s, compared to those in their 40s . Although ~90% of the participants napped during and/or after a night shift, only 50.8% napped for >2 h during their shift and 32.8% napped in the morning after a night shift. In the high-fatigue group, significantly more nurses went to sleep after 00:25 hours than before 00:26 hours the night after a night shift. Furthermore, those nurses who napped for >2 h during their night shift exhibited a significantly lower rate of some cumulative fatigue symptoms, compared to those who did not. In addition, a combination of napping in the morning after a night shift and beginning the following night-time sleep before 00:26 hours were associated with a significant decrease in fatigue symptoms.

CONCLUSIONS

Naps at an appropriate time and of an appropriate duration, along with the practice of beginning the night-time sleep early after a night shift, might relieve cumulative mental fatigue in nurses who are working 16 h night shifts.