Nurses’ perceptions of night shifts: A qualitative study

In the context of the global shortage of nurses, how hospitals can best use nurses to provide quality patient care is a major challenge [1]. Due to the particularity of the occupation, nurses need to work in 24 h shifts. Creating an appropriate shift pattern is critical for optimizing the allocation of resources and improving the quality of care [2]. Previous studies have shown that shift work and the resulting asynchrony of circadian rhythms adversely affect nurses' health and quality of care [3], particularly among night shift nurses. It has been reported that night shift nurses have higher rates of obesity [4], cardiovascular disease and diabetes [5] and poorer sleep quality and health conditions [6] than day shift nurses.

Nursing staff shift patterns constitute a complex topic that has attracted increasing attention. Internationally, many hospitals have routinely adopted an 8 h rostering pattern [7]. To lower manpower costs and promote continuous care, some hospitals began to introduce a shift pattern of 12 h or longer in the 1970s [8]. Subsequently, such long shifts (≥12 h) became a trend in the United States, New Zealand and some European countries [9]. The trend was based on the assumption that there might be economic advantages in reducing the number of overlaps between shifts and number of employees required [10]. Previous studies have extensively explored the impact of shifts of different lengths on nurses and nursing. According to a survey [11], 83.5 % of nurses preferred a 12 h shift pattern when working 36 h per week. Managers were more likely to report that they had sufficient staff when using exclusively long shifts rather than a mixture [12]. However, concerns regarding long shifts have been raised, and negative results have been reported. A study showed that nurses working shifts longer than 13 h were more likely to experience burnout and intended to leave their job [13]. Compared with those working 8 h shifts, nurses working long shifts were more likely to report poorer quality of care and patient safety [14], higher incidences of missed care [15] and patient mortality [16]. Accordingly, managers and researchers believe that it is necessary to re-examine the long shift pattern. Especially since the impact of night shifts is greater than that of day shifts, further research investigating how the night shift length affects nurses and nursing is needed.

More recently, attention to the experience of nurses and managers on shift patterns has been raised in qualitative research. The experiences and perceptions of nurses in acute mental health settings [17] and newborn intensive care units [18] regarding the change from a traditional 8 h shift to the new 12 h shift have been explored. However, most previous studies focused on the overall characteristics of shifts or day shifts while failing to investigate the impact of night shifts on nurses or nursing. In this sparse research field, only two studies explored the effects of night shifts as perceived by nurses [19] and night shift nurses’ perceptions of drowsy driving and their measures to combat it [20]. However, there is still a gap in how nurses respond to different night shift patterns. There is also a lack of clear evidence regarding the best night shift length for nurses that might guide decision makers [2]. The complexity of night shifts may not be fully understood. A comparison of different night shift patterns may not be sufficient when examining a few fixed factors, and an open discussion from the stakeholder perspective is needed.

In ever-changing dynamic environments, such as emergency departments, nursing is highly risky, unstable and irregular. More specifically, emergency nursing is characterized by multitasking, overcrowding and interruptions attributed to inconsistent arrival of patients, difficulty in identifying patients, unpredictable workload and multilingual patients [21]. Especially in cases of increased numbers of patients at night and complicated conditions, night shift nurses may experience greater work pressure. In China, due to the large population base and the perennial shortage of nurses [22], the emergency departments of general hospitals usually adopt long night shifts of 12 h and 16 h. Since most provinces have issued documents [23], [24], [25] suggesting that tertiary hospitals entirely stop general outpatient infusions for adults, the number of emergency department admissions has rapidly increased, leading to an excessive workload. Considering the work pressure caused by long shifts, many hospital emergency departments are switching to 8 h shifts. The purpose of this study was to describe the experiences and perceptions of emergency nurses regarding the shortening of night shifts and identify aspects of nurses' preferences for night shifts.

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