Night Shift Fatigue and Other Consequences

Night Shift Fatigue and Other Consequences
The Joint Commission Journal on Quality and Patient Safety (2007) reported that nurses do not meet average daily sleep requirements. Research was conducted to assess if less than 11 hours off work between work shifts (quick returns) was related to insomnia, sleepiness, fatigue, anxiety, depression and shift work disorder among nurses. A questionnaire including established instruments measuring insomnia (Bergen Insomnia Scale), sleepiness (Epworth Sleepiness Scale), fatigue (Fatigue Questionnaire), anxiety/depression (Hospital Anxiety and Depression Scale) and shift work disorder was administered. Among the 1990 Norwegian nurses who participated in the study; 264 nurses had no quick returns, 724 had 1–30 quick returns and 892 had more than 30 quick returns during the past year. 110 nurses did not report the number of quick returns during the past year. The prevalence of insomnia, excessive sleepiness, excessive fatigue, anxiety, depression and shift work disorder was calculated within the three groups of nurses. Crude and adjusted logistic regression analyses were performed to assess the relation between quick returns and such complaints. Findings illustrate a significant positive association between quick returns and insomnia, excessive sleepiness, excessive fatigue and shift work disorder (Ferngreen, 2009). Anxiety and depression were not related to working quick returns. There is a health hazard associated with quick returns. Further research should aim to investigate if workplace strategies aimed at reducing the number of quick returns may reduce complaints among workers (Eldevic et al, 2013).
The aim of this second study was to investigate the relationship between sleep deprivation and occupational and patient care errors among staff nurses who work the nightshift. Whereas the aviation and trucking industries report that sleep deprivation increases errors, few studies have examined sleep deprivation association with occupational and patient care errors among nurses (Egenes, 2009). A cross-sectional correlational design was used to evaluate relationships between sleep deprivation and occupational and patient care errors in 289 hospital nightshift nurses. More than half (56%) of the sample reported being sleep deprived. Sleep-deprived nurses made more patient care errors. Testing for associations with occupational errors was not feasible because of the low number of occupational errors reported. Interventions to increase the quality and quantity of sleep among hospital night shift nurses are needed. Improved sleep among night shift nurses will reduce the impact of sleep deprivation on patient care errors (Jason et al, 2014).
Night work has been reported to be associated with various mental disorders and complaints. Investigated has been conducted on relationships between night work and anxiety, depression, insomnia, sleepiness and fatigue among Norwegian nurses (Winkel, 2009). The study design was cross-sectional, based on validated self-assessment questionnaires. A total of 5400 nurses were invited to participate in a health survey through the Norwegian Nurses’ Organization, whereof 2059 agreed to participate (response rate 38.1%). Nurses completed a questionnaire containing items on demographic variables (gender, age, years of experience as a nurse, marital status and children living at home), work schedule, anxiety/depression (Hospital Anxiety and Depression Scale), insomnia (Bergen Insomnia Scale), sleepiness (Epworth Sleepiness Scale) and fatigue (Fatigue Questionnaire). They were also asked to report number of night shifts in the last 12 months (NNL). First, the parameters were compared between nurses i) never working nights, ii) currently working nights, and iii) previously working nights, using binary logistic regression analyses. Subsequently, a cumulative approach was used investigating associations between NNL with the continuous scores on the same dependent variables in hierarchical multiple regression analyses. Nurses with current night work were more often categorized with insomnia (OR = 1.48, 95% CI = 1.10–1.99) and chronic fatigue (OR = 1.78, 95% CI = 1.02–3.11) than nurses with no night work experience. Previous night work experience was also associated with insomnia (OR = 1.45, 95% CI = 1.04–2.02). NNL was not associated with any parameters in the regression analyses. Nurses with current or previous night work reported more insomnia than nurses without any night work experience, and current night work was also associated with chronic fatigue. Anxiety, depression and sleepiness were not associated with night work, and no cumulative effect of night shifts during the last 12 months was found on any parameters (Oyale et al, 2013).
