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Night Shift Nursing: Self-Care is Key

Tips for nurses on remaining emotionally and physically fit while working the night shift.

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One in five Americans works nontraditional hours, including the many nurses working the night shift in hospitals and other healthcare facilities around the country.1

Working the night shift can lead to "shiftwork disorder syndrome," which can alter one's ability to function well in life or work, contribute to health problems and adversely affect personal relationships.2

Not only is working the overnight shift implicated in heart disease and obesity, but a recent longitudinal study of more than 4,000 women also found those working the night shift had an increased risk for breast cancer.3,4 

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Making a Self-Care plan

To best care for others, nurses must first care for themselves.

Circadian Rhythm

The circadian rhythm is a biological internal "clock" regulated by sunlight and darkness over roughly a 24-hour period.5

The day/night cycle drives sleeping, eating, body temperature regulation, brain wave activity, hormone production and release, as well as cell regeneration (Table 1).

Rebelling against this biological cycle can result in problems such as sleep disturbances, increased accidents and injuries, and social isolation.6

What's more, recent research shows sleep-deprived individuals eat 500 extra calories more per day than do those who get enough rest.7

Lack of Sleep & Hormones   

Lack of sleep can interfere with several important hormones that regulate hunger and fat storage:

Leptin is released during sleep and acts as an appetite suppressant.8,9 Some tips to encouraging leptin production include making sure your diet includes protein (including fish), fiber and oatmeal. (Table 2).

Ghrelin (a peptide produced by the stomach) is increased when sleep deprived and has been shown to increase hunger while decreasing metabolism. Night shift workers generally higher body fat percentage than those who work the day shift.10-11  

Cortisol is responsible for the lifesaving "fight or flight response" as well as fat and carbohydrate metabolism. Increased cortisol levels have been associated with night shift work, which can elevate blood sugar, suppress the immune system, and interfere with hormonal functioning.12 Cortisol is also released with stress; often a byproduct of sleep deprivation and interrupted circadian rhythm. Excess cortisol production can contribute to insulin resistance and may lead to fat deposits, particularly in the abdomen and upper back.

Melatonin is a powerful antioxidant that is released during sleep (in darkness).13 Experts suggest melatonin can reduce levels of circulating estrogen. Estrogen is credited with slowing the growth of breast tumors and possibly breast cancer. Prolonged light exposure inhibits melatonin production. One way to increase your melatonin level is to sleep during the day with black out curtains.

Serotonin Researchers compared serotonin levels in rotating shift workers and found people who work the night shift have lower levels of the "feel good" hormone.14 Decreased serotonin is linked to depression, anxiety and sleep disorders.15 Carbohydrates (not protein) increase serotonin, explaining our desire for comfort food when we are tired or stressed. Lack of sleep is associated with increased carbohydrate intake, likely the body's attempt to raise serotonin.16

Expert Recommendations

"If you're really not feeling well or something just doesn't seem right, a checkup and discussion with your doctor can help to determine if what you're experiencing is physical exhaustion or clinical depression," recommends Matthew P. Thomas, MD board certified psychiatrist and clinical assistant professor, Florida State University.

"Warning signals like worsening fatigue, muscle aches and tension may be signs of depression- and may be more serious than low levels of serotonin related to lack of sleep. If you are feeling sad, can't focus at work, are irritable with those around you, or begin to feel badly about yourself, it's definitely time to visit your doctor.  For those who are feeling hopeless or have thoughts about hurting themselves, it's time to get to help immediately."

1. Manage Your Work Schedule
If you have the option, choose less frequent rotations; work a shift for three weeks rather than rotating to a different schedule every week. A more natural sleep pattern results when your shift sequence is working a week of dayshifts, then a week of evening shifts, then night shifts rather than day-night-evening. The best rotating shift system within one week is fast forward rotation: Two mornings followed by two afternoons then a night shift. A schedule that is most unnatural is a backward rotation of night shifts, then afternoons and mornings. 

