Image: David Quitoriano, Flickr (CC BY 2.0)
I’m wearing scrubs, but it doesn’t help. I still have to pass the pharmacist’s quiz. Why do I want Restavit? Have I taken it before? Am I aware it will make me drowsy during the day? Would I ensure not to take it more than eight days in a row? I answer the negatives and affirmatives in the right places, hand over my driver’s licence details, pay, and toss the precious white box into my bag. I use this antihistamine to drug myself to sleep. After downing bitter black coffee to remain awake long after I’m meant to be asleep, I must also put to bed some of the shocking things I’ve witnessed and haven’t the time or inclination to process. I need to rest.
Approximately 1.4 million or 16 per cent of the Australian workforce work throughout the night. Nurses form the majority of Australian health workers, of whom 46 per cent work rotating night shifts, including me. We work nights because we have to, we want to, or feel we should. Upon becoming a nurse, I felt I personified that ‘should’, with the essential nursing ethos of altruism at its core—the very selflessness that encourages nurses to destroy their circadian rhythms for the benefit of strangers. After all, nurses are taught that we can’t create a healing environment without securing the patient-clinician care relationship with altruism, the value or practice of caring for others.
Fremantle-based endoscopy nurse Jodie Esmond embodies altruism in her motivations for becoming a nurse. ‘I wanted a job where I felt like I was making a difference. I love nothing more than seeing how our interventions can improve a patient’s quality of life and hopefully send them home, happy and healthy, to their family and friends,’ she says. Fellow West Australian Kristie Woods has four years’ experience as a surgical nurse and affirms her motivations: ‘I wanted to be in a career that helps people.’ Although the meaning and importance of altruism have evolved in the face of modern individualism, the fundamentals of care, sympathy and responsibility remain. In our day-to-day translation of nursing care plans, these values are embodied in our presence, empathic listening, advocacy and technical skills, while walking almost six kilometres a shift.
Night shift nursing, however, pushes me to the limits of my benevolence. The German philosopher Immanuel Kant stated, ‘You only know me as you see me, not as I actually am.’ It’s never truer than when working nights. Some adapt beautifully and do their best work after dark, but not me—I’m transformed from a competent, capable and efficient nurse into an irritable, dopey and inept imposter. I don’t like this version of myself, yet despite repeated night shift cycles I’ve never improved upon her.
Some adapt beautifully and do their best work after dark, but not me—I’m transformed from a competent, capable and efficient nurse into an irritable, dopey and inept imposter.
I’m not the only one. Anna Miller was an intensive care and renal transplant nurse with 13 years’ experience in the United Kingdom and Australia who left ward nursing due to night shifts. Now working in procurement at a Melbourne hospital where she enjoys ‘normal office hours’, she relates feeling ‘exhausted, running on empty and like a zombie on nights. Sometimes it was okay and other times I detested it. I was so jealous of other people sleeping and wanted to be in my bed!’ She continues, ‘If it was a slow night you felt even more exhausted and fatigued, as at some workplaces there wasn’t a dedicated place to nap. We only had the tearoom where people were talking and eating with the television on. Research shows that naps improve mental reflexes, and I felt the difference when I could nap when working in Scotland. I was able to cope better with night shifts.’
Night shifts present a powerful challenge to our body’s circadian rhythm, which alerts us to when to waken and when to sleep in synchronicity with a 24-hour solar day. Our rhythm relies on entrainment, in which our bodies seek external cues including sunshine, eating and darkness to set its internal clock (the central circadian pacemaker, located in the brain’s hypothalamus). When presented with an abnormal sleep-wake cycle, night-time light exposure suppresses melatonin, the ‘darkness hormone’ whose secretion is controlled by the biological clock, itself regulated by light exposure. Melatonin, alongside other synchronising agents, plays a central role in reinforcing our circadian rhythm by mediating signals of darkness and promoting our drive to sleep.
When our body’s daily rhythm is disturbed, the cascade of side effects is profound. Significantly, night shift workers report difficulties in falling and staying asleep, and don’t get enough restorative sleep, with six hours minimum required for adequate brain function. One 2019 systematic review showed that 92 per cent of nurses are able to sleep only four hours a night and are so fatigued during night shifts that 65 per cent find it hard to stay awake and 20 per cent fall asleep at work. Moreover, fatigue diminishes judgement, attention, concentration, vigilance and reaction times, which decrease proportionally to the number of working hours. Even modest levels of protracted wakefulness can impair driving performance to the same or greater degree as unacceptable driving blood alcohol levels, and health care workers are implicated in a significant number of post-work motor vehicle accidents. Esmond describes her 40-minute early-morning drive home as ‘very scary.’
Fatigue provokes medication errors and nurses working nights are twice as likely to make errors compared to days. Esmond explains that during night duty, ‘there are less staff to deal with complications, wandering patients, falls risk and unsettled patients, whereas day shift is busy but you have lots of people around to assist when you need it. Nights have a much higher nurse to patient ratio as well, which can be really difficult when you have a high-needs patient or an emergency.’ Woods explains that during nights it’s not uncommon for her ‘to have eight patients, and if a couple are really sick that can make it hard.’
Fatigue diminishes judgement, attention, concentration, vigilance and reaction times, which decrease proportionally to the number of working hours.
In June 2019, the International Agency for Research on Cancer classified night-shift work as a probable carcinogen to humans. This decision was based on substantial correlations with cancers in the breast, prostate, colorectal, liver and lung systems, the first three of which are influenced by sex hormones whose production is augmented and mistimed in night-shift workers. Insufficient sleep is correlated with heart disease, gastrointestinal health problems and stomach ulcers, and increases the risk of obesity and diabetes. It changes appetite-regulating hormones such as cortisol, leptin and thyrotropin, which may contribute to the frequently erratic eating habits and higher obesity rates of night shift workers. According to Miller, her ‘eating and other patterns were all over the place’ when working nights, and when Woods is also more likely to make bad food choices. Sleep debt also suppresses the immune system. Night shift workers, as Miller reports, ‘are more susceptible to infections, which I agree with, as I had a lot of chest infections and colds.’ More sick calls are made by night shift nurses compared to day shift nurses.
Qualitative phenomenological studies of nurses reveal the negative impacts of night shift on their personal life. Nurses become obsessed about sleeping and experience difficulties obtaining restorative sleep. Despite this, they willingly sacrifice sleep to family, children or other responsibilities including education or religious practice, while often losing friends unsympathetic to the difficulties that night shifts present. Night duty on a geriatric orthopaedic ward completely changed Esmond’s family life. ‘I found that when I did nights, I was existing day-to-day,’ she recalls. ‘No social life, no cleaning, no cooking, just rest and work. My family got used to the fact that, when I was on nights, I was not present. Sleep, work, repeat!’
Nurses like Miller report feeling socially isolated; ‘you feel that you are missing out on things on the weekend and in the evenings. I wanted to be a “normal person”.’ Woods, too, describes a diminution in socialising; ‘[night shifts] wipe me out. I feel I’m not as connected to loved ones.’ The strain in maintaining a relationship or family and household, and the stress inherent in the job—the pervasive concern about patients or particular workplace events—make it hard to relax, which further diminishes sleep amount and quality. Nurses are left with a persistent sense of disappointment that their personal ideals of who they want to be are unachievable.
Sleep debt augments depression, irritability and stress. Miller say she was ‘grumpy, moody and had a really short temper with the kids when I had to work nights. It always took me a few days to recover’, which mirrors my own experience. Little wonder, then, that sleep-deprived nurses live shorter lives than those who manage eight or more hours’ sleep a night. Of the decades of data gleaned from studying prolonged sleep deprivation in healthy adults, none have demonstrated any benefits.
*
At the end of my inaugural two-week night shift cycle, I told myself: never again. Once I’d slept what felt like two solid days to restore cognitive function and reattach limbs to my core, the sensation of numbness enveloping me evaporated. I relived the fortnight with a sense of dumbfoundedness. How had I been permitted to work around profoundly unwell people with my incapacitated brain? How had I been entrusted to make decisions on their behalf and provide the necessary care to stabilise or improve their health? I wouldn’t want someone intoxicated to take care of my loved ones, and yet I find myself caring for patients feeling as if I’ve drunk half a bottle of wine. Healthcare interactions are essentially ethical dilemmas, and I have become one. How can I continue to care for some of society’s most vulnerable citizens when I might endanger them?
But if not me, then who? Somebody must nurse patients overnight, and there aren’t enough nurses who prefer full-time night duty. I chose to become a nurse. I chose to alleviate suffering, which doesn’t conveniently end at 2130 and recommence at 0700. And so, every eight weeks, I wash my wardrobe of scrubs and ensure I have my supply of arabica coffee and little white pills. My husband will protect my sleep by taking our children out all day, and I’ll reward him by being a grouch. What does abusing my body and destabilising my family matter when lives must be saved?
I chose to become a nurse. I chose to alleviate suffering… What does abusing my body and destabilising my family matter when lives must be saved?
Research data confirms: the longer the shift, the worse nursing care and safety become, and that naps, caffeine and light exposure are the key error-minimising strategies. Ideally, night shift nurses would like to nap during their breaks in a comfortable dedicated area, be offered shifts of different durations and healthy food options, receive rosters well in advance to better arrange their personal lives, senior staff to ask how they are coping and functioning, have onsite counselling, gym and childcare access as well as the ability to job share and swap shifts. Shift patterns can greatly impact how nurses cope with and recover from night shifts. When rostered to finish night shifts on Sunday mornings, Miller would only sleep until 1330 to re-synchronise her body to start work Mondays at 0700. ‘My high dependency unit patients would ask me if I was okay, as I looked terrible!’ she laughs. The worst was when she continuously worked a day and a night shift every week: ‘It killed me! I felt rotten all the time.’
Despite all the difficulties, night duty offers some benefits. I can be present for my family at breakfasts, dinners and bedtimes. I can hazily host play dates, help with homework, and attend appointments or school events in the afternoons. Woods states that some nurses prefer nights because they can sleep during the day when their children are at school, and in attracting a 35 per cent penalty rate, night nurses can earn the same money as day nurses while working fewer hours. When all patients sleep without misadventure, I continue my professional education packages and update care plans. Esmond says she ‘loved nights when the pace was slower, relaxed and calmer’ and could more readily offer comprehensive care. She thoroughly read patients’ histories to identify issues, check results and create plans. She comforted patients and actively listened to hear ‘all the little things that they want to tell nurses during the day but don’t want to bother them as they are too busy.’ Night-time hallways are cleared of relatives, health teams and ancillary staff; lights are extinguished, creating an almost aphotic environment.
Miller reminds me that intensive care retains the same intensity day and night, but even so, social connection makes night shifts more bearable. When we can, we sit at the main desk, an eye on the monitors, enjoying precious moments of camaraderie. In our cocoon, we have the time to learn about each other, share experiences, and teach each other clinical skills. We talk to distance ourselves from the harrowing immediacy of our patients’ stories, and to remind ourselves that while we pour our love into strangers, outside the hospital walls there are those who love us. We laugh—gosh, we laugh—often about our mistakes, the more bizarre of our patients, but mostly at ourselves. We laugh long and loud because if we didn’t, at times we might cry.
But for all our night-time camaraderie, sleep deprivation suppresses our ability to demonstrate empathy. One morning, I held the hand of a patient for two hours, responding incoherently and perhaps micro-sleeping as he spoke. Fatigue denied his words access to my heart. I’m the nurse who whispers, ‘I’m sorry, please can I take your vital signs?’ into the 0400 gloom, but I don’t really feel sorry because I no longer feel anything.
*
I force myself to push through, caffeine draining from my dehydrated cells, my eyes scratchy from the air conditioning and hand shakily adding addendums to patient notes with fingers stinging from constant hand hygiene. I’ll continue titrating pills, coffee doses and sleep times, swap shifts and delegate tasks to improve my alertness and competence, now more than ever. The COVID-19 pandemic entered our hospital in early March, a clarion call to health professionals to address our emotional and physical wellbeing because our workload has been additionally burdened. While Miller continues to source gloves, gowns, masks and contingency products such as reusable isolation gowns in the face of global shortages of raw materials, the units in which Esmond and Woods work initially scaled down their activities, deferring elective procedures—the lists have increased by thousands more—and ward staff were transferred into the new COVID-19 clinics. ‘March was a very scary time,’ Woods says. ‘Nurses were upskilled. We were asked to work extra shifts and told we would more than likely have our leave cancelled. There was high anxiety, although now thankfully the crisis has de-escalated.’
No other employment has given me the soaring sense of accomplishment to be found at the sharp edge of life and death. Yet no other job has pushed me to my limits by challenging my body’s internal clock.
Four months later, mask rationing, staff safety concerns, and protocol confusion persist, although health services are better prepared to manage coronavirus cases and address any future pandemic waves. Since coronavirus impacts our airways and breathing, the two highest concerns on the assessment and treatment algorithm, nurses have needed greater round-the-clock organisational support. However, for some, the inverse has happened. Any hint of upper respiratory tract infections keeps clinicians understandably at home causing, as Esmond describes, ‘a great deal of pressure on staffing just when there is a massive increase in our theatre lists and workload as we try to clear the backlog of patients, whose health has often worsened during the protracted wait’. Nurses, working at the forefront of coronavirus care and aware of the risks it presents to themselves and their families are pushed further, Esmond reports, ‘to be to be on our toes, which is exhausting.’
Night shifts not only impacts nurses’ professional capacities, but our personal lives and our willingness to care for others too. Currently, healthcare organisations measure nursing by the number of completed tasks and errors. They remain far from introducing the institutional changes nurses require to enable them to cope with night shifts and assure the safe and empathetic care associated with benevolence and vocation, for shift swaps, store-room trolleys for nap-taking and cheap coffee granules only go so far. It’s hardly surprising when nurses are questioned about what altruism means, they are equivocal and ambivalent, viewing it as one amongst many motivations for the profession. Nevertheless, the Danish philosopher and theologian Søren Kierkegaard might have considered that nurses, who defer their own needs and render themselves morally and ethically accountable, embody his notion of responsibility for the other. Woods believes that nurses are indisputably ‘a giving group of people, even if that means giving all we have for others. This can often mean that when we are exhausted, we agree to do a double shift because we know our patients need us.’
*
At 0700, when the sun casts her golden rays over the Dandenong Ranges and I’m checking that my patients are correct and present, toileted and ready for their breakfast, calm suffuses through me. Handover done, freed from the blinking fluorescent globes of the artificial hospital culture, my eyes adjust to the diffuse sunlight while a cool breeze caresses my cheeks. Kookaburras cackle in the arcade of eucalyptus branches, and I inhale the menthol perfume of a newborn day. I’m one of the armies of uniformed nurses fanning the streets who form the unassailable chain of human care, and a sudden kick of pride makes me smile.
I love my job. No other employment has given me the soaring sense of accomplishment to be found at the sharp edge of life and death. Yet no other job has pushed me to my limits by challenging my body’s internal clock. I strive to provide safe and compassionate patient care, and yet I cannot ensure it. The fight against my circadian rhythm is one I can’t win.