The effects of inadequate sleep on clinical decisions may be important for patients in critical care units, who are often more vulnerable than patients in other units. Fatigued nurses are more likely than well-rested nurses to make faulty decisions that lead to decision regret, a negative cognitive emotion that occurs when the actual outcome differs from the desired or expected outcome (Chin, 2008). Objectives of the study entail examining the association between selected sleep variables, impairment due to fatigue, and clinical-decision self-efficacy and regret among critical care nurses. Decision regret was the primary outcome variable. A non experimental, descriptive design and extant measures were used to obtain data from a random sample of full-time nurses. Binary logistic regression models were used to examine the association between sleep variables, fatigue, and clinical-decision self-efficacy and regret. The discrimination of the models was compared with the C statistic, the area under the receiver operating characteristic curve. A total of 605 nurses returned the questionnaires (17% response rate). Among these, decision regret was reported by 157 of 546 (29%). Nurses with decision regret reported more fatigue, more daytime sleepiness, less intershift recovery, and worse sleep quality than did nurses without decision regret. Being male, working a 12-hour shift, and clinical-decision satisfaction were significantly associated with decision regret (C statistic, 0.719; SE, 0.024). Nurses who experience impairments due to fatigue, loss of sleep, and inability to recover between shifts are more likely than unimpaired nurses to report decision regret (Scott & Erogen, 2014).
Quantitative Studies
Factors that reduce alertness, poor performance, and increased risk of fatigue, and other adverse events from night shift work are attributed to circadian rhythm alterations that reduce physiological functioning at night, and increased homeostatic need for sleep caused by restricted duration, and reduced quality of prior sleep (Smith, Kilby, Jorgensen & Douglas, 2007). A strategy suggested by various researches to meet the homeostatic demand for sleep during night shift, alleviating fatigue, and restoring executive functioning is napping.
Napping as Night Shift Fatigue Intervention
Napping is attributed to increased mental alertness, vigor, and decreased fatigue, and has been shown as an effective strategy to reduce night shift-induced fatigue. In the randomized, controlled cross over study conducted of a small cohort of night shift Australian nurses and scientists (three male, and six females) by Smith, Kilby, Jorgensen, and Douglas (2007)the effects of a 30-minute nap break is examined. Measurement of subjective sleepiness, and objective alertness among the participants were measured throughout the night shift on nights with and without scheduled nap breaks. Psychomotor performance measurements post nap resulted in faster reactions responses, and improved self-reported sleepiness (Striepe, 2012).
Napping is also attributed to counteracting negative consequences of acute sleep deprivation, and fatigue, as well as the restoration, and improvement of executive functioning in a repeated measures study by Tempesta, Cipollo, Desideri, Gennaro& Ferrara (2013). The study comprised of 54 interns (32 females, and 22 males) as participants from the Faculty of Medicine of the University of L’ Aquila in Italy. Thirty-two participants who already worked the night shift were assigned to a wake or nap group (WG, NG), while the remaining 22 participants, who maintained regular diurnal working hours, and were assigned to a control sleep group (SG).

References
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Eldevik, M. F., Flo, E., Moen, B. E., Pallesen, S., &Bjorvatn, B. (2013). Insomnia, Excessive Sleepiness, Excessive Fatigue, Anxiety, Depression and Shift Work Disorder in Nurses Having Less than 11 Hours in-Between Shifts. Plos ONE, 8(8), 1-9. doi:10.1371/journal.pone.0070882 .
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Johnson, A. L., Jung, L., Brown, K. C., Weaver, M. T., & Richards, K. C. (2014). Sleep Deprivation and Error in Nurses who Work the Night Shift. Journal Of Nursing Administration, 44(1), 17-22. doi:10.1097/NNA.0000000000000016.
Øyane, N. F., Pallesen, S., Moen, B. E., Åkerstedt, T., &Bjorvatn, B. (2013). Associations Between Night Work and Anxiety, Depression, Insomnia, Sleepiness and Fatigue in a Sample ofNorwegian Nurses. Plos ONE, 8(8), 1-7. doi:10.1371/journal.pone.0070228 .
Scott, L. D., Arslanian-Engoren, C., &Engoren, M. C. (2014).ASSOCIATION OF SLEEP AND FATIGUE WITH DECISION REGRET AMONG CRITICAL CARE NURSES.American Journal Of Critical Care, 23(1), 13-23. doi:10.4037/ajcc2014191
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