Impact of shift system on quality health care and health practitioners
Shift work is a known phenomenon in the job industry. It is usually dependent on supply and demand of staff. Workers are often rotated through set periods throughout the day, typically performing the same kind of work.
Further, shifts extend beyond the traditional “9 to 5” workday to include evening/night shifts, early morning shifts, and rotating shifts. A mix of these can be seen in the Jamaican health system.
What are researchers saying?
While production and output may be satisfactory, shift work is thought to affect the amount of sleep one receives (Kawada & Suzuki, 2002). There is an inextricable link between physiological problems and shift work — the night shift in particular. Noticeable change has been observed in working, eating, and sleeping phases, which is due mainly to a condition referred to as Circadian Desynchrony. Manifestations of this condition include poor performance, gastric complaints, fatigue, and sleep disturbances (Berger, 2006).
It is known that humans have a natural rhythmicity to many bodily functions, referred to as the circadian rhythms. Functions such as cell division, respiratory rate, body temperature, hormone production, and urinary excretion can be modulated by exogenous factors such as work schedules, social climate, and light-dark cycle.
To maintain rhythm synchrony, the light and dark cycle and temporal cues such as exercise, meal times, clocks, noises, act to adjust the circadian system (Berger, 2006). Of note is that sleepiness is maximised during the night.
It has been found that inadequate and inappropriately timed sleep results in increased sleepiness, fatigue levels, debility, and reduction in working function. Additionally, lack of sleep due to long shifts and shift work sleep disorders pose a serious health burden which alters quality of life, affects work performance, and impairs safety (Flo et al, 2014).
The following events associated with complaints of excessive sleepiness were found to be related to the shift system:
(1) symptoms such as sleep-related accidents, depression, absenteeism, and/or missed family and social activities (Drake et al 2004);
(2) errors in administering drugs, medical equipment operated incorrectly by nurses, and needle stick injury (Ohida, 2005);
(3) nurses experienced limited ability to function due to mental and physical health hazards; and
(4) nurses adopted varying coping skills from the use of stimulants such as caffeine and energy drinks during shift work, for sleep and post-shift work.
Within the Jamaican context, nurses who are assigned to work on night shift showed signs of agitation, fatigue, anxiety, and reported incidence of gastrointestinal disturbances (personal communication).
Generally, individuals working on shifts are more susceptible to comorbid conditions such as cardiovascular disease, diabetes, gastrointestinal disorders, and depression (Steefel, 2013). Others may experience exacerbation of these conditions.
Additionally, the following conditions or states were noticeable among shift workers: higher blood pressure, chest pain, swollen feet, weight gain, impaired physical activities, impaired cognitive functioning, impaired emotional functioning (Rathore, 2012). Shift workers also experienced abdominal pain, disruption of the menstrual cycle, spontaneous abortion, low birth weight and prematurity (Harrington, 2013).
Compelling evidence from analysis of the work of nurses indicated that both the nurses’ job performance and their job-related stress were linked to the type of shift they worked. Overall job performance was highest for the nurses on the day shift, followed by the night, afternoon, and rotating shifts. Rotating shift nurses experienced the most job-related stress, followed in turn by the afternoon, day, and night shift nurses (Coffey et al, 2006). This undoubtedly has implications for quality care. To address this phenomenon, some researchers suggested a two-hour nap, an increase of staff, and a day off to reduce the nurses’ workload when they have long night shifts (Fukuda et al, 2002).
The International Labour Organization, in 1990, introduced radical new standards for working patterns in order to limit working hours. Working long hours was deemed to be ‘too long’ or ‘abnormal’, which is hazardous to one’s health. Countries and institutions were therefore expected to implement creative measures to avert any deleterious effects of shift work on employees.
Nurses and shift system
Researchers have posited that 32.3 per cent of shift workers are made up of nurses. Nursing, a 24-hour job, necessitates this. It is true that when other medical staff members have retired from work, nurses are the practitioners who continue the care of patients (Australian Journal of Advance Nursing, 2006).
Feedback on the shift system was ascertained from selected urban and rural health institutions in Jamaica. Nurses in a Type C hospital claimed that they work the traditional three-shift system and are contemplating changing to 12-hour shifts. The drivers for change included (1) individuals not committed to night shift (2) night shift does not allow for social activities (3) skeleton (inadequate) staff on night shift. It was felt that sufficient staff is crucial, especially for emergencies and transfer of patients by ambulance. Of note is that they felt the quality of care may be affected once the change is implemented.
Nurses in a Type B hospital also indicated that they utilise the traditional three-shift system; however, they were busy exploring a flexi-shift system to reduce the length of night shift, which has a duration of one month. Concerns raised regarding staff on the night shift were (1) high absenteeism (2) sleep deprivation and (3) working long hours. Importantly they felt that the quality of care was not affected despite the negative effects of the night shift on nurses.
The situation at a Type A hospital was similar; nurses also utilised the traditional three-shift system. They opined that they would change but are unable to do so because the manpower of the shifts is needed. Some concerns regarding shift system that were highlighted included (1) nurses not having enough time for their children, (2) distance of home from work, and (3) inability to manage pregnancies well while on night shift. Notably, their night shift had a duration of two weeks. They felt this shift arrangement is not affecting the quality of care.
