Night-Shift Nursing


Night-Shift Nursing

Working when the sun goes down

By Kristin Cassell
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Kevin Moran’s world just turned upside down. Nothing is the same: eating, sleeping, interaction with friends and family. Every facet of his life has morphed into something abstract, foreign and unnatural.

Three months ago, Moran gave up the comfort of living within his body’s natural rhythms by choosing to work the night shift. He sleeps during the day, he eats breakfast at 10pm, and fights lethargy at 3am.

The transition has been much more difficult than he anticipated, and has devastated his body. “I am always sleep deprived,” he explained. “I sleep as much as possible and still cannot function. I am a ghoul.”

Abby Ritter, RN, BSN, works in NICU/PEDS and has considerable experience as a night nurse. She said a strict schedule is the most important aspect for night workers. “Sleep during the day is not the same kind of sleep as you get at night.”

Moran agreed. “When the kids are [at home], I lay on the sofa and snooze until my wife gets home. Then I can go to bed until I have to go to work.”

Each year, the National Sleep Foundation publishes a poll called Sleep in America. According to 2009 statistics, the average adult is getting only six hours and 40 minutes of sleep on a typical weekday instead of the seven hours and 24 minutes needed to function their best. Throw in a total upheaval of your circadian rhythm by switching to the night shift and … is there any advantage?

Riding the Emotional Roller Coaster

Beyond the obvious adjustments to daily living routines, transitioning to nights cultivates emotional and mental stressors that those making the transition often don’t anticipate.

In 2007, the University of California, Berkeley, published a study in Science Direct titled “The human emotional brain without sleep: a prefrontal amygdala disconnect,” where MRIs were used to evaluate the correlation between lack of sleep and the human emotional response. The study focuses on the medial prefrontal cortex and its proposed control of the amygdala, which performs a primary role in processing emotional reactions.

Matthew P. Walker, the primary author, told the San Francisco Chronicle, “One of the functions of sleep is to reset and replenish the emotional integrity of our brain circuits so we can approach the day's emotional challenges in appropriate ways. If you don't get a good night's sleep, you'll be making irrational choices.”

Choices like these are all too familiar to Moran. “I have extreme mood swings,” he said. “With sufficient sleep I am extremely caring, kind and loving. With not enough or too much sleep I become short, rude and obnoxious. I go from being Mr. Jekyll to Mr. Hyde.”

Thankfully, the effects of sleep deprivation are not permanent. According to Walker’s study, “… a night of sleep may ‘reset’ the correct brain reactivity to next-day emotional challenges by maintaining functional integrity of this MPFC- amygdala circuit, and thus govern appropriate behavioral repertoires.”

Mind Games

According to Sleep-Wake Cycle: Its Physiology and Impact on Health, published by the National Sleep Foundation in 2006, “In the past few years, investigators have found that sleep loss may have harmful consequences for our immune and endocrine systems, as well as contribute to serious illnesses such as obesity, diabetes and hypertension.”

These effects hit home for Ritter, whose appetite decreased significantly when she worked as a night nurse. As a result, she said, “I felt tired and under the weather all the time. I was a lot slower than normal and not as cognitive.”

Francesco Cappuccio, professor of cardiovascular medicine and epidemiology at Warwick Medical School, told the British Sleep Society, “Fewer hours sleep and greater levels of sleep disturbance have become widespread in industrialized societies. This change, largely the result of sleep curtailment to create more time for leisure and shift work, has meant that reports of fatigue, tiredness and excessive daytime sleepiness are more common than a few decades ago.”

Function Malfunction

From the everyday traffic accident to large-scale incidents like the Exxon Valdez oil spill, sleep is an essential part of our cognitive function. And Moran is among many who can personally attest to the consequences of disrupting this connection. In September 2007, he caused an automobile accident that resulted in a significant amount of damage.

“This was my first accident in 36 years,” he explained. “My reaction time was slower than normal. I ended up totaling my truck and rear-ending another driver. I was at fault because I was tired. Because of that [accident] I have committed myself to getting a minimum of eight hours of sleep. If I don’t, I won’t drive.”

