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"We must look at our practices and attitudes about shift work"

Nurses need to look at how they can reduce the toll that night shifts can take on their health and wellbeing

Night shifts may be an essential part of working life for most nurses - but they are also bad for their health. There is an overwhelming body of evidence to suggest that working nights can be detrimental to our wellbeing. This is related to the fact that
night shifts disrupt circadian regulation, which is thought to be responsible for a wide range of physical and psychological disorders.
Night-shift workers are reported to experience sleep of a lower quality than their fellow day workers. The rotations of days to nights, and vice versa, disrupt circadian regulation still further. Worryingly, there appears to be some correlation between sleep deprivation and tiredness and the incidence of professional mistakes, such as drug administration errors, incorrect operation of medical equipment and needlestick injuries.
However, despite the difficulties they can cause, night shifts are a fact of nursing. Most of us knew when we began our careers that nursing was a 24/7 profession. But perhaps trusts and other healthcare organisations could do more to reduce the physical and psychological burden of night working.
Operationally this may be difficult. While shift pattern rotations have been suggested that reduce circadian disruption, these may not be practical in a service that needs to be dynamic and responsive to service requirement. The one thing that is likely to upset nurses more than having to do nights is changing their working
patterns and shift times.
The trend towards 12-hour shift patterns started in the 1980s, influenced by nursing staff shortages. And, while nurses grumble about long shifts, the chances are that suggesting working five days a week instead of three would not be popular.
The increase in pay due to working unsociable hours does soften the blow of nights - but then night workers often miss out on the services available to day duty staff, such as access to hot food, break times, and professional development and learning opportunities. Perhaps trusts could make more of an effort to ensure these services are available both day and night?
While trusts need to explore ways of offering more support, nurses also need to look at how they can reduce the toll working can take on their health and wellbeing. Nurses often arrive for a night shift having already done a day’s work at home - such as housework or childcare duties - without having had enough sleep. Yet surely we have a professional responsibility to make sure we are sufficiently rested to carry out our clinical duties and are fit for practice?
When it comes to reducing the burden of shift work, nurses will always suggest they lack adequate support. But we have to remember that organisations may find it difficult to provide such help. That’s why we need to look at our own attitudes and practices around shift work - if we do that we may be able to find ways that will help ease that burden.

Dan Higgins is senior charge nurse, critical care, University Hospitals Birmingham NHS Foundation Trust

Readers' comments (39)

  • I absolutely agree with this! I have been shouting for years now that the current system is insane and does not in any way take into account work/life balance or staff health. This is absolutely wrong, and managers, and Nurses themselves, need to have a fundamental culture shift if things are to change.

    For example, it is common now to do random shifts, early, late, early, day off, a string off nights, a day off, then straight back onto early's. How many of you recognise this pattern? How many off you have split days off constantly? How many off you work too many night shifts without a break?

    This needs to change. It is not difficult to minimise the effects of nights by ensuring not too many are done each month or for those who do permanent nights that too many nights are not worked in the week and there is a sufficient block of days off so the body can recover afterwards. Services SHOULD be available 24 hours too. If management expect US to work, then surely they have a responsibility to look after us?

    But within this it is Nurses who are often our own worst enemy, yes managers and trusts have a responsibility, but why are we as Nurses accepting it as 'just the way it is' (it is only that way because people accept it!) But why accept split days off? DEMAND your time off be taken together. REFUSE to do day shifts too soon after nights. Stop doing all the overtime to cover for staffing shortfalls, even though you are exhausted, don't listen to the emotional blackmail! YOU have to look after your health too.

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  • tinkerbell

    Mike totally agree. Talk about flogging a dead horse! I just posted a much longer response to this article but it got lost in cyberspace and can't go through it all again, but suffice to say unless nurses take care of themselves and say 'no' to excessive demands on their wellbeing, unfortunately how can they expect anyone else to care. On rare occasions we've had nurses faint on the job and get carted off to A&E on stretchers. What a game! I managed to do half a shift whilst lying on the floor when my back seized up and everyone just walked around me at my request as i couldn't move and the doctor said 'that's the best place for you' whilst i handed over the patients. Had to laugh, what other job eh? We seem to think this is all 'quite normal' in our world. If we carry on like this won't be many of us around to claim the old 'gold plated' pension at 68.