2. Plan Your Sleep
The most effective way to manage your circadian rhythm and overall health is (stating the obvious) getting enough sleep!17 Scheduling blocks of solid sleep are critical, but power naps are valuable too. Studies show naps of 40-60 minutes are the best duration.18,19 Maintain a regular sleep schedule by sleeping during the day even on your days off. The night shift is difficult enough for your body to manage but flip-flopping is even more confusing. "When driving home, use polarized sunglasses if the sun is up," says Dr. Thomas, "and choose a quiet, peaceful, dark room for sleep as soon as possible after your shift ends." Try black-out curtains for your bedroom and leave the TV in the den. Develop a ritual that you associate with relaxation and sleep; for example, a relaxing shower followed by cup of caffeine-free tea, or your favorite book and a bubble bath.  

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3. Seek Family Support
Make sure your family and close friends respect your sleep! Even with best intentions, phone calls and visits during your sacred sleep time will interrupt your much-needed rest. Emphasize how important sleep is to your health and career. 

4. Think Safety
Driving after being awake for 17-19 hours leads to poor reflexes similar to someone with more than .05 blood alcohol level (legally impaired). Be aware of this risk and drive smart.20    

5. Nutrition 
Dodge the late night traps of vending machines, restaurant delivery and hospital cafeterias!  Plan your meals ahead of time and bring food from home. Not only less expensive, your own food is conveniently ready when you get a few free minutes. Frequent meals of protein, fruits and vegetables are not only healthy but the freshness of the food may be invigorating. 

6. Stay in Touch!
Social isolation is a risk associated with shift work so maintaining social ties is critical to mental health and overall levels of happiness and life enjoyment.21 Plan for social time; for example, planning "date night" with your significant other can foster an emotionally healthy routine. "Make it a priority to stay connected with family and friends, but not only the wired, online type of connection as nothing beats face-to-face relationships" says Dr. Thomas. "Try to remain involved in as many family and social functions as possible when you're not working. This can be tough to negotiate, but it's critically important for long-term satisfaction at work and at home."

7. Schedule Exercise
Create an exercise routine that works around your schedule.22,23 Convenience is essential- pick a gym or Yoga studio with a shower for pre-work exercise or a running route that is near work or home. 

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Nurses appreciate working the night shift for a variety of reasons- quality of work/life, time for family, and other commitments. Learning your circadian rhythm and following these tips are vital to staying healthy. Proper planning, remembering to nurture personal relationships, and making time for you daily are vital to a healthy work-life balance.

References for this article can be accessed here.

Krista Bragg, DNP, CRNA, is Chief CRNA at Reading Hospital, Reading, Pa., and author on healthcare, patient safety, and fitness topics. Kenneth Bragg, BSN, BS, RN, is a professional drug-free body builder, trainer and freelance author. Expert commentary provided for this article by Matthew P. Thomas, MD, clinical assistant professor, Florida State University, Tallahassee, and board certified psychiatrist in private practice, Sarasota, Fla.


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I have worked night schift for abount 20 yearss. When I had to work a day shift, I had stomack problems, sleep problems, and felt sick all the time. When I went back to nights, I felt fine.

Elsieann Lithgow,  RNJune 17, 2013
Lakeland, FL



I am very empathetic. After working 7 years on nights I eventually got a day job due to someone leaving, but after 2 years I had to leave work due to illness. Now after many years I'm ready to back and it will probably be nights all over. I never got used to it and couldn't sleep more than a few hours. I did find it helpful to sleep in the evening after supper for as long as possible before going to work. This really took the edge off. It is not normal to be up all night. There has been research done where nurses are encouraged to sleep on their breaks to help reduce errors. I don't think every employer would be supportive of this.


Carla ,  RNMay 24, 2013
MA



I've been working the night shift for 20 years and it works out very well for me. When I first started I had trouble sleeping during the day and it took me 2-3 months to adjust. What I find helpful is to work my 12 hour night shifts in a row and then on my nights off I do "hybrid" sleeping, i.e. stay up late and sleep in late. I get 7-8 hours of sleep during the day when I'm working and find myself sleeping 9-10 hours on my nights off. I'm very well rested and enjoy my night shift work. If I happen to get less sleep before work I simply have an extra cup or two of coffee and that works for me. I think that some people are cut out to work the night shift and I'm one of them. I feel very fortunate.

Cheryl ,  RNC-MNN,  Edward HospitalMay 22, 2013
Naperville, IL



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