Ritter had a similar incident. “I’ve actually run off the highway before because I was so tired,” she said. “I used to sit at stop lights focusing on making it through the next few minutes until I got home.”

According to the Association for the Advancement of Automotive Medicine, more than 100,000 crashes are caused by sleep-deprived drivers each year, resulting in 71,000 injuries and more than 1,500 deaths.

The 2009 NSF Sleep in America poll found that 54 percent of adults said they had driven at least once while drowsy in the past year, and 28 percent reported they drive drowsy at least once a month. What's more, this year's poll was the first time an association has been found between drowsy driving and engaging in other unhealthy or unsafe behaviors. It states that chronic drowsy drivers are twice as likely as others to say they aren't able to do the following because they're too sleepy: work well and efficiently (22 percent vs. 10 percent); exercise (23 percent vs. 12 percent); eat healthy (17 percent vs. eight percent); have sex (17 percent vs. seven percent); and/or engage in leisure activities (24 percent vs. 11 percent).

In an article published in the Journal of the American Medical Association, University of Michigan researchers studied the physical reaction time of medical professionals who work extended night shifts and compared it to quantitative blood alcohol levels. They found that long hours and night shifts equated to a blood alcohol level of .04 percent.

“The reaction time of residents who had just finished a month of heavy work schedules was seven percent slower and they committed 40 percent more errors than when they were on a month of light schedules,” the article stated. “On a driving simulator, they had more difficulty maintaining a consistent lane position and a constant speed during the heavy work compared to the lighter work schedule.”

The Night Nurse

Arlene Johnson, Ph.D., RN, OHN, a former assistant professor at the Deep South Center for Occupational Health and Safety at the University of Alabama at Birmingham School of Nursing, studied the effects of sleep deprivation associated with nurses working night shifts. Of the 289 nurses studied, 56 percent of subjects showed quantitative effects of sleep deprivation.

“Reduction in the amount of sleep predisposes individuals to sleep deprivation, resulting in poor psychomotor performance,” Johnson explained in a Science Daily article. “Nurses who work the night shift may be particularly subject to sleep deprivation because of irregularity of sleep hours and disruptions in the circadian cycle.”

Johnson presented the results of the study at an annual meeting of the Associated Professional Sleep Societies; they revealed that a severe lack of sleep impacts decision-making processes, performance, cognitive function and productivity.

“Poor psychomotor performance has been associated with an increase in error, which can be translated into an unsafe work environment,” she said. “The identification of sleep deprivation in nurses is essential for maintaining safe working conditions.”

If You Don’t Snooze, You Lose

So, what has this experience taught Moran and Ritter? That switching shifts is not easy. But, when done effectively, the transition can yield some benefits, such as a quieter environment and a less harried pace; the ability to spend time with your children before and after school; an increased pay scale; and a cohesive work environment.

Moran regrets the choice to switch, however. "Seek alternative choices if you can," he said. "Really think about it before. It completely changes your life."

Ritter didn't exactly agree. Before she had children, she found she preferred the night shift. "I loved the people who worked with me," she said. "They are a different breed, more laid back, a lot of fun and we worked well together. They were like my family away from home."

Surprisingly, the chasm between Moran and Ritter narrows with the consideration of one variable: children. After they came along, Ritter found it extremely difficult to keep night shift hours and care for an infant during the day. She was required to stay alert and awake during the day to provide care for her daughter, and napping when she napped did not sufficiently fill the void. If the children are school-age, however, the opposite applies. "You utilize your time in the right way," Ritter said. "The night shift schedule allows you to maximize your family time."

So, what is the best way to effectively make the transition from day to night?

Your body will suffer the change regardless of how resilient you think you are, so don’t fool yourself into thinking you are immune to the effects of sleep deprivation. Be aware of those effects and monitor your body’s response to ensure your own personal safety and the safety of your patients. Follow a strict schedule to maximize the well-being of your health and family dynamics, and even discuss the transition with your doctor, as he or she may recommend a sleep aide.

