I've had to think up a way to survive Since you said it's over Told me good-bye I just can't make it one day without you Unless I pretend that the opposite's true Rivers flow backwards Valleys are high Mountains are level Truth is alive I'm perfectly fine And I don't miss you The sky is green And the grass is blue How much can a heart and a troubled mind take Where is that fine line before it all breaks Can one end their sorrow Just cross over it And into that realm of insanitive bliss There's snow in the tropics There's ice on the sun It's hot in the Arctic And crying is fun And I'm happy now And I'm glad we're through And the sky is green And the grass is blue And the rivers flow backwards And my tears are dry Swans hate the water And eagles can't fly But I'm alright now Now that I'm over you And the sky is green And the grass is blue And I don't love you And the grass is blue
Wednesday, 29 February 2012
Compassion is Key to Elderly Care - Download the Commission on Improving Dignity in Care for Older People Report
Monday, 27 February 2012
Sunday, 26 February 2012
Friday, 17 February 2012
© 2012, Ryan PriceRyan Price is a Registered Nurse, freelance writer, photographer, designer and philanthropist. He is a keen supporter of the Cystic Fibrosis Trust and a passionate mental health advocate. His first critically acclaimed novel, 'Wrong Rooms' is due for republication in the summer of 2012. He lives in Glamorgan with his partner.
For more information, contact firstname.lastname@example.org
Thursday, 16 February 2012
Tinkinswood was a once a village but now all that remains is the burial chamber and Tinkinswood Barn. Tinkinswood burial chamber is around 6,000 years old, making it older than Stonehenge by 1,000 years. It is the largest burial mound in the UK and Europe.
Wednesday, 15 February 2012
Few early users of social networking sites could have predicted how the phenomenon would both grow and grow up. Their incredible success has seen Facebook move from a domain dominated by gossiping teenagers to a powerful communication tool used by millions of people of all ages. Around 355,000 nurses and midwives registered in the UK are on Facebook.
By allowing people to share information and images with a few clicks of a mouse, social media platforms – which enable users to build, integrate or facilitate community – have fundamentally shifted our relationship with the internet. As well as using the web as an extensive information source, we can now upload a huge amount of personal content. Each user of social networking sites can choose to communicate an unlimited level of personal information and opinion, and build an online persona which may be closely linked to their real identity.
As the use of sites like Facebook and Twitter has expanded, many organisations have been quick to harness their potential as powerful tools for education and communications. The NMC uses social networking sites to engage with nurses and midwives, students and the public, and is active on Facebook, Twitter and LinkedIn. Its Facebook page alone has attracted over 21,000 regular users since its launch in 2008. It is used to share tools with online communities and answer queries on regulatory issues.
Alongside the benefits of these new communications channels, there are dangers when the online activities of regulated professionals blur the boundary between their personal and professional lives. Users of social networking sites may feel they can behave in ways they would not consider acceptable in ‘real life’. The ease of posting can make it tempting to disclose information, opinions and images that might previously have been shared only with people close to us. This highlights a tension inherent in the use of social networking sites. ‘Users desire social interaction and connectivity and disclosing information plays an essential role; yet users may not wish to have their information publicly accessible to an unknown audience’ (Bateman et al 2010).
Nearly 80 percent of adults would change the information they publish about themselves online if they thought the material would later be reproduced in the mainstream media (Press Complaints Commission 2008). This reveals a fundamental lack of understanding of the nature of sites that are as openly available as mainstream media unless the strictest privacy settings are enforced. In practice, observing professional boundaries remains more vital than ever when communication is so easy and on a much larger scale.
‘Establishing strict privacy settings represents a good first step to separating personal and professional personas’
Most nurses, midwives and students successfully manage their online presence, either by limiting the content they share or by restricting access to it. The NMC, however, has seen an increasing number of fitness to practise cases involving the use of social networking sites and other online activity. Although each case is unique and is judged on its own merits, the referrals can be divided into two broad camps: those using social networking sites to share content inappropriately, and those using them to pursue unsuitable friendships or relationships.