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  • doing the 'off duty' seems a highly complex task (which thank goodness I have never had to do although i believe there are some good computer programmes although they may not take the human element into consideration). This task can make senior nurses feel unpopular as they cannot please everybody all the time. It was one of the greatest causes of conflict on our ward. It was often left to the very last minute on the pretext of work overload and lack of time and when it was finally done it often appeared carelessly done with discrepancies and shifts which were sometimes totally unworkable. If this was pointed out it was often met with anger and aggression! Special requests and even holidays were sometimes ignored as well quite unreasonably and we were told once it was done it was too late to change but we had the opportunity to ask someone to swap which could be quite difficult at short notice. If I was available I liked to accommodate my colleagues some of the time so that if ever I needed them to swap with me they would be more willing. Some nurses are much better than others at doing the off duty and really make an effort to make it fair as possible.

    Tinkerbell, I have a similar story to yours which I think I have posted on here before.
    My very first ward was high dependency with a small separate four bedded room at the end for patients requiring cardiac monitoring, etc (a mini ICU). One very old lady removed her oxygen mask during the night and became very hypoxic and confused. She pulled out her drip and the night nurse, probably in a rush, bent across the bed to fix it instead of going to the side of the bed where the drip had been sited. The old lady gave her a sharp cuff under the chin and the poor night nurse was laid out cold and flat on the floor. An obese 40 year old district nurse was in the next bed recovering from her umpteenth myocardial infarct and told the next one would kill her. However, she lept out of bed to the rescue pulling out all her leads, wires and drips, etc. and promptly collapsed on top of the nurse. Colleagues called the duty HO who sorted out the patient and they all managed to get her back into bed and breathing again but as he was considered 'JUNIOR' in status to the qualified nurse in question he was not allowed to touch her. When she came round her colleagues ordered a taxi, bundled her in and sent her home in the early hours of the morning! When Sister arrived the next morning the remaining night nurses had to explain why there was nobody from this small unit for the handover to her and the day staff. She was always angry at someone or something and bullied everyone under her including the patients, mercilessly although she seemed to enjoy buttering up the doctors. nobody was very sorry when we, not long after this incident, learned she would be absent for a while as she had drunk too much and fallen down some steps and broken her leg. On her return, just as I was leaving, she gave me a glowing report but could not even remember who I was or even having worked with me even though she had tried her bullying tactics on me too by trying to make me force a patient to eat and I was not allowed to leave his bedside until he had cleared his plate! Great for my first taster of nursing on a ward and the glowing report was of little help to me as it contained no constructive (or even destructive criticism) she just filled the 'excellent' column all the way down but she was not the sort of person to discuss it with so I just accepted it grateful to be moving on! This was way back in the mid-70s when I started nursing as a mature (or fairly) student.

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  • @ Mike
    'DEMAND your time off be taken together. REFUSE to do day shifts too soon after nights'

    It is easy to say, but in practice how can we? If we need to demand, surely we are becoming as unflexible as the management that we are trying stand up to? Surely some form of compromise and mediation can be used before we all start making demands. Nursing is full of demands, lets not add more - especially ones that will put us at odds with each other. We need to pull together, not apart.

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  • Anonymous | 5-Nov-2011 7:46 pm actually it is very easy to do, and it is not as divisive as you seem to assume. It is not a case of standing in a corner stamping your feet refusing to do any shifts that do not suit you, it is about all of us collectively working in a way that takes into account our health and work/life balance, expecting this as a norm should be a given, we shouldn't have to even argue about it. Why should we put up with a system that has been proven to have negative health effects just because it suits management? Nursing as a profession seems to have this strange 'martyr syndrome' where we put up with anything that is thrown at us. What other job or profession does this? Even bloody factories group their shifts together into earlies, lates and nights with suitable time off in between!

    And yes, I have flat refused to work rota's that have put me on 7 nights in a row without a night off or put me on earlys after a stint of nights with only 1 day turnaround. I even used some colourful language when one manager put me on a late shift the day after a night shift (and no, I am not kidding!) Needless to say I didn't do it.

    I agree we need to pull together anon, but in a way where we can collectively demand a workable, healthy and sensible rota system.

    Oh, and for the record I have done rota's myself on many, many occasions. It isn't difficult to take into account health and work life balances, such as giving people days off together or grouping shifts, I can even include most peoples SENSIBLE requests. I disagree with Anonymous | 5-Nov-2011 5:22 pm, it ISN'T a complex task at all, it is just that far too often it is a task that is done from the wrong paradigm. It is a task often done as quickly as possible with no thought for the staff as long as each shift is covered with as few staff as possible, when it SHOULD be getting done to cover the needs of the ward but also taking into account the needs of your staff. If your staff aren't looked after well, they can't look after the patients well, it really is as simple as that sometimes.

