Sleep and fatigue management strategies: How nurses, midwives and paramedics cope with their shift work schedules—a qualitative study

Abstract

Aims

To understand the benefits and challenges of shift work, and the coping strategies used by nurses, midwives and paramedics to manage the impact of shift work on sleep and fatigue from shift work.

Design

A single case study with embedded units.

Methods

Twenty‐seven participants were interviewed exploring their shift work experiences, coping strategies used to improve sleep, and what their recommendations are for improving shift work management. Interviews were completed between November and December 2022.

Results

Participants enjoyed the lifestyle, flexibility and financial rewards offered by working shift work. However, fatigue and sleep deprivation undermined these benefits, as it impacted their ability to enjoy social and family events. There were also concerns of long‐term health consequences of shift work and delivery of care. Changes to rostering practices and sleep and shift work education were common recommendations.

Conclusion

This study provides insights on how healthcare professionals manage sleep and fatigue due to shift work and the inadequate support. There is absence of adequate policies, processes and training at an organizational, academic and personal level on how to best manage sleep and fatigue when working shift work. Future research is needed to explore how to equip healthcare shift workers with the skills to successfully manage their schedules to mitigate the negative impact that poor sleep and fatigue has on the health and safety of themselves and their patients.

Implications for the Profession and/or Patient Care

Understanding the specific challenges of shift work and how workers manage their shift work schedules is critical for improving the health and safety of themselves and their patients. This study identified that there is insufficient training regarding sleep and shift work management strategies, potentially leading to occupational health and safety concerns. Further education and training to equip staff with the necessary information, training and guidance to staff on how to reduce fatigue risk is required.

Patient or Public Contribution

This study involved healthcare shift workers in semi‐structured interviews. Data gathered from a previous survey that participants were involved in helped shape the interview topics and the study design.

1. INTRODUCTION

Approximately 1.5 million people in Australia are employed in shift work, with healthcare workers making up the largest proportion (Australian Bureau of Statistics, 2011). It is estimated that by 2025, there will be a shortage of 100,000 healthcare workers in Australia (Collett et al., 2020). Low retention is an issue in the healthcare industry, with almost 70% of Australian nurses report experiencing fatigue and burnout (Australian College of Nursing, 2022). Inadequate management of shift work schedules is one contributing factor for shift workers not coping with workloads, resulting in sleep impairment and fatigue. This can increase the risk of poor physical and mental outcomes of shift worker, and occupational health and safety risks (Cho & Steege, 2021; Di Muzio et al., 2019; Ganesan et al., 2019; Rajaratnam et al., 2013). Additionally, the annual cost of productivity loss in Australia that is attributable to inadequate sleep is approximately $17.9 billion per year (Sleep Health Foundation, 2011, 2017). Consequently, those who experience severe sleep disruption are most likely to leave their job within the next 2 years due to fatigue and burnout (Han et al., 2020; Hayes et al., 2012). Therefore, it is important to understand how healthcare shift workers are managing their shift work schedules to mitigate sleep and fatigue, and what measures needs to be taken to improve their coping strategies to maximize health and wellbeing and ensure safety of workers and their patients.

2. BACKGROUND

Healthcare is a challenging, high demand industry, especially combined with working shift work. Shift work is difficult because it requires workers to stay awake and alert during times when they would normally be asleep and sleep during times when they would naturally be awake. Consequently, shift work can have a negative effect on worker's ability to achieve sufficient sleep duration and quality (Ganesan et al., 2019; Sallinen & Kecklund, 2010). Sleep impairment reduces both alertness and performance, impairing cognitive function which can increase the risk of occupational injuries, such as medical errors, workplace injury, absenteeism, and motor vehicle accidents (Di Muzio et al., 2019; Ganesan et al., 2019; Rajaratnam et al., 2013). This can have a major effect on the health and safety of both the workers and patients (Berger & Hobbs, 2006; Dorrian et al., 2008; Sleep Health Foundation, 2017; Uehli et al., 2014), with research showing the odds of having a workplace injury, or making a medical errors increases by 2.43 when a shift work's sleep is impaired, compared to workers without sleep issues (Daley et al., 2009; Economics, 2017).