The first type of complaint might result from something as simple as a newly qualified midwife inappropriately posting an image of a baby she has delivered, or a nurse inadvertently sharing with patients inappropriate images from her social life by failing to adjust the privacy settings on her Facebook page. The second type of complaint is exemplified in the recent case of a community psychiatric nurse, Timothy Hyde. He was struck off in September 2010 for conducting an inappropriate relationship with a former patient. He had met her when she attended a screening assessment, and offered her counselling and support. He contacted her through Facebook two weeks after she was discharged; they saw each other regularly and developed a sexual relationship.
The NMC has introduced advice on the use of social networking sites to support nurses and midwives in this new terrain. Social networking sites (NMC 2011) sets out how The code: Standards of conduct, performance and ethics for nurses and midwives (NMC 2008) should be applied to social networking, and provides practical tips. The principle that conduct online and conduct in the real world should be judged in the same way, and should be of an equally high standard, is central to this advice.
The code says nurses and midwives must uphold the reputation of the professions at all times. This may mean deliberately keeping personal and professional lives as separate online as you would at work. Even those who do not identify themselves as a nurse or midwife online should remain mindful that their conduct there could jeopardise their registration as easily as their ‘real life’ actions.
Establishing strict privacy settings represents a good first step to separating personal and professional personas, but in essence everything posted online should be considered potentially public. Before posting information or images, nurses, midwives and students should always consider whether it would be appropriate to share them in real life. If they would feel concerned about posting a particular image where patients could see it, or befriending online the partner of a woman they had assisted in labour, they should be equally cautious online. Work-related conversations that would be inappropriate on a bus are just as unacceptable on a social networking site. The premise that online behaviour should be as professional and private as possible is a helpful starting point.
See the article NHS Facebook misuse should be resolved at local level by Andy Jaeger, Assistant Director of Professional and Public Communications at the NMC, Publisher of NMC Review and author of Caught in the Web.
- Bateman, P J, Pike, J C and Butler, B S (2010). To disclose or not: publicness in social networking sites. Information Technology & People, 24(1), pp 78-100.
- Press Complaints Commission (March 2008). Public Concern about Social Networking MORI poll.
- Nursing and Midwifery Council (2011). Social networking sites
- Nursing and Midwifery Council (2008). The code: Standards of conduct, performance and ethics for nurses and midwives.
Tuesday, 14 February 2012
Monday, 13 February 2012
Personal Perspective: The Real, 'Dirty' Truth About Nursing (by Ryan Price, RN. Originally published December 2002. Republished and revised © February 2012)My partner is hospital at the moment. People - family, colleagues and other nurses - assume that because I'm a Nurse, I can deal with how sick he is, and maybe that I don't need the support a 'regular' relative needs. This isn't true, and when his Nurses catch-on to my profession, they exclaim to me "Oh, you're a Nurse!" my usual flippant reply is "maybe, but I'm firstly his partner!" It made me think hard about how we are seen as Nurses. Often, even the healthcare profession forget to see the human element behind the facade of uniform. It's downright terrifying for anyone to be faced with their own mortality, and maybe moreso when faced with the daunting prospect of what may lie ahead for their most precious, dearest loved one. So, while spending countless hours at his bedside, I allowed myself a few distractions after he finally settled and slept through the most awful fever. On this occasion, Facebook was my distraction. And then I saw it. Again...
Most people seem pretty hung up on faeces. I don’t know why; on a scale of one to repulsive, most of the poo earns a mediocre score, at best. Maybe this is because it’s so ubiquitous - most people are going to poo while they’re sick, and if they don’t, we might give them medicine to help things along. If this fails, some lucky glove-clad nurse will win the opportunity to join the digital age. Many nurses are fixated with bowels. Anyway, unless a poo is exceptionally vile - or 'offensive', as we call it in the trade, it’s unlikely to phase most nurses (on a side-note, I always giggle inside when I see 'offensive diarrhoea' written in notes or reported on, as I get this mental image of a watery, but really angry turd jumping out and yelling "get-you-bitch-mother" at any unsuspecting nurse! Aaaanyway...). So, when people lead off with the “Soooo…is it hard cleaning up all that poo?” question, I just smile and say, “not really, you get used to it.”
