A New Day: A New Psychological Contract with Night Nurses

[RoxyDi]

Recently, I've read several articles in healthcare industry publications related to sleep deprivation and the unsafe conditions faced by medical students and residents, and how their work is negatively impacted as well as their personal lifestyles. Missing from most of these articles, it seemed, was the corollary discussion of the same problems facing far more individuals right there at the patient's bedside: nurses.

Rarely am I captivated by the HR component of my current MHA degree coursework, but in the 7^th chapter of my Healthcare Resource Management text, I was intrigued from the first paragraph that discusses how one corporation that owns three hospitals developed and implemented programming related to adjusting to the night shift into their orientation of new graduate nurses. Bravo! This led to reflection on my own experiences.

I graduated from nursing school in May in Central Illinois in 1981. Immediately I took a position at my local hospital on the night shift on a medical floor, as was the usual custom. Within 3 months, I got married, adding another layer of stress on top of graduation, a new position and the night shift challenge. Unlike today when HR personnel are looking at work/life balance, at that time, nurses knew they just had to get lucky” to land a day job, or work the dreaded 3-11 shift instead, or pay dues” on the night shift. Eventually, we knew we would be rewarded with a more normal lifestyle if we hung in there. If.

No one seriously considered the consequences of night shift duty and sleep disruption to the nurse or his or her patients re: safety, but we nurses felt them. I remember many days when I slept for only a few short hours, only to be awakened in the middle by a telephone that couldn't be turned off, or by the dog barking at the mailman, or by the sight and feel of pure and lovely sunshine pouring through my curtains, begging me to join the rest of the daytime world. It was my introduction to the frustration of sleeplessness in the midst of exhaustion.

Inadequate sleep didn't affect only me, but also my husband, and very likely, my patients. Those short few hours of poor sleep caught up with me between 1 and 3 am during my shift, when caffeine wasn't sufficient to make up the difference, and I had to will myself to stay awake and focused on my work. It was difficult, but I was young. Apparently, I was supposed to be able to handle it.

But my nursing school friends and I were all too aware of much more serious things than jitters from excessive caffeine consumption that could befall new graduates working the night shift. One of the nurses ahead of our class died shortly after graduation—within the first year or two, having fallen asleep at the wheel on the way home after work one morning. Only in her early twenties, she was at work one day and gone forever the next.

That somber event was tragic and memorable for her fellow schoolmates and all nurses who knew her. I'm not sure we stopped to wonder how it could have been prevented by workplace's policies, though. It was a different time. Today, our text tells us that the psychological contract between employers and employees has been altered to incorporate the expectation of work and home life balance. Thank goodness things are changing.

Just as warned in the chapter that discusses the corporation's strategies to protect their nurses and thereby, their patients, I left my first position before a year was up, and took a daytime job with one of the internists who practiced on my unit. I loved hospital nursing—but I didn't love working the night shift! I am just one example of the undesired outcome of new graduate nurses who leave nightshift employment due to unresolved associated stresses. New grads need all the help they can get.

Since then, I have repeatedly been amazed at the lack of attention paid to retention of hospital employees, especially nursing staff members who are the backbone of hospital care. Things are changing for the better, but more needs to be done.

Upon my graduation from my MHA program, I plan to add to others' contributions by remembering where I came from, and where we need to be as a profession that cares for the safety and well being of the workforce and patients alike. I hope to work as a leader in hospital administration, where I can influence those outcomes directly, in remembrance of those who paid a high price for our former ignorance.

[meanmaryjean, DNP, RN]

Shift work adaptation, circadian disruption, and fatigue countermeasures have been the topic of my MSN and DNP work. I have published and presented extensively as well. On March 16th- I will be doing a Navigate Nursing webinar for the ANA on the topic of nurse fatigue.

The problem IS being addressed- have you seen any of the recent literature on this topic?

[RoxyDi]

Thanks for the information. What I meant about not seeing information about the topic is that in the publications I've seen (management, patient safety, risk management, health care industry in general) most of the discussion on safety about sleep has been regarding physicians. I will try to catch your webinar if it is available to the public. It is good that more attention is being given to the effects on other workers as well.

[NurseGirl525, ASN, RN]

But what do you suggest? In all honesty. Things happen at night. Traumas, bowel perforations, strokes, heart attacks.... They don't happen between the hours of 9-5. What do we do? Yes, it is difficult to work night shift. I do currently. I worked last night 1900-0730. We had 4 admits for various critical things. I bet those people and their families are very happy that we were all there to help their loved ones live. From the surgeon that did the dirty work to Environmental Services who cleaned rooms STAT for us last night. It's the nature of the beast unfortunately and you have to get into this field with your eyes wide open.

For the record I have been up since 0700 Saturday morning. With maybe a couple of hours smattered in there. Like when I first got home this morning and on my break last night.

[elkpark]

Thanks for the information. What I meant about not seeing information about the topic is that in the publications I've seen (management, patient safety, risk management, health care industry in general) most of the discussion on safety about sleep has been regarding physicians. I will try to catch your webinar if it is available to the public. It is good that more attention is being given to the effects on other workers as well.

I've seen and heard this discussed within nursing for decades. I've worked night shift in the past, and my employers have been as supportive and helpful as it's possible, realistically, for them to be (considering that hospitals are 24/7 operations and someone has to be there at night). I agree that there are personal and safety considerations involved in night shift work, but I disagree that no one in nursing cares or has been talking about it. None of this is "new."

[HouTx, BSN, MSN, EdD]

I love OP's passion about this issue.

Chances are, since she is in an MHA program, they don't include much "Nursing" literature..... just another example of the status of our profession. I have noticed that other countries are not only recognizing health and safety issues associated with working "unsociable hours" (love the British terminology), but they are actually beginning to take steps for corrective actions. Of course, these countries are probably not as mired in free enterprise & the capitalism of healthcare as the USA.

On a side note - I have been following the current unrest/issues with Junior Doctors in England with some amusement. They have/are organizing work stoppages (strikes) due to being asked to extend working hours... schedules more closely aligned to those that have always been required for nurses. The docs are very vocal in expressing shock and dismay related to the possibility of disrupting their personal lives & fear of burnout. Meanwhile, the nurses just keep on keeping on - probably just like we do.