In addition to these organizational impacts, there are significant physical and mental health consequences for workers, including increased risk of depression, anxiety, diabetes, obesity and cardiovascular disease (Booker, Sletten, et al., 2019; Costa, 2010; Zhao & Turner, 2008). In severe cases, sleep impairment from shift work can result in a circadian misalignment sleep disorder known as Shift Work Disorder (SWD). SWD affects between 20% to 30% of the shift work population (Booker et al., 2022; Di Milia et al., 2013). This is characterized by chronic insomnia (difficulty falling, staying asleep and/or not feeling well‐rested) and/or excessive sleepiness (American Academy of Sleep Medicine, 2014). The development of SWD can exacerbate the ill effects and risks associated with shift work (Booker, Sletten, et al., 2019; Waage et al., 2014; Zee & Goldstein, 2010).

How shift work is managed is critical for the health, safety and longevity of a shift worker's career. Almost 70% of healthcare shift workers report experiencing fatigue and burnout (Smart et al., 2014; World Health Organization, 2020), with poor sleep being a contributing factor (Australasian Sleep Association Foundation, 2023; Chin et al., 2015). Applying evidence‐based sleep and shift work management strategies designed to increase alertness during shift work and improve sleep quality and duration after shift work can mitigate the impact of shift work on workers (Booker et al., 2022). These strategies include good sleep hygiene behaviour, bright light exposure (during shift), light avoidance (after a shift), scheduled napping, exogenous melatonin, timed caffeine consumption and specific shift work patterns (Barion & Zee, 2007; Waage et al., 2014; Wright et al., 2013; Zee & Goldstein, 2010). Improving our knowledge and understanding of how these strategies apply to healthcare shift workers can be an effective way to improve sleep outcomes (Booker, Barnes, et al., 2019; Vedaa et al., 2020). Understanding the benefits and challenges of shift work as perceived by healthcare shift workers and their coping mechanisms to manage sleep and reduce fatigue is important to inform future potential approaches and schemes.

3. THE STUDY

3.1. Aims and objectives

The aims of this study were to understand the benefits and challenges of working shift work and the coping strategies used by healthcare shift workers to manage sleep and fatigue due to shift work schedules.

3.2. Design

The study was a qualitative study design with a single case study with embedded units was used (Stake, 2013).

3.3. Participants

The project was a sample of convenience. This project followed on from a larger quantitative survey where participants had the option to be contacted for a follow‐up interview by providing their email address. Participants who provided their email address were sent information about the interview and a copy of the Participant Information and Consent Form (PICF). Once participants consented, a suitable day and time was organized to conduct the interviews. The project was promoted through relevant representative organizations, and social media and targeted adults over the age of 18 years that were currently employed as a nurse, midwives or paramedic in Australia and undertaking shift work.

3.4. Data collection

Data were collected using semi‐structured interviews. Questions were generated based on the projects survey findings and designed to provide a more in‐depth description of participants' experiences (positive and negative) with working shift work within a healthcare setting. A script with prompts was developed for the interviews and a test of the script was undertaken internally with registered nurses at the University. The script included questions around what coping strategies participants were engaging in to stay awake during shifts and sleep after shifts, what challenges, constraints and concerns they had working shift work (both mentally and physically), and if they had received any training and education on how to manage shift work schedules safety. In addition, they were asked if they had recommendations on how shift work conditions might be improved (at the individual and organizational levels).

The interviews took 30–40 min and were recorded in order to be transcribed and analysed at a later date. Based on past research and the repetition of interview data over time, 27 interviews were deemed sufficient and at saturation (Guest et al., 2006; Hennink & Kaiser, 2022). NVivo was used to code and categorize transcripts. Interviews were conducted between November and December 2022.

3.5. Ethical considerations

The study was approved by the REDACTED Human Research Ethics Committee in August 2022 (Ethics number: REDACTED). The project was not associated with the participants employer, as to assure confidentiality and anonymity and remain impartial from their place of work and was voluntary. Participants gave written consent to participate in the interviews and for the interviews to be audio recorded. They were fully informed about the study before giving consent and had the right to withdraw at any time. Data were saved under a unique identification number according to the rules and legislations of the participating institutions.

3.6. Data analysis and rigour

Interviews were recorded and transcribed verbatim. A preliminary round of coding and categorization was conducted by the team to identify initial themes. Transcripts were then entered into qualitative analysis software NVivo where they were coded and categorized. Selected grounded theory methods of initial and intermediate coding and the constant comparison of data were used to analyse each transcript (Birks & Mills, 2015). Data analysis was conducted by two authors independently to promote consistency and dependability. The final themes and subthemes identified were assessed and verified by the members of the research team.

