January Newsletter: Coping with Shift Work

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📔 On Shift Work

Although not all domains of nursing require shift-work, it is often seen in 24/7 care centres. The typical full time schedule in the Canadian hospital setting is 12 hour shifts: 2 days, 2 nights, then 5 days off. (It is interesting to note that in the USA, consistent day and consistent night schedules are more common than rotating shifts).

A lot of people appreciate this format as it allows them to have a series of days off. However, for many nursing students who are used to consistent waking and sleeping schedules, shift work can be very daunting.

This newsletter is for those going into consolidation who don’t have control over their schedule - there are still ways to protect your health and wellbeing.

🩹 Anticipating Health Risks

It is important to be aware of the impacts that rotational schedules have on our health, so we can understand the rationale behind some of the tips in this newsletter!

Through evolution, humans have adapted to adjust to 24hr cycles. We have a circadian rhythm, whereby the brain’s hypothalamus sends important signals to the brain to adjust hormone levels, body temperature, digestion, etc. that affect sleep. This is affected by cues such as light (suppression of melatonin), or clock and meal times ¹.

Shift work can be very difficult to get used to since it goes against what we are biologically adapted to. You may feel excessively fatigued and disoriented at first. It is important to acknowledge that night shift work has been classified as a Group 2A carcinogen by the International Agency of Research on Cancer (IARC) ² and rotational shift work can lead to decreased quality and quantity of sleep and GI and cardiovascular symptoms ³.

💤 Key Need #1: Sleep

Implications of Shift Work on Sleep

⚠️ Increased fatigue: 

• Sleep is neuroprotective - it helps us remove toxic waste byproducts that accumulate throughout our waking hours and helps to consolidate memories ⁴. Fatigue alters judgment and makes you prone to mistakes, decreases your stress and irritation threshold ⁵.

• Additionally, cognitive functioning is significantly diminished after 17 hours without sleep and people who are awake over 21 hours function as if they are legally drunk (BAC 0.08) ⁶

🥱 Reduced sleep quality

•  It can be difficult to sleep during the day due to inconsistent sleep schedules, external noises (family members, construction, traffic), and exposure to blue-wavelength light.

What to Do?

🗓️ Sleep schedule: 

• Here are a few suggestions from nursing colleagues, but ultimately everyone’s body is different, and it will take time to figure out what works for you

  • Welltrack Boost, a CBT Program for Healthcare workers recommends the following:

    • Night shifts: get a large chunk of sleep immediately after coming home (6h+ during the day), then a 90 minute naps right before the next night shift, which is the duration of one REM cycle ⁷.

    • Night to day shifts: take a 90 minute nap after your night shift, stay up during the day, then get a large chunk of sleep afterwards (6h+ during the night).

  • Here is another example of a sleep schedule:

🛖 Setting up your environment

• To optimize your sleep and reduce disruptions, here are a few tips that can help:

  • Block out daytime stimuli:

    • “I would suggest the use of blackout curtains, earplugs/ music, white noise machine, or eye mask, for a better conducive sleeping environment.” - Miguel Rams (also a fantastic nurse!)

    • Set your phone to silent

    • Let loved ones know about your schedule, place a DND sign on your door

  • Sleep hygiene

    • Reduce blue-light prior to sleep as it suppresses melatonin secretion ⁸. Although tempting, try not to use your phone 1-2 hours before bed.

    • Place warm red-yellow hued lights that can help stimulate melatonin release and relaxation ⁹

💡 Additional tips:

• Wear sunglasses on the way home to minimize exposure to strong lights following a night shift. Please make sure you are not excessively drowsy when doing so ¹⁰.

• After a night shift, it is okay to not be productive when everyone is rushing to start their days. Take the time to reflect and relax, practice self-care. If you try to do too much, you can get a second wind (aligned with the body’s release of cortisol), which will make it harder to sleep ¹¹.

• On your off days, you will sleep a lot. It might feel like wasted time, but it is not. You need sleep to function!

🥝 Key Need #2: Nutrition

Implications of Shift Work on Meals

🍩 Increased risk for poorer diet

• It’s normal to get very hungry on night shifts. Ghrelin, a hormone that promotes appetite, increases when we are sleep deprived. This causes us to crave high-carbohydrate, high-lipid and high sodium foods ¹².

  • In Ottawa, there are also very limited food choices at night - vending machines and few late-night fast food delivery restaurants.

🤢 Increased risk for indigestion

• Gastrointestinal motility (gastric electrical activity and bile synthesis) is lowest at night, leading to delayed emptying which leads to increased gastric acid secretion ¹².

What to Do?

📆 Meal prep

• Try to make your meals ahead of time, on your rest days or when shifting from day to night shift.

• Night shift meals should be light, but frequent, because the delayed gastric emptying can lead to indigestion and heartburn. Heavy meals that are high in refined carbohydrates can increase fatigue after meals ¹³.

• Try to pack foods that are high in fibre, protein and with low glycemic index to help stabilize blood glucose and help you feeling fuller for longer ¹⁴.