The week before starting a night schedule, Moran suggested the following course of action: “Stay awake to 1 or 2am and sleep during the day. On the next night stay up until 3am. Keep pushing the time you are awake at night and sleep during the day. The goal is to see how coherent you are into [early] morning hours.”

By slowly transitioning yourself over the course of a week, it eases the body’s response to night wakefulness. Ritter was not afforded the previous option, however; instead she jumped right in.

“When I worked three [12-hour shifts] in row, it wais a lot better,” she said. “The first night is really hard; the second is not as bad; and the third night is better. It was the window of the day before and after [three consecutive shifts] that was hard.”

On the day before Ritter faced her trio of night shifts, she stayed awake all day and night, forcing her to sleep during the day before her shift. She woke up around 4pm and prepared to go to work. When she got home, she continued a night shift schedule until her three 12-hour shifts were finished. Then she returned home and stayed awake all day so she could sleep that night. This routine forced her body back to the schedule of a day worker.

Before choosing to flip your world upside down, consider and weigh your options. Be honest with yourself when assessing if the risk of transition outweighs the rewards. If you decide to give it a try, understand that it may turn out to be either the best or the worst choice. Most importantly, consult your fellow workers and assimilate their advice. You may even, as Moran said, “… learn to like grits, eggs and beer at 8am on a Friday morning.”

Shift Work Sleep Disorder

One consequence that can develop from taking the graveyard shift — or having a job with rotating shifts — is shift work sleep disorder. A 2007 article in SLEEP, the journal of the Associated Professional Sleep Societies, describes it as, “A circadian rhythm sleep disorder that occurs due to a work schedule that takes place during the normal sleep period. This schedule requires you to work when your body wants to sleep. Then you have to try to sleep when your body expects to be awake. The timing of when you sleep and wake is much different than what your internal body clock expects.”

The Cleveland Clinic website says the disorder is common among people who work between 10pm and 6 am, and it results in insomnia or excessive sleepiness, making workers less alert and increasing the risk of injury on the job.

Listed below are symptoms, risks and ways to manage the disorder as listed on the Cleveland Clinic site. For further information, contact your health professional.


The most common symptoms of SWSD are insomnia and excessive sleepiness. Other symptoms include:
    * Difficulty concentrating
    * Headaches
    * Lack of energy


    * Increased accidents
    * Increased work-related errors
    * Increased sick leave
    * Increased irritability, mood problems, etc.


*Minimize exposure to light on your way home from work if you are on the night shift to keep morning sunlight from activating your internal “daytime clock.” Follow bedtime rituals and try to keep a regular sleep schedule — even on weekends. Go to sleep as soon as possible after work so you can get at least seven to eight hours of sleep every day.

*Ask family and friends to help create a quiet and peaceful setting during your sleep time by having them wear headphones to listen to music or watch TV; also have them avoid vacuuming, dish washing and other noisy activities.

*Decrease the number of night shifts worked in a row. Night shift workers sleep less than day workers and become progressively more sleep-deprived over several days. You are more likely to recover from sleep deprivation if you can limit your number of shifts to five or less, with days off in between. If you work a 12-hour shift, you should limit work to four shifts in a row. After a string of night shifts, you should have more than 48 hours off, if possible.

*Avoid working prolonged shifts and putting in excessive overtime. Make sure you have time to sleep and participate in family and social activities.

*Avoid long commutes, which can take time away from sleeping.

*Avoid frequently rotating shifts. It is more difficult to deal with rotating shifts than it is to work the same shift for a longer period of time.

*Get enough sleep on your days off by planning and arranging a sleep schedule and by avoiding caffeine, alcohol and nicotine. Do not start a night shift with sleep deprivation.

*Caffeine and prescription wake-promoting drugs have some role in helping you stay awake during work hours, but the best strategy is to get adequate sleep.


American Sleep Association
Science Daily
Deep South Center for Occupational Health and Safety
Journal of the American Medical Association
National Sleep Foundation
Cleveland Clinic
American Sleep Disorders Association
Associated Professional Sleep Societies


Kristin Cassell is a freelance writer for Working Nurse.

This article is from

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