Casualty/Holby City/Gray's Anatomy,
The emotional impact
This is divided into two camps: people who assume that nurses must spend their entire lives perpetually drowning in sorrow as a result of what they see at work, and people who assume that nurses are completely emotionally numb and, as a result, uncaring. The truth is probably somewhere in the middle. We do see a great deal of catastrophic changes in people’s lives. We do have to maintain a certain level of detachment, both in order to do the job, and in order to retain our own sanity. We genuinely do care, though. You know that adage that says “if you didn’t laugh, you’d cry”? Sometimes we laugh at inappropriate things, sometimes we look stoic when you can’t imagine how anyone couldn’t be moved to tears, and sometimes we cry, but mostly we try to keep the focus centered on the care of our patients and their families. Our grief at seeing a patient’s prognosis turn poor can’t begin to compare to the grief of that patient or that patient’s loved ones, so we pigeon-hole or compartmentalise our feelings, and carry on doing the things that need to be done to care for the patient. Actually, the ability to compartmentalise emotions is probably the most important skill a nurse can learn. If I have to deal with something that’s frightening or upsetting or disgusting or otherwise troubling, it’s important to be able to acknowledge my reaction to it, but put it on the back burner until the patient is cared for. I’m not trying to paint a picture of saint-like selflessness - I do this to protect myself, my personal relationships as well as to protect my patient. It’s just the reality of the job. And yes, I’ve locked myself in the bathroom to cry, out of stress or frustration or just sheer sadness, on more than one or two (or two hundred) occasions over the years. I’d be worried about any nurse who didn’t.
The sex thing
No, not that sex thing (and now I suspect that you’ve been watching too much Gray’s Anatomy or Holby, but I’ll give you a few moments to stop thinking about Dr. Valentine, Dr. McDreamy or whoever). I actually meant the idea that nursing is a woman’s field. Some of the best nurses I've met with or worked with are men - and funnily enough, so am I. To my initial disappointment many years ago, they’re not all gay, girlie or somehow compromised by their professions, nor are they “just working as a nurse while they put themselves through medical school” (thank you, Friends episode in which Phoebe has triplets, for that stunning misrepresentation of the nursing career path). I won’t say much more about this, because I’m a man and cannot compare myself to the majority of my female colleagues, but I will say this - it’s bloody hard as hell to be a nurse sometimes, and both the women and the men have to be tough and smart. There are also some exceptionally bad male nurses - and terrible female nurses, but generally, most nurses are essentially decent and diligent, and work damn hard. They manage to care, often under negative conditions such as stress, understaffing, under-funding, under-supported and under-appreciated. Yet, they - we - carry on and do the best we can.
Just a nurse?
How annoying is that? As long as we’re sort of hovering around the subject, nurses aren’t the doctors who didn’t get into medical school. Nursing is a completely different specialist practice. If someone actually is working as a nurse just to get through medical school, then they might be on the wrong path. It doesn't work. Nurses go to university for, at minimum, three years (not counting the pre-nurse exams/training/getting grades up to scratch and all the other prerequisites) to become qualified to take the finals and then obtain the coveted UK Registration PIN with the Nursing and Midwifery Council (NMC). Nursing courses in the UK are pretty tough to even get admitted to, and even tougher to stay on and tougher still to complete, and then you still have to pass exams, assessments, monitoring and maybe even convince the licensing people at the NMC that your prior criminal record was just youthful high-spirits (seriously, if you have anything worse than a speeding ticket on your record, you’d better be prepared to explain yourself, in detail). Then afterwards, we get the sublime joy of having people assume that we’re essentially McDonalds employees or cleaners or doctors-maids in scrubs.
At the other end of the spectrum exists the people who assume we’re all incredibly full of ourselves. I have only this to say: if you’ve been a nurse for longer than five minutes, and you haven’t found anything to be humbled by, then you are in the wrong field.
In essence, nursing is a great big balancing act. It’s an art and a science, and those practicing it must balance confidence with humility, emotion with detachment, fear with nerve, and knowledge with intuition. It’s frightening and lonely sometimes, but that’s why we keep our friends around, and hope like hell that we’re working with a team that has our backs. I have had both excellent friends and amazing colleagues over the years. You know who you are, and I appreciate you, more than you’ll ever know.
© 2012, Ryan PriceRyan Price is a Registered Nurse, freelance writer, photographer, designer and philanthropist. He is a keen supporter of the Cystic Fibrosis Trust and a passionate mental health advocate. His first critically acclaimed novel, 'Wrong Rooms' is due for republication in the summer of 2012. He lives in Penarth, South Glamorgan with his partner.
For more information, contact email@example.com
Saturday, 11 February 2012
Saturday, 4 February 2012
The Night Shift
Few nurses seem to really love working the night shift. Sure, we all know nurses who thrive on the night shift or who choose it for personal reasons. Some prefer to work when the ambience is quieter, there are no visitors, rules are less strictly enforced, and interruptions are fewer. Some work nights for family reasons -- perhaps they have young children at home and working the night shift allows them to share caretaking responsibilities with husbands/partners who work conventional daytime hours. For some, the night-shift differential is incentive enough to choose nights. However, many nurses work nights not out of choice but because they are required to do so. Usually, these nurses are farther down on the seniority list, and most will gravitate to the day shift as soon as they get the chance.
Of course, nurses are not the only night workers. It is estimated that 15%-20% of workers in industrialized countries work nontraditional hours. Intolerance to working nights even has its own label -- shift work disorder. People who have this often undiagnosed and undertreated problem have trouble getting to sleep and waking up and often experience excessive sleepiness during their shifts. Chronic fatigue in these individuals can impair productivity, safety, health, and quality of life.
A Hazard to Your Health?
The health of the night-working population has not been ignored in epidemiologic research. Numerous studies have investigated the possible health consequences of working the night shift. Judging by the number of studies alone, it seems that these health consequences are significant and could represent a huge public health problem in our increasingly 24-hour society. Some of the health problems found to be associated with working nights include the following:
- Increased risk for breast cancer[2,3] and colorectal cancer;
- Increase in inflammatory markers (IL-6, C-reactive protein, white blood cells, neutrophils, lymphocytes, and platelets);
- Irregular menstrual cyclesand reduced fertility;
- Increased risk for ischemic stroke;
- Increased wrist and hip fractures;
- Pronounced insulin response to eating;
- Increased development of the metabolic syndrome;
- Increase in type 2 diabetes;
- Increased blood pressure;
- Increased cardiovascular disease; and
- Increased risk for mental health disorders, including anxiety and depression.
It's a miracle that anyone is willing to work nights. The night shift does pay a little more, but can you put a price on your health?
Of course, observational studies that have linked serious health effects with working nights do not establish causation. Furthermore, a publication bias prevalent in the health literature can mean that studies with positive findings make it into print, whereas those finding no association may not. Yet, many of the negative health outcomes associated with working nights are considered biologically plausible. This plausibility, combined with evidence for one of the most serious shiftwork-related health effects -- cancer -- although limited in humans, prompted the International Agency for Research on Cancer to declare that "shiftwork that involves circadian disruption isprobably carcinogenic in humans."
A phrase that jumps out here is "circadian disruption," because this is the putative link, and possibly the critical exposure variable, in the chain of causation. What constitutes circadian disruption, and is it an inevitable consequence of working nights?
Circadian disruption -- also known as chronodisruption -- is a disturbance of the circadian organization of human physiology, endocrinology, metabolism, and behavior. A master biological clock, located in the suprachiasmatic nuclei of the hypothalamus, controls circadian rhythms generated by feedback loops that involve multiple "clock genes." Core body temperature, blood pressure, sleepiness/wakefulness, mental performance, alertness, and secretion of hormones (such as melatonin, cortisol, prolactin, and growth hormone) are all linked to circadian rhythms.
The major synchronizers of circadian rhythms are exposure to environmental patterns of light and dark. These patterns control biological cycles that repeat roughly every 24 hours (the solar day), and we are entrained to these rhythms. They allow us to have regular oscillations between sleep and wakefulness, and fasting and eating, that are critical to health. When our rest-activity cycles match the light-dark cycles of the environment, we are said to be "in phase." If a person is exposed to inadequate or irregular amounts of light at certain times of the day, circadian rhythm can be disrupted, causing asynchrony between the circadian system and the solar day. This is believed to be the root of long-term negative health outcomes, such as cancer.
