Across the globe, nurses are needed in many different settings to care for patients at night. Despite the continued demand for nurses to work this challenging shift when most others are sleeping, little is known about nurses' perception of the night-shift work environment. Evidence exists on the differences in how hospitals organize care during the day shift compared with the night shift. For example, overnight less diagnostic and treatment services are available, staffing generally includes fewer and newer nursing and ancillary staff who operate with less supervision, and surge capacity includes more on-call personnel.1-3 Researchers have also found some positive aspects related to working night shift: night nurses experience more teamwork, camaraderie, and autonomy during their shift, and they have the benefit of fulfilling family responsibilities when others are working.4-7
Yet, working at night disrupts nurses' circadian rhythms and has consequences for their physical and mental health, with ramifications related to job performance and satisfaction.8-13 The National Academies of Sciences, Engineering, and Medicine (NASEM) recognized that performance deficits are associated with disruption to nurses' normal circadian rhythms.14 And most recently the NASEM Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report recognized that working the night shift can lead to long-term insomnia and increased injury risk and that a near majority of newly licensed nurses begin their careers working the night shift.15
Although an impressive body of literature exists that demonstrates a positive nurse practice environment is important to better nurse and patient outcomes, gaps persist in understanding, describing, and quantifying the impact of the night-shift nurse practice environment.16,17 Therefore, we need to better understand nurses' experiences and work environment when working at night, outside the regular routines of society.
Background and literature review
The night shift is defined by the US Bureau of Labor Statistics as the time between 9 p.m. and 8 a.m.18 The most common hours worked by night-shift nurses are between 7 p.m. and 7 a.m. or 11 p.m. and 7 a.m. Of the almost 5.2 million RNs in the US, the exact percentage of nurses working the night shift is unknown.19 However, staffing data at nine acute care hospitals in one healthcare system reveal that approximately 40% of the hospital nursing staff work the night shift.20
In the late 1970s, concern about the US nursing shortage prompted researchers to explore why some hospitals could better attract and retain direct care nurses despite the nursing shortage.21 In this seminal work, nurse leaders recognized the quality of staff and staffing as integral components of professional practice, whereas direct care nurses noted autonomy, professional recognition, respect, and "the ability to practice nursing as it should be practiced."21 From this qualitative inquiry by McClure and colleagues, researchers discovered that these "magnet" hospitals all shared a common set of organizational characteristics that facilitate or constrain professional nursing practice and thus defined the "nurse practice environment."21,22
In response to critical care nurses' concerns about their poor work environments and the increasing evidence of the outcomes of unhealthy work environments, the American Association of Critical-Care Nurses (AACN) issued in 2005 the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence.23 Features of the nurse practice environment overlap with the AACN's six standards for a healthy work environment (HWE), which include: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.23 The HWE is defined as a work environment that's "safe, empowering, and satisfying," and "a work setting in which policies, procedures, and systems are designed so that employees can meet organizational objectives and achieve personal satisfaction in their work."24
A recent systematic review revealed that HWEs impact nurse job satisfaction, retention, and job performance, and patient-care quality.26 Research also demonstrates that unhealthy work environments cause medical errors, ineffective care delivery, conflict, stress among health workers, dissatisfied staff, low staff retention, a breakdown in communication among different disciplines, and poor patient outcomes.27,28
The first meta-synthesis finding from a qualitative systematic review that explored the experiences and perceptions of nurses working the night shift or rotating between day and night shifts revealed the unique characteristics of the night-shift work environment.29 The other meta-syntheses were how nurses juggle their need for sleep with their family and personal responsibilities and the coping strategies nurses use to deal with the fatigue and exhaustion and keep their patients, themselves, and others safe.29 This review identified the need for organizational strategies and support for those working night shift to enhance both nurse and patient safety. Yet information is lacking on the night-shift work environment. Because of its distinctive stressors, such as the disruption to nurses' normal circadian rhythm, and differences in organization from the day shift, it's important to describe and quantify this work environment.
Nursing Workplace Environment and Staffing Councils (NWESCs) were implemented in New Jersey hospitals beginning in 2017 to establish safe and healthy work environments. The Organization of Nurse Leaders of New Jersey established this statewide initiative that provides a forum for discussion about staffing and the work environment with nurse leaders and direct care nurses.30 The AACN HWE standards were used as the framework for the NWESC, and the councils consisted of 51% direct care nurses, including nurses working the night shift.30
Thus, this research on night-shift direct care nurses' perception of their work environment is the next step in understanding night-shift nurse work environment. With a better understanding of the night-shift work environment, we can begin to explore initiatives to address the challenges and minimize the potential detrimental effects of working at night, which in turn can lead to improved nurse and patient outcomes.
Methods
This descriptive, cross-sectional, correlational study was conducted to describe the relationship between night-shift direct care nurses' perception of their work environment, job enjoyment, and the HWE Assessment Benchmark data.31 Institutional Review Board (IRB) approval was obtained from the hospital system IRB.