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  • At present I am a 2nd year student nurse having just finished four nights, a day off then back on to early, late, early, day off, then late, late, early, early. My body clock is all over the place. I am a mum to five, It takes me two hours to get to placment by bus so I find myself having to leave home at five am to get to the hospiatl on time (oh & before anyone asks yes I have pleaded, beseched my university for a trust closer to home, which by the way is 25 minutes by bus from my front door) all to no avail. I 'm fed up, tired, run down and quite honestly I'm wondering if its really worth it? I love the job but is it enough? Having no time for myself and my family makes me wonder if I really need the aggravation?

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  • Sorry about the spelling mistakes. I'm just tired.

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  • Anonymous | 6-Nov-2011 1:44 pm I feel for you, I really do. I have been in the same situation as you as a student, (albeit without the five kids! How do you handle that?!?!?) as I'm sure many of us have. This is far from rare, and is the exact reason I have said what I have above. When you qualify, do not become one of the martyrs, do not accept conditions like that, do not allow management to put you on an early straight from nights, etc. Regardless of what Anonymous | 5-Nov-2011 7:46 pm says, there can be NO compromise on allowing this ridiculous, unsafe and unhealthy situation to continue.

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  • tinkerbell

    Anonymous | 5-Nov-2011 5:22 pm

    Couldn't make it up could you. A day in the life of a nurse.

    We have the computer erostering, or as i call it 'old black heart'. It takes no account of the person, you are just a number. Swings staff backwards and forwards between days and nights, split days off and then it takes an absolute age to try and make it more human friendly.

    When one of our nurses complained that they were so tired at the quick turnaround from days to nights and nearly crashed their car on the way home i suggested he take the matter further as i was fearful for his safety. OH recommened he get public transport home. Unbelievable!

    When i did the off duty by hand it was much more considerate, but obviously can't please everyone as there are so many factors to be taken into consideration, but whereas now it takes hours to complete an eroster i could bash of a reasonably compassionate off duty in a half hour and it was always done at least 6 weeks in advance. You do need to do an off duty to understand all the different problems of doing one, but this attitude that nurses can work until they drop needs to change.

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  • Exactly Tink! As I have said on a separate thread, there needs to be a fundamental culture shift in the NHS, where staff are seen as essential and looked after as such!

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  • Little One

    I have to agree with the previous student, last week I did a Long Day Sunday, University Monday, Night Tuesday & Wednesday, Day Off Thursday and a Long Day Friday. It is incredibly hard to cope with, and don't know where I stand with regards to requesting a sensible off duty.

    My Migraines are triggered by stress and lack of sleep so had 2 last week. I asked my mentor about shifts and she just said I'd have to put up with it at they are the shifts available. I also requested to do short days when possible and was told that the ward didn't routinely offer them so it would be doubtful I would have them.

    I have also yet to be on a placement where my requests for days off were taken into consideration, I have had to check the off duty and plead with another staff nurse to supervise me if swapping means I can't work with my mentor. And, by the looks of things, despite asking for my final Christmas off, I'll be at work on Christmas Day. :-(

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  • Little one, students in general are given the shaft when it comes to off duty and I am sorry about that, but there are some things you can do.

    First of all, unless your university have released statements about you working Christmas, no student should be in on Christmas Eve, Day or Boxing day. That is completely unreasonable. My University stated that we had to work over Christmas years back, and there was an outcry from students as wards rubbed their hands in glee and tried to use us in the numbers as staff wanted the days off. We were basically being used as free labour. Uni backed down in the end. You are supernumerary, there is no need for you to be working Christmas. Just refuse it. Any half decent mentor wouldn't ask you to do it anyway! I have given my students who are in over the period those three days off at least! It isn't difficult.

    Secondly, your off duty is often based around what your mentor does, and there does have to be a little give and take on that from both sides, but that doesn't mean you should be landed with a rota that should not be allowed. It is often the case where mentors who are assigned to students are completely inappropriate in terms of shifts worked (I have been given mentors on permanent nights, part time ones who only did two days a week, even ones who were on long term sick, I'm not kidding!) You can ask to have your mentor changed. Go to the ward manager or even your uni if you have to. Those shifts you are working are completely unreasonable, no one should have to work nights and days in the same week, it is ridiculous!

    Go and speak to your mentor first (try again, just to say you have given them every opportunity), your ward manager next, and uni third.