If you doubt that working the night shift seriously disrupts circadian organization, consider this: Working a typical night shift schedule creates biological clock stress that is analogous to the jet lag of flying back and forth between Tokyo and San Francisco every few days. It is no coincidence that airline personnel who criss-cross time zones have health consequences similar to those of night-shift workers.
The basis for night shift chronodisruption is exposure to light at night, when humans are supposed to be sleeping. The pineal gland-secreted hormone melatonin is the "messenger of time" that transmits information about environmental light and darkness, obtained from ganglion cells in the retina, through the hypothalamus to all tissues of the body.Melatonin is synthesized and secreted at night, acting as a signal for the length of day and night. Melatonin is also a well-known oncostatic hormone that inhibits tumor growth. Light suppresses melatonin secretion in a dose- (or intensity-) dependent manner. Night sleep normally occurs during the rising phase of melatonin secretion. If a person tries to sleep during the declining phase of melatonin secretion, sleep can be shorter with more awakenings.
A Good Day's Sleep
The other significant health risk comes from the nature of sleep itself when one works at night and sleeps during the day. Fatigue in night-shift workers is the result of a classic one-two punch: shorter duration and poorer quality of sleep. Daytime sleep is more fragmented and less restorative than nighttime sleep. Night workers are not only deprived of more restful sleep, their sleep deprivation is compounded by sleep loss that builds over successive shifts because their sleep times are shorter, often by 1-4 hours, compared with night sleepers. This results in a cumulative "sleep debt" and feelings of chronic fatigue that can't easily be erased with "catch-up" sleep.
More than half of night-shift nurses (56%) in a study using sleep diaries were found to be sleep-deprived. Night nurses more often report low-quality sleep and are more likely to use medication to get to sleep. Those who work long stretches or more than 4 shifts per week are more likely to report sleep disturbances.
To make matters worse, many night-shift workers are already sleep-deprived on their first shift. This is a consequence of the tendency to switch back to a "normal" (day) schedule on their days off, so that many nurses rise early on their first work day, go to work that night, and end up staying awake for up to 24 hours or longer.
Sleep expert Ann Rogers differentiates between "fatigue" and "sleepiness." Sleepiness is a tendency to fall asleep, whereas fatigue is an overwhelming sense of tiredness, lack of energy, and exhaustion. Both affect night workers. Night-shift nurses report struggling to stay awake during their shifts, and studies show that nurses do, indeed, regularly fall asleep for brief periods during the night shift or in the car on the way home in the morning.[27,28] Fatigue, on the other hand, is associated with impaired physical and cognitive functioning and contributes to the increased tendency for errors.
Sleep, Fatigue, and Safety
It bears reminding that many of the worst industrial accidents in history have taken place on the night shift. Over the years, nurse researchers have put their own profession under the microscope and studied the effects of fatigue on performance in nurses. The results have been equivocal, but most point to reduced performance and increased risk for errors and accidents, influencing both patient and personal safety, on the night shift.[23,29-31]
Following are some of the effects of fatigue:
- Slowed reaction time;
- Attention lapses;
- Less attention to detail;
- Compromised problem-solving;
- Impaired psychomotor skills;
- Reduced coordination; and
- More errors of omission.
Fatigue isn't the only subjective symptom experienced by nurses working the night shift. Irritability, forgetfulness, stress, chills, nausea, and eye strain are other common complaints of night-shift nurses that could affect performance or physical and mental well-being. A survey of critical care nurses found that 26% had experienced personal work injuries or near injuries, 16% had been involved in patient safety incidents, and 20% had accidents or near accidents on the drive home -- all believed to be related to fatigue.
Research confirms that the ability to perform tasks declines throughout the night shift, especially during the second half of the shift. The worst performance coincides with the time when body temperature is lowest, at 0400-0600, a finding supported by lower levels of perceived alertness during these hours. Medication errors that occur on the night shift vs the day shift are more often reported to be a consequence of sleepiness.
Even partial sleep deprivation is associated with an increased likelihood of making an error and a decreased likelihood of catching someone else's error. Rotating shifts, especially more rapidly rotating schedules, are associated with increased error rates in nurses. Moreover, the risk for making an error or being involved in an incident increases with of the number of successive night shifts. The risk for an incident at work is 6% higher on the second night shift, 17% higher on the third, and 36% higher on the fourth.
Whether these findings are due to increasing sleep deficits on the part of night shift nurses or other factors associated with working nights is not known. Increased errors on the night shift could reasonably result from several factors, such as staff shortages, increased patient-to-nurse ratios, and reduced support and resources during off hours. Admi and colleagues did not find a difference in performance or rates of error between day and night shift nurses, including nurses who were less well-adapted to working nights.
Personal safety is a significant concern for nurses who are fatigued and/or sleepy. Working the night shift has been associated with an increased risk for percutaneous needle punctures, lacerations, and consequent exposure to blood-borne pathogens. Extreme drowsiness while driving or cycling home, including near-miss accidents, has been reported by nurses who work nights.[28, 38] The effects of sleep deprivation on mental alertness are similar in magnitude to those seen in people with blood alcohol concentrations over the legal limit.
Substantial interindividual differences in the level of cognitive and performance impairment induced by fatigue are known to exist, making it difficult to predict how much sleep an individual requires to make him or her "safe." Nor is there any consensus on the extent of impairment resulting from a given amount of sleep loss.
Chronotype: Which Bird Are You?
People often describe themselves as being either a "morning person" or a "night person." Some people feel better and are more alert and energetic at different times of the day, a characteristic known as "chronotype." Putting an avian twist on chronotype, people are often characterized as "larks" or "owls."
If you prefer to rise early, feel most alert and perform best in the morning, and go to bed early, you are an early chronotype, or lark. If you prefer to sleep late, work best later in the day, and stay up well past midnight, you are a late chronotype, or owl. Those who are somewhere in between (which is most of the population) are hummingbirds. Experts say about 1 in 10 people are larks, 2 in 10 are owls, and the rest are hummingbirds.
Of course, these labels are slightly misleading. Even "owls" don't stay up all night like some species of owls. It is simply not natural for humans to do so, and human "owls" have difficulty resetting their internal clocks if compelled to stay awake all night.
Adaption to the Night Shift
Recently, a research team at Vanderbilt University examined how chronotype, along with an individual's sleep strategies, might influence how well a nurse adapts to the night shift. Gamble and colleagues hypothesized further that genetics, and in particular the body's "clock" genes, might play a role in how well a nurse adapts to working nights.
They recruited a convenience sample of 388 nurses who worked 12-hour shifts (days or nights) at a university hospital. Most (331) were women, and their average age was 36.5 years (range, 22-76 years). Participants completed self-reported surveys on sleep-wake patterns and had blood drawn for genetic analyses. "Adaptation" was a composite of variables, such as how the nurses felt, fatigue levels, regularity of sleep patterns, how long it took them to get out of bed, how much caffeine they ingested, and how likely they were to fall asleep during the day.
The researchers found that night-shift nurses reported significantly poorer adaptation to their work schedules than day-shift nurses. The former group had significantly later chronotypes than the latter. Examining the relationship between chronotype and adaptation to shift work, they found that earlier chronotypes had higher adaptation scores for the day shift and lower scores for the night shift. Later chronotypes had intermediate adaptation scores for both day and night shifts.
Although previous research has found that night-shift nurses get fewer hours of sleep than day-shift nurses, sleep duration in this study did not differ between day- and night-shift nurses. However, that night shift nurses had poorer adaption to their work schedules suggests that adaption is affected not only by how much sleep a nurse gets but when he or she sleeps relative to working. This, in turn, is influenced by an individual's sleeping patterns -- the strategies an individual uses for switching back to a normal sleep schedule on days off from work and for reverting back to nights.
In the genetic analyses of the nurses, some changes in the "clock" genes were associated with alcohol and caffeine consumption and sleepiness, as well as sleep characteristics. Many of these results were specific to the type of shift, suggesting an interaction between the genes and the environment (in this case, the "environment" was shift work).
This study was unique in identifying and describing both the working and off-working sleep strategies of night shift nurses. A few nurses remain on "nights" even on their nights off -- staying up all night and sleeping during the day, a strategy favored by older and more experienced nurses. Far more common, however, was trying to switch to a "normal" sleeping schedule (eg, sleeping at night) on one's off days, a strategy followed by half of the study participants. These nurses generally tried to sleep in as late as possible on the day of their first night shift to ease the transition to nights. In contrast, a quarter of nurses deprived themselves of sleep by rising at an early hour on the day of their first night shift and forcing themselves to stay awake for 24 hours. It is perhaps no surprise that these nurses were the most poorly adapted to working nights and were more likely to report dozing off at work during sedentary activities.
How to Survive the Night Shift
The extent to which human circadian rhythms can adapt to a night shift is not known. Nor is it known whether such adaptation would negate the health consequences of working the night shift. However, the findings of such studies as that conducted by the Vanderbilt team suggest that on some level, at least some nurses can adapt to working nights.
A member of the Vanderbilt research team, Carl Hirschie Johnson, spoke with Medscape about the practical implications of the study. "With respect to adaptation, the best strategy is staying awake at night, and sleeping during the day, even on your days off, if your family obligations allow you to do that. To entrain yourself, you have to simulate a reverse day. Sleep in a very quiet, very dark room (or use a blindfold). At work, seek out brightly lit areas. You need bright light exposure, but most indoor lighting is insufficient. Don't nap during your shift. If you can't stay on this schedule (and fewer than 5% of nurses in the study did), the next best strategy is that of sleeping late before your first night shift, rather than going without sleep."
- If you work 8-hour rotating shifts, rotate clockwise (days, then evenings, then nights);
- Avoid rapid rotation (eg, working different shifts in the same week);
- Follow a regular sleep schedule regardless of which shift you are working;
- Use room-darkening or blackout shades in your bedroom;
- Spend as much time as possible in brightly lit rooms;
- Wear sunglasses to block blue light when driving home in the morning;
- Don't schedule appointments or activities during your routine sleeping hours;
- After your last night shift, sleep for 4 hours;
- Avoid eating large meals within 4 hours before sleeping;
- Avoid caffeine and nicotine before sleeping; and
- Seek exposure to bright light after waking.
Many other measures have been assessed for their value in helping workers adapt to shift work, including supplemental melatonin, chemical sleep aids, use of stimulants, and physical exercise.With the exception of physical exercise, all of these measures have potential drawbacks. However, a regular exercise program can benefit night-shift workers not only by helping them tolerate the night shift but also in reducing the somatic symptoms associated with poor sleep and working nights.
My Kingdom for a Nap
Naps are often recommended, and frequently practiced, as an effective strategy for staving off sleepiness on the night shift. On the surface, napping makes sense. Many people nap, if they are lucky to have this rare privilege, to counter sleepiness at other times of the day. The National Sleep Foundation recommends "short naps breaks throughout the shift" for night workers, maintaining that napping can be essential for some shift workers. Short, restorative naps at night are widely believed to help reduce sleepiness and fatigue and increase alertness. In a small study, 10 of 13 critical care nurses who napped regularly during breaks reported improved energy levels, mood, vigilance, and decision-making abilities.
In a larger, Internet-based survey, to which 536 critical care nurses in Canada responded, nurses were asked about their typical napping practices during the night shift napping practices. In this sample, 66% reported napping during their breaks, and 30% of those nurses believed that their care was safer after a nap. Most (80%) believed that napping was beneficial. Even though the primary reason for a nap might be sleepiness, nurses who are struggling to stay awake may also fear that without a brief nap they are unsafe to deliver patient care.
More objective research, in both the laboratory and work settings, has yielded moderate support for the benefits of night shift-napping in terms of performance and self-reported measures of fatigue and sleepiness,[45-49] even when the nap is short and the sleep is of poor quality. These findings have been fairly consistent despite varying nap durations. Sleeping on the job during the night shift may also partially compensate for the shorter daytime sleep at home among night workers.
Why Not Nap?
Many of the studies conducted to date identified a potential disadvantage of napping -- a phenomenon known as "sleep inertia." Sleep inertia is a period of disorientation and performance decrement that can occur immediately upon waking from a nap. If you have ever taken a nap in the middle of a night shift, you are familiar with this unpleasant, groggy feeling. Although sleep inertia is transient, some research suggests that the problem correlates with the length of the nap and recommends short naps, of 15-20 minutes. A meta-analysis of studies of napping as a countermeasure for fatigue concluded that sleep inertia, if present, was not a significant concern because it was counteracted by the beneficial effects of the nap.
Despite widespread desire for the option of napping on the part of night-shift nurses, a few considerations argue against this practice. Carl Johnson explains why napping during the shift might be a bad idea for some workers. "In contrast to the usual situation of taking a mid-day nap when you are on a more typical daily schedule, taking a nap when your body is telling you it is "sleeptime" is likely to not only prolong the nap into a full-blown sleep episode (which will lessen alertness on the job after the "nap" is over) but also to make the phase-shift to a night-active phase even slower." In other words, if you are trying to truly adapt to night work and day sleeping, taking a nap at night is counterproductive.
I'm Not Sleeping on the Job, I'm Napping on My Break!
The benefits of napping have not led to universal adoption of this practice during the night shift by nurses or encouragement of this practice by employers. Barriers to napping include lack of designated nap facilities, patient care demands, understaffing, interruptions, and perceived lack of management support. Nurses are made to feel guilty for napping at night, and in some hospitals they are disciplined for doing so, even when the nap is taken during scheduled breaks.
This guilt is not entirely unfounded. Most employers do not currently allow napping in the workplace, but this could soon change. The National Sleep Foundation maintains that napping can reduce fatigue-related accidents and workers' compensation costs, making a ban on napping a legal liability. Efforts to make workplace policies nap-friendly will be increasingly important.
According to nurses, in addition to administrative support for napping, the following provisions would improve their ability to take a restful nap during the night shift[32,54]:
- A quiet, safe, clean "nap room" that is close to the unit and has a private area for each user (eg, not a multiuse room or staff lounge used for other purposes);
- Comfortable napping surfaces, such as beds, sofas, stretchers, or reclining chairs;
- Blankets and pillows, or storage areas for staff to bring their own items;
- Low lighting levels, preferably with dimmer switches;
- Timers with audible alarms to awaken nappers at the end of the nap (20 minutes is ideal); and
- Relief from patient responsibilities during nap breaks.
Still, whether napping should be a stop-gap measure to combat unanticipated sleepiness or part of a planned sleep-wake strategy to promote sleep health in regular night-shift nurses is not currently known. Nor is there much known about the effects of napping at night on subsequent sleep quality, or whether napping regimens can counteract the negative physiologic sequelae of working nights in the first place.
A Professional Imperative: 24-Hour Care
Nursing is, and always will be, a 24-hour business. We must find the healthiest and safest ways for nurses to work at night, or we might as well close the hospital doors.
The idea that some people might be genetically better suited to working nights is intriguing and supported by evidence suggesting that nurses who choose to work the night shift find it less disruptive. Perhaps future research will better identify why certain individuals adapt more easily to nights and clarify the best methods for individual adaptation to shift work. Whether better adaption will overcome the negative health outcomes associated with working nights remains to be seen.
The Danish government recently awarded compensation to a number of women who developed breast cancer after years of working nights, a signal that the public health problems associated with working nights are being taken seriously. In addition, the problem of fatigue in healthcare workers is receiving attention from many quarters, including the Joint Commission, which recently issued a sentinel event alert on this topic. Although the focus of the alert is on fatigue caused by extended work hours, the recommendations offered have equal applicability to fatigue caused by night-shift-related sleep deprivation.
In the meantime, love it or hate it, if you have a tip for surviving the night shift, please share it in the comments below. I will compile your tips and publish a follow-up article here on www.uselessdesires.co.uk