Nurses at a specialist hospital also worked on the traditional three-shift system and were contemplating changing to a 12-hour shift. They alluded to the fact that this allows nurses longer periods of time off duty. Concerns raised about the existing system, especially the night shift, included nurses feeling disoriented during the night shift stint and disruption in sleeping patterns. They felt that the quality of care may be affected when people are not alert on night shift.
Does the shift system affect the quality of care?
Demystifying quality care requires an entire paper and, as such, I will be very conservative with the use of the concept. Of particular interest, however, is the multidimensional nature of the concept of quality care. It has two principal dimensions, namely access and effectiveness.
In trying to determine quality care offered by health practitioners working on shift systems, several studies have been conducted. Focus is often on the impact of resident-physician and nurse work hours on patient safety. The evidence demonstrates that work schedules have a profound effect on practitioners’ sleep, their performance, their safety and that of their patients.
Health practitioners, including nurses working shifts greater than 12.5 hours, are at significantly increased risk of:
1) making a medical error,
2) experiencing decreased vigilance on the job, and
3) suffering an occupational injury.
Physicians-in-training working the 24-hour on-call shifts are also at increased risk of experiencing occupational sharp injury, experiencing a motor vehicle crash on the drive home from work, and making a serious or even fatal medical error (Lockley, 2007).
Studies have also shown that when working 16-hour shifts, on-call residents have twice as many attentional failures when working overnight, and commit 36 per cent more serious medical errors. Reports also revealed that the same category of health practitioners made 300 per cent more fatigue-related medical errors that led to death of patients (Lockley, 2007).
Concerns have been expressed about the ability of nurses to provide high-quality care when working overtime and/or extended shifts. One study showed that nurses who worked 12-hour shifts made more errors in grammatical reasoning and chart reviewing than did nurses who worked shorter shifts (Mills et al, 2002). Studies which focused on nurses who work traditional and rotating shifts and their ability to remain awake and vigilant at night, as well as the duration of the nurses’ daytime sleep, found that nurses often have difficulty remaining awake on duty. An association might also exist between alertness and errors among nurses, because nurses who worked nights and rotating shifts reported making twice as many errors as nurses who worked day and evening shifts (Gold et al, 2007). Generally, longer work duration increased the likelihood for errors and near errors among nurses, physician residents, intensivists, and anaesthesiologists.
Recipe for burnout
The shift system was also found to be a risk factor for burnout. Nurse burnout, as measured by feelings of emotional exhaustion and lack of personal accomplishment, is a significant factor influencing how satisfied patients are with their care (Vahey et al, 2004).
Burnout and psychological stress of nurses in two- and three-shift work was also analysed. The findings showed that female nurses in three-shift work reported more stress symptoms and did not enjoy their work as often as those in two-shift work. Psychological fatigue and hardening were not found to be dependent on the shift work. Male nurses, on the other hand, experienced similar levels of burnout and stress in two- and three-shift work.
Of equal importance is that studies have repeatedly shown that higher levels of burnout were associated with lower ratings of the quality of care, and as such reducing nurse burnout may be an effective strategy for improving the quality of care in hospitals (Poghosyan, 2010).
12-hour vs 8-hour shifts
Some local institutions are contemplating changing from 8-hour shifts to 12-hour shifts. Will this be beneficial to health practitioners? In one study, psychological and social well-being, health, sleep, job satisfaction, and burnout of Intensive Care Unit (ICU) nurses on 12- and 8-hour shifts were investigated. The 12-hour shift nurses, when compared to their 8-hour shift colleagues, experienced more chronic fatigue, cognitive anxiety, sleep disturbance and emotional exhaustion. No relationship was found between the shifts and job satisfaction, suggesting that it is independent of the shift duration (Iskera-golec et al, 2007).
The nurses on 12-hour shifts reported less social and domestic disruption than those on 8-hour shifts. On the other hand, the 12-hour shift nurses showed worse indices of well-being, burnout and health than the 8-hour shift nurses. One explanation posited for this finding is that the indices may be associated with their longer daily exposure to the stress of work. Increased number of rest days of 12-hour shift nurses, however, sufficiently dissipated the adverse health and well-being effects over the longer shifts (Iskera-golec et al, 2007).
Altogether, empirical evidence suggests that the shift system, more so long working hours, have deleterious effects on health personnel, including nurses. Despite its importance in the health sector, the shift system may result in situations that jeopardise the safety of patients and staff, affect users of the health sector’s ability to access care, and affect the quality or effectiveness of care received.
For the most part, there is a dearth of data on the shift system within Jamaica and the region. Hence, a lack of sufficient policies and programmes to address the effects of shift work on health personnel. Policymakers and relevant stakeholders need to address with alacrity this phenomenon. Engaging in research may be the catalyst to determining the extent to which working on shifts affects the quality of life of health personnel and the quality of care and services they offer to users of the health system. Undoubtedly, data obtained may be utilised to inform policies and programmes to address the deleterious effect of shift work.
Adella Campbell, PhD, is an associate professor and head of the Caribbean School of Nursing at University of Technology, Jamaica. Send comments to the Observer or adcampbell@utech.edu.jm .