4. FINDINGS

4.1. Overview of findings

A total of 27 participants were recruited to the study having expressed interest in being interviewed post a cross‐sectional survey. The sample included 20 nurses, five paramedics and two midwives. Employment locations were evenly distributed between metropolitan (n = 14) and regional/rural (n = 12) areas, with one participant working in a mixed location (both metropolitan and regional). The mean years of experience was 20.7 years. The sample composition reflects the Australian health workforce with a predominance of nurses as compared to paramedics and midwives. The sample size generated sufficient data to theoretically saturate the three categories identified in the analysis of the data (Birks & Mills, 2015). (1) Benefits of working shift work (2) Consequences of working shift work, and (3) Strategies to manage sleep and fatigue due to shift work. Each of the categories had a number of properties that illustrated aspects of the data.

4.2. Benefits of working shift work

For most participants, lifestyle and the increased flexibility of shift work schedules were discussed as the two main positives. This was followed by pay, job satisfaction and the belief that participants were helping people and doing valued work. Various work or travel incentives were also discussed as benefits, where they existed.

4.2.1. Lifestyle

Lifestyle benefits referred to the fact that shift work deviated from a ‘normal’ 9 am–5 pm, Monday to Friday job, offering the potential for more than merely a standard weekend off from work. This allowed participants time off during the week which improved access to various institutions, such as banks and post offices. This in turn made the organization of their lives easier, as the running of errands, shopping and other appointments could be conducted outside of busy weekend trading hours.

I enjoy shift work. I like being there at different times and having the ability to go to the shops etc. when nobody else is there. I think shift work's not bad. – 125/NSW/Nurse

It is nice sometimes to have a morning off during the week to do other things and then go to work in the afternoon. – 96/VIC/Midwife

This, coupled with the opportunity for late starts or early finishes, meant that shift workers often felt they had more personal time available: to exercise, sleep in or pick up their children.

There's a lot of positives. I mean, you get random days off when everyone else is doing stuff. So, you get time to do whatever. You get days to use for your self‐care, to enjoy the world, and it's at the least busy period … I know it sounds silly, but I love seeing the sun come up in the morning. –104/VIC/Nurse

All in all, shift work was seen as a positive way of having a work/life balance, that allowed the flexibility to do other things.

I've got a really good work‐life balance at the moment … I do my six shifts in seven days and then I've got seven days I can do whatever I want. That's convenient for me and it's very positive. –92/VIC/Nurse

4.2.2. Flexibility

Flexibility, which is closely associated with lifestyle, refers to the ability of shift workers to nominate their preferred shifts. Making strategic requests can result in extended periods of time off without using annual leave.

One of the big ones is that you do slightly longer shifts overnight, so then you have more days off than if you were doing just day shifts … and because like the three shifts are equivalent to four days … so it's like … there's one less shifts a week per fortnight I don't have to do. – 116/VIC/Agency Nurse

We get time off when everybody else is at work. And it's sad, because sometimes you've got to work weekends, but other times you've got weekends off, or you've got long weekends when it's not really a long weekend … so you gain time and, if you manage your roster, you can make it very comfortable for yourself. – 6/SA/Registered Nurse

4.2.3. Financial remuneration

Financial remuneration was often discussed as secondary to the lifestyle and flexibility benefits of shift work but was still a major positive aspect. Due to the existence of penalty rates, applied to different hours of work, and the fact that some shifts may be longer than ‘normal’ (9 am–5 pm) hours, some workers felt that they were paid more for completing less work [fewer hours in total].

You get more money for doing less shifts or less hours … or you get penalties for doing the not‐so‐fun shifts. – 116/VIC/Nurse

The shift penalties do help as well. I'm not going to say I don't like the money on the weekends and nights and afternoons. – 7/QLD/Registered Nurse

Additionally, various allowances were available to some workers, and this too helped contribute to a sense of financial reward.

There's actually a lot of incentives. So, we get paid like living away from home allowance. And we get paid to travel there as well. So, whether that's if we drive up, we get paid [kilometres] in travel time, or they'll fly us up and they'll pay for that. – 146/NSW/Paramedic

While lifestyle factors and financial rewards were the major positives of working shift work, other notable benefits were discussed. These aspects related to the benefits of specific shift types (e.g., night work).

Just that night‐time is a really nice time in the hospital. Basically… it's not a bad time to be working. It's like the lack of sleep… the payoff is that the hospital is quieter, you can get on with your work. – 125/NSW/Nurse Manager

Shift workers who enjoyed the nature of the work itself and the fact that health work was a benefit to others, discussed these as additional positives, that both kept them working in health care (acknowledging that often required shift work) and helping to counter some of the negatives of shift work.

I know there's other jobs that have shift work as well, it's not just healthcare. I think with healthcare … you have that other little gem that you're a service to others. – 113/QLD/Registered Nurse

4.3. Consequences of working shift work

The challenges of shift work centred around the many compromises that individuals had to make. The detrimental effect of shift work on worker health was commonly discussed, along with the compounding effect that certain rostering practices (e.g. working late‐early shifts) could have. The effects of fatigue and anti‐social hours on workers' families and social lives were also acknowledged as major negatives. Overall, these challenges served to undermine some of the positive aspects cited above, reinforcing this concept of compromise.

4.3.1. Fatigue

The major issue with shift work was fatigue, as this touched every aspect of workers' lives, both on and off the job. While individual participants commonly discussed feelings of tiredness and the effect this had on their ability to function and focus at work, it became clear that fatigue was apparent in every facet of their lives.

I would say absolutely the sleep, because if you don't sleep properly, it affects you mentally, physically, socially, psychologically. It hits every aspect of your life. – 104/VIC/Registered Nurse

I think coffee's been the big changer for me … getting the energy to get through the shift and stay awake and focus. Because the other thing is you have to be very focused. You can't make mistakes. You can't make drug errors. You can't forget stuff. – 96/VIC/Midwife

Fatigue could be exacerbated by various rostering practices, with the acknowledgment of the cumulative and detrimental effect of working “late‐earlies”.

Switching from nights to days, back to nights again, it really kills you. – 23/VIC/Nurse

This sentiment was identified multiple times, with one worker describing it as ‘torture’ ‐7/QLD/Nurse.

However, it was not common for participants to act when fatigued, instead participants generally endeavoured to make it through to the end of a shift, despite tiredness and fatigue. The workplace culture affected staff behaviour, with some workers commenting on their reluctance to burden other team members with their own fatigue.

You feel very guilty for taking a sick day cause you've woken up at 3:00 AM, and you've only had three hours to sleep before work, but you're like: ‘I can't call in sick because they'll be short’. – 62/VIC/Nurse.

[if] you say that person ‘I'm so tired I can't do it’ … in a sense, you're not being a team player, being unfair, because they're just as tired as you are. – 11/NT/Nurse

However, some workers did take the required actions when fatigue was experienced, acknowledging their personal responsibility in ensuring they and the people around them were safe.

Calling in and saying I'm tired and going: ‘you know what? It's not worth my life, it's not worth killing somebody’. So, I have a really low threshold for that. Where some of the others don't. So, for me, if I've had a busy period, I could get 80 hours and go: ‘I'll finish now, I'm tired’ and I'll just book off for the rest … it's just not worth it … to have that accident or injure somebody or kill somebody. – 44/SA/Paramedic

4.3.2. Health concerns

Participants felt real and immediate health implications as the result of shift work due to a lack of sleep and exhaustion. Additionally, unmanaged fatigue risked exacerbating any pre‐existing health conditions they had. The ramifications for long‐term heath were also a concern for workers, some of whom had spent considerable time working such rosters.

I'll probably look 20 years older than I should and I'm probably going to die young because I'm pretty sure this shift work is not ideal. – 147/NSW/Paramedic

Goodness knows what it's done to my health doing 19 years of especially night duty. – 72/VIC/Registered Nurse

And some participants felt that long‐term health issues were an unavoidable consequence.

I think that you pretty soon cotton on to the fact that you're going to feel rubbish for most of your life. –125/NSW/Nurse

4.4. Social compromises

Not only did fatigue directly impact personal health but also anti‐social hours and cumulative fatigue meant that absenteeism and the need for recovery impacted their ability to attend events and to be wholly present even when there. As a result, a worker's family and social life could suffer.

When I had young kids, it was really hard, because I always [had to] try and work Christmas, like all your public holidays, especially Christmas and Easter, I'd have to work night shifts just so I could stay awake and be there for my kids. – 115/VIC/ Nurse

While