From the Massachusetts Nurse Newsletter
March 2005 Edition
By Joe Twarog
Associate Director, Labor Education & Training
What does the following list have in common?
- The nuclear accidents at Three Mile Island (1979) and at Chernobyl (1986).
- Increased risk (by 35 percent) of developing colorectal cancer.
- High incidence of drowsy-driving accidents.
- The Union Carbide chemical accident in Bhopal, India (1984).
- Increased risk of infertility, cardiovascular illness, diabetes and gastrointestinal disorders.
- Increased social difficulties including, irritability, impatience, anxiety and depression.
- An estimated financial loss to Americans of at least $100 billion per year due to lost productivity, medical expenses, sick leave, and property and environmental damage. (National Sleep Foundation)
- The Exxon Valdez oil spill in Alaska of 1989.
- The shuttle Challenger NASA flight managers and the decision to launch the 1986 flight despite concerns over the O-rings.
- The Titanic hitting the iceberg!
All of these events, risks, consequences or behaviors are directly related to night shift work, fatigue and sleep deprivation. The accidents at Bhopal, Three Mile Island, Chernobyl and the Titanic all occurred during the “grave yard shift”—11 p.m. to 7 a.m.
Many clinical studies have been done to identify the hazards of working either rotating shifts, extended work shifts or the night shift. All have concluded there are serious consequences involved for the work as well as the worker. In addition to the above list, studies in recent years have pointed to:
- an increase in breast cancer among nurses who worked rotating night shifts for 30 or more years (Harvard’s Nurses’ Health Study);
- an increased risk of coronary heart disease of 21 percent for nurses working less than six years’ rotating shifts (at least three nights per month) and 51 percent for those working more than six years;
- approximately 95 percent of night nurses working 12 hour shifts report having had an auto accident or near miss while driving home from work;
- rotating shift work is associated with low birth weight and spontaneous abortion.
While the human body performs at peak performance during the day, the biological clock (circadian rhythms) drops to its low point during the night — usually a time meant for rest. But those who work the night shift have to reverse this cycle and operate at top performance as the body struggles to adjust. Rotating shifts create the most severe problems as adjustment is not possible.
Night shift workers generally get 1.5 hours less sleep than workers who work day shifts. And the sleep that night shift workers get is during the daytime, when the body rhythms are geared up for activity. This is often light sleep and unsatisfying, leading to general fatigue even following the sleep period. Yet hospitals are 24-hour operations and the off-shift work is a reality that will always be an issue.
The union response to the issue
There are a number of areas that the union can focus on to address the issues and problems of working these shifts. They include:
Differentials. More pay in the form of a shift differential. This extra pay helps to make up for some of the physical and social disruption and has been the most common means of addressing the problem. The differential may act as an incentive for some nurses to opt to work the night shift as opposed to those who are less able to adapt to the off shift work. But a differential alone does not mitigate the real physiological problems of working these shifts.
Training. The hospital should provide specific training on the hazards related to shift work. These trainings should also include guidelines and tips on how best to minimize the physical effects of these shifts.
Meals and drinks. Usually the hospital cafeterias close during off-shift hours. RNs are then limited in their options for obtaining food. Hospitals should make healthy food options available for employees on these shifts. Similarly, dehydration is another side effect of working long shifts or the night shift. Hospitals must make clean water available.
Lighting and ventilation. Well lit work areas with good ventilation signals the body that it is time to be awake and alert, rather than a time for rest.
Fixed shifts. As much as possible, the contract should minimize if not totally prohibit rotating shifts. The effects of shift rotation are the most difficult for the body to adjust to (if at all possible) and consequently the situation that will result in the worst outcomes.
Transportation services. Those nurses working the evening or nights shifts have the added concern of safety in transportation. Escorts can be negotiated for the nurse’s safety as they move from their vehicle to the hospital. Additional clauses that could be negotiated: well lighted parking lots; and, reserved spaces for the off shifts to be able to park near the facility.
Rotation speed and direction. If shift rotation is unavoidable at the workplace, there are points that can be considered to reduce the impact of such rotations. According to the National Institute for Occupational Safety and Health (NIOSH) adapting to shift changes can be affected by the speed of the rotation and the direction of the rotation. The studies have mixed results regarding the speed of shift, but rapid changes (two days per shift) seem to be the most harmful. However, research clearly suggests it is better for a forward rotation (clockwise, or following the sun) of shift changes. This forward direction is healthier for allowing the body to adjust to new sleep times. Backward rotations force the body to adapt against the body rhythm by forcing sleep earlier and earlier.
Rest breaks. NIOSH points out that card dealers in casinos get a 10 to 15 minute break each hour because their jobs require so much concentration and the casino wants to avoid losing money to players taking advantage of the dealer’s fatigue. It would follow that health care workers should be accorded a similar allowance given that they are dealing with patients’ health and well-being. Negotiating more break time and even nap time for off-shift workers is an area that could be explored. “Studies show that napping at work is especially effective for workers who need to maintain a high degree of alertness, attention to detail, and who must make quick decisions.” (National Sleep Foundation)
The Wall Street Journal recently reported (Jan. 24, 2005) among the many perks now being offered by some companies include nap rooms (among other perks as massage therapists, live music performances, day care centers, yoga lessons and other creative benefits). The Journal article stated, “Things like nap rooms and massage recliners… can boost productivity when there are older workers with sore backs, or young parents with sometimes sleepless nights. (But) companies trying them say they can be done simply and inexpensively, and that they produce better morale, increased motivation and less stress.”
Flexible work schedules. Experiment with flexible work schedules jointly through a negotiated arrangement. The parties could try reducing other job requirements as a trade-off for working the off shifts, such as a reduction of weekends and/or holidays required to be worked.
It is important to recognize the hazards associated with night shift, rotating shift and extended hours of work—both in impact on judgment and performance at the workplace and for the well-being of the nurse involved. Then it is incumbent to attempt to minimize and manage the effects of fatigue and sleep deprivation. A creative and aggressive approach to the problem can qualitatively change the workplace as well as the stresses and attitudes associated with these shifts. The union plays that critical role of recognizing and defining the problem and then finding solutions.