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  • Ellen Watters

    Oh my goodness, I'm exhausted reading all of this. I have done my time doing horrendous 12 and a half hour shifts. The rattiest I have ever felt was from the sheer mind numbing exhaustion of long shifts. No wonder families and relationships are put under so much strain.

    Thsi is one of the reasons I am unlikely to ever return to the NHS and instead work full time Monday to Friday for a charity. Which is a shame because I do miss the patient contact.

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  • tinkerbell

    Little One | 7-Nov-2011 11:39 pm

    You are supernummerary remember, is your mentor working christmas day and if so fair enough, and are you working the nights your mentor works? Do you not have an associate mentor? I know you have to spend the majority time with your mentor but not the point where instead of being supernummerary you are just being 'exploited' As a student on our unit, you do not have to work nights, or maybe only one for the experience. We certainly wouldn't put a student on a stint of nights and that is hindering their overall placement learning needs to have experience of other specialities during the day. Sorry to hear it is already affecting your well being. Unless things change sadly it doesn't get any better once you qualify within in patient care. I am not a very physically robust individual myself but have managed to survive somehow but life should be more than just survival and after so many years it does take its toll on a body.

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  • I am a manager of an Out of Hours District Nursing service, I became manager of this team after working as part of the team for many years(I know how tiredness feels). We are a human team, not cyber nurses! of about 30 and respect each others tiredness, we rosta as a team and try as much as we can to meet the needs of the individual staff member, we support each other and have give and take and step in for each other. I still work in the team as much as possible and this helps me to realise what my staff are feeling and the pressure as management the NHS is putting on them. We care,........... about the patients and each other, it is possible but you will never meets the needs of all the team all of the time.....flexibility and equality and human understanding is crucial to prevent tiredness out of hours.

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  • Although i do not do nights with the edis system I really feel for those who work 1 day, nights the next day, day off then an early shift. No way could I cope with that. And now bringing twightlights in- finish at 2am, may use an on call room if you have no transport, but the room as to be vacated by 0900. Plus no beverage facilities.

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  • I thought there were employment laws which determined the minimum length of time off allowed between shifts. What happened to health and safety?

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  • There is no need for student nurses to work over Christmas or New Year. The university where I qualified provides 2 weeks off over Christmas, 2 weeks off around Easter and the whole of August. Unless your mentor is upposed to work those same shifts then there is no reason for a student to have such a bizarre set of shifts.
    I have been in the situation where I have started annual leave on the Monday and have been given the nght shift on the Sunday, which meant that I was working 7.5 hours on the Monday from the night and also having 7.5 hours annual leave on the same day, when I asked the ward manager about this, her response was that the 7.5 hours workes belonged to last week whilst my annual leave belonged to this week!
    I work with a shift pattern that means every 5 weeks I do a week of nights followed by a week of nights off. This I prefer as it means that I can switch over to night mode without having to worry about the interference of day shifts. Although, since nights shift is not dissimilar to travelling to a time zone 12 hours behind UK time there is the associated 12 hour jet lag when switching back to day time living and it is suggested that it takes one day for each hours jet lag to fully recover, 7 nights off may not be enough.

    Anonymous 8-nov 10:26 pm true the working hours directive states there should be a minimum of 11 hours between shifts, except you will find there are exceptions in the legislation and nursing is one of those exceptions.

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  • Little One

    Thanks Mike, I have spoken to my mentor about my shifts, they are so all over the place because I am spending half my time with one mentor and half with the other. I have asked not to do nights and days in the save week again, but was told she couldn't promise it, and they've really dug their heels in about Christmas.

    Tink, my mentor is working the 21st, 22nd, 23rd and 24th Nights. My other mentor is working 21st and 23rd Long Days. I only have to work 12 hours my final week to make up my hours and they've put me down for the 23rd and Christmas Eve Night. In 4 weeks I've already done 7 Night shifts. I don't mind doing them but not when I feel like I'm replacing members of staff which I think is clearly what is happening for Christmas Eve.

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  • Anonymous | 9-Nov-2011 9:34 am

    As you say, I thought there was legislation between hours off between shifts but I hadn't realised nursing was an exception - is this a legal exception? This doesn't solve the problem of night shifts though and I do not know about any employment laws concerning this. I guess for the sake of economy and convenience to employers nursing is an exception to this anyway as well!
    Seems strange if this is the case as nurses are not different beings from the rest of the population with any different health and welfare needs or any less vulnerability! Supernurse! Superhuman!

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