  • This includes a balance of vegetables, fruit, lean proteins, dairy products, grains, and bread.

🛖 Meal timing

• Try to keep meals at the same time;

  • “When you’re heading into your set of night shifts, you need to follow your regular day routine the day you’re starting the night shift. Eat 3 meals or whatever your routine is. Take a nap. When you get to work, fuel up on coffee. Get all the clinical things done before 2300. Try to eat something around 2200-2300.” - Jennifer Hurtubise, great nurse who worked over 10 years in med-surge units and who spoke on our podcast!

• On nights, eat lightly throughout the shift and have a moderate breakfast. This way, you won’t get too hungry while sleeping during the day, and digestive discomfort should be minimal.

💡 Additional tips:

• Drink lots of water (2000cc) to stay hydrated during your shift.

• Supplement Vitamin D (some studies recommend 2000-5000IU) as needed ¹⁵.

• Try to do food and shopping before nights to minimize the amount of chores you need to do when you are tired.

💪 Key Need #3: Exercise

Implications of Shift Work on Exercise

🏀 Decreased opportunities for physical activity

• It becomes difficult to adhere to exercise commitments because organized recreational sports often have rigid schedules which don’t match unusual times of day, or if you are sleep-deprived ¹⁶.

🧠 Impacts on CV and psychological wellness

• Exercise plays a key role in helping us metabolize stress chemicals, release endorphins, and improves brain health ¹⁷.

What to Do?

🥅 Weekly exercise goals

• Although we walk a lot for our occupation, it is important to include at least 2.5 hours of moderate-vigorous aerobic activity and 2 resistance/strength training activities a week ¹⁸.

  • Unfortunately, sometimes this means exercising alone in 24/7 gyms (ie. GoodLife Fitness attached to TOH campuses with discounted employee rates or Fit for Less facilities with flexible hours), outside, or at home.

🏥 Work shifts

• Try to fit in some light exercise during or after a shift.

  • Wall push ups, running up and down the stairs, or dynamic stretches can increase alertness during your breaks. (If you are self-conscious, you could use a quiet stairwell!)

  • “A bit of light exercise for the purpose of tiring yourself out, I guess. That’s what I do anyways” - Miguel Rams

♨️ Coping Strategies

Now that we touched upon our foundational needs, we can move onto some coping strategies: substance use, leisure and stress management.

Substances

☕️ Caffeine

• If choosing caffeinated drinks, try to use early in night shift since the half life of caffeine is 5 hours ¹⁹.

• Moderate caffeine doses up to 200 mg can increase alertness and improve cognitive performance, but higher doses (daily limit of 400mg) can often result in poorer sleep outcomes ²⁰.

  

  Taken from Celsius

🍶 Alcohol

• Many people report that unwinding with alcohol helps them fall asleep faster as it is a CNS depressant. However, it reduces the amount of REM sleep you get, which can increase fatigue in the long run ²¹.

  

  Taken from Alcohol and Sleep - Sleep Foundation

🍃 Cannabis (THC, CBD, CBN)

• Please ensure that you do appropriate research about key topics (tolerance, rebound insomnia, impairment - Cannabis Made Clear) and consult healthcare providers if considering these options.

  • THC: delays onset of REM stage and reduces number of REM cycles, which can impair memory, increase grogginess and lethargy. It is also important to note that the duration of psychoactive effects can last longer than anticipated. Read more about the CNO’s stance on Cannabis use.

  • CBD and CBN: these substances have been used in patients with insomnia, depression and PTSD and have been shown to decrease sleep onset latency (allowing people to fall asleep faster). However, research on CBN is still unclear ²².

Leisure

🎾 Take leisure seriously

• Allocate time to spend with friends and family for wellbeing. Do activities that would make your inner child happy - Listen to music that resonates with your soul, play games with loved ones, create art in any form, remember to express yourself and find the joy in life.

Stress Management

😟 It is normal to feel stressed

• One aspect of managing stress is looking for areas where you have choices. You may not have the choice of whether you work nights or not, but you do have the choice of how to think about the night shift and whether you make the best of it. Sometimes just acknowledging that you do have a choice helps you focus on the positives ¹¹. 

  • Actively look for and pay attention to the good things. Practising gratitude can help you focus on the pleasant aspects of life.

🙅 It’s totally ok to not want to do shift work

• Everyone’s values, lifestyles and bodies are different. There are many other domains of nursing that will not require rotational shifts:

  • Community, public health, and outpatient jobs usually have a Monday to Friday, 8-hour schedule;

  • Many states in US have straight Day or straight Night without having to rotate between the two

  • Other nurses have decided to work casually and pick-up only day shifts that are available (but this might make schedules more unpredictable)

🎏 For those going through it right now, you are not alone

• Seek help from coworkers, talk to your classmates or upper-years who have been through it, listen to your body, tune into podcasts, or even write to the Beating Burnout team!

  • About 1 in 10 Canadians are shift workers or night shift workers ²³. You are not alone, even when it might feel that way. Don’t wait for things to build up - for more resources, click here!

Resources 🌳 

Link to all references used in this newsletter here.