To recruit a convenience sample of RNs, administrative or house supervisors who attended the third annual regional Administrative (Evening/Night) Supervisor Conference forwarded an email with a survey link to night-shift RNs at their organization. The survey period was from April 30 to June 29, 2019. The survey consisted of the informed consent agreement for participants to provide electronic consent and the AACN Healthy Work Environment Assessment Tool (HWEAT), Job Enjoyment Scale, and demographic data form.
The HWEAT, developed by the AACN, measured night-shift direct care nurses' perception of the HWE.32 The HWEAT is an 18-item instrument with six subscales that measures each of the HWE standards. Participants were asked to indicate their level of agreement or disagreement with each item using a Likert-type scale with five response options (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). The HWEAT tool has been used with nurse leaders, physicians, and direct care nurses.33,34 Cronbach alphas for the HWEAT total and subscales range from 0.77 to 0.97.33,34
The seven-item Job Enjoyment Scale was used to measure overall nurse job satisfaction. Five questions evaluate perception of positive aspects of the unit and overall enjoyment with work (for example, "Nurses with whom I work would say that they: [a] are enthusiastic about their work . . . [b] find real enjoyment in their work"); two items evaluate negative perceptions (for example, "have to force themselves to come to work" and "feel that each day will never end").35,36 Participants were asked to indicate their level of agreement or disagreement with each item using a Likert-type scale with six response options (1 = strongly disagree, 2 = disagree, 3 = tend to disagree, 4 = tend to agree, 5 = agree, and 6 = strongly agree).36 Reliabilities range from 0.91 to 0.97 at the unit level for the scale.37,38 Participant characteristics were captured by asking participants to provide demographic information such as age, gender, position title, education, certification, and hospital information.
Results
RNs (N = 166) working in direct care during the night shift at one of seven hospitals in New Jersey responded to the survey. The hospitals were all American Nurses Credentialing Center Magnet(R)-recognized and not-for-profit hospitals ranging in size from 160 to 553 beds. Additionally, all hospitals had night-shift councils and three hospitals had an NWESC.
The night-shift nurses were an average age of 39 years, had an average of 13 years of nursing experience, and had been in their position an average of 8 years (ranging from a few months to 40 years). Most nurses had a baccalaureate degree (71%), held national nursing certification (64%), and worked full-time (82%) (see Table 1).
The night-shift direct care nurses rated the HWE overall as good, 3.14 (SD, 0.78). The HWEAT scores for each standard were all categorized as good, in the range of 3.00 to 3.99, except for the appropriate staffing standard, which was categorized as needs improvement, in the range of 1.00 to 2.00.31 As shown in Figure 1, the appropriate staffing standard was rated the lowest and the effective decision-making standard was rated highest. Additionally, the night-shift nurses who had higher overall HWEAT scores had higher job enjoyment (r = .664, P < .001), and more years working as a RN (r = .197, P < .001) (see Table 2).
When the night-shift direct care nurses HWEAT scores were compared with the AACN HWE benchmark data, the overall HWEAT score and the scores for each standard were all lower than the AACN HWE assessment benchmark (see Figure 1).31 There were statistically significant mean score differences between night nurses and the AACN HWE benchmark aggregate mean score (P < .001) for the overall and all HWE standards.
Measured by the Job Enjoyment Scale, job satisfaction was an average of 3.36 (SD, 0.66). As shown in Table 2, the night-shift nurses who had higher job enjoyment had been working more years as an RN (r = .271, P < .001).
Post-hoc analysis was done to compare the HWEAT responses of night-shift nurses who worked at hospitals with an NWESC to the night-shift nurses who worked at the hospitals without an NWESC. Night-shift nurses who worked at hospitals with an NWESC rated the overall HWE and each standard as higher than nurses who worked at hospitals without an NWESC. There was only a statistically significant difference in the appropriate staffing standard [t(164) = (-)2.28, P = .024] (see Table 3), with night-shift nurses who worked at hospitals with an NWESC rating this standard higher.
Discussion
The findings from this study demonstrate the overall HWEAT score for night-shift nurses was good and positively related to their job enjoyment. However, the overall HWEAT score and the scores for each standard were all lower than the AACN HWE Assessment Benchmark Report, which signifies an opportunity for improvement of the night-shift work environment.31 Additionally, this is one of the first studies demonstrating the value of NWESCs and involving direct care nurses in staffing decisions. This study demonstrated that the appropriate staffing standard was significantly higher with night-shift nurses who worked at hospitals with an NWESC.
The night-shift nurses rated effective decision-making as the highest standard. These Magnet-recognized hospitals have shared governance and night councils that provide a mechanism for night nurses to share their input into policies and practice changes. Nurse leaders need to support the attendance of night-shift nurses at night council meetings and ensure unit council meetings are held at a time when night-shift nurses can attend. Obtaining feedback from night-shift nurses on policy and procedure changes, such as frequency of vital signs at night, benefits the organization and, most important, patients.
The administrative supervisor, the nurse leader present during the night shift, sustains the night-shift work environment by building trust with the staff, doing rounds, educating, and providing support.39 Direct care nurses confirmed the importance of having an administrative supervisor who's approachable and trustworthy.39 Considering that trust is a characteristic of authentic leadership, we can theorize that night-shift nurses rated authentic leadership as the second-highest standard because of their relationship with the administrative supervisors.40 Administrative supervisors use their leadership skills and work with night-shift nurses to resolve concerns and ensure quality patient care. As night-shift critical care and ED charge nurses commonly transition to the administrative supervisor role, organizations should offer authentic leadership education to these aspiring leaders.41
The skilled communication standard, which was rated good, recognizes the importance of nurses being proficient in communication with patients, other nurses, and the interdisciplinary team. Communication is inherent in the Magnet standards, and communication can be enhanced with change-of-shift huddles for sharing important information with staff members between shifts.42,43 Additionally, considering the hours that night-shift nurses work, nurse leaders need to ascertain and respect their preferred method of communication-email, text, or phone call-and avoid contacting them during their hours of sleep. As we have learned during the COVID-19 pandemic, communication can be further enhanced by conducting nursing meetings virtually.
Considering that meaningful recognition, which was rated as good, has been linked to decreased burnout and increased compassion satisfaction, it's important to provide recognition to all nurses, including night-shift nurses.44 Meaningful recognition of nurses working the night shift can be accomplished through formal recognition programs, such as The DAISY Award, or hospital-specific awards such as nurse excellence or nurses' week awards.45 Nurse leaders need to ensure that nurses working the night shift are considered for these awards. The administrative or night-shift supervisors can also advocate for recognition of night-shift nurses by including information about their good work in their report or sending a thank you email specifying the details of the nurses' actions to the nurses and their nurse manager.
The collaboration standard was rated as good by the night-shift nurses. Interprofessional collaboration is woven throughout all the components of the Magnet standards, and the night councils at these hospitals foster interdisciplinary collaboration.42,46 For instance, at a night council meeting at one hospital, a night-shift nurse raised concerns about the need for more security presence during the night shift. This concern resulted in increased security rounds during the night shift and the regular participation of a security officer at the night council meetings. Nurse leaders can foster collaboration by listening to the concerns of night-shift nurses brought forth by the night council and serving as an intermediary between the night council and the interdisciplinary team. Leaders can also help to foster interdisciplinary collaboration by encouraging night-shift nurses to participate in interdisciplinary team projects.
The appropriate staffing standard was rated the lowest, and the score indicated improvement is needed. Although appropriate staffing scores for hospitals with and without NWESCs indicated needed improvement, it was encouraging that hospitals with NWESCs had a better score (statistically significant) than hospitals without NWESCs. Nurse leaders should consider implementing NWESCs at their organizations or at minimum educating the night-shift nurses on how staffing is determined for each shift.
Limitations
A limitation of this study is that the participants were a voluntary convenience sample of night-shift direct care nurses who worked at seven acute care Magnet designated hospitals in New Jersey; their perceptions may not reflect the perceptions of night-shift nurses who work at non-Magnet hospitals or at hospitals in other parts of the state or country. This was not a randomized national sample, so generalization of findings may be limited. The results provide an overall HWEAT score and a score for each of the standards for nurses working the night shift at seven Magnet-recognized hospitals. Evaluating the HWE by hospital and unit level would provide more specific screening data on the night-shift work environment.
Implications for nurse leaders
Nurses and nurse leaders need to recognize that not only is the night-shift work environment different than the day-shift work environment but working at night disrupts nurses' circadian rhythms and impacts their physical and mental health. Organizations need to cultivate the HWE on the night shift, starting with assessment of the work environment followed by tailored initiatives. Night council meetings can be held to provide a forum for nurses and other interdisciplinary team members to discuss issues specific to the night shift. By implementing initiatives to improve the night-shift work environment and minimize the potential detrimental effects of working at night, organizations can foster a healthy frontline night-shift nurse workforce to adequately care for patients.
Conclusions
The need to improve the work environment for nurses and other healthcare workers is undeniable. Hospitals function around the clock, and the care nurses provide during the night shift has an impact on outcomes. As nurse leaders continually search for ways to improve the nursing work environment, more research needs to specifically explore the night-shift work environment. Particularly because past AACN Critical Care Nurse Work Environment studies didn't provide information on the shift worked, future studies should examine and explore the difference between day- and night-shift work environments.46,47 Nurse leaders should employ initiatives to promote the HWE standards, such as recognizing the night staff who work the extra hour at the end of daylight-saving time with a "Fall Back Celebration." Leaders should foster the HWE standards, which in turn can enhance patient, nurse, and organizational outcomes.
INSTRUCTIONS From dusk to dawn: A healthy work environment for nurses working night shift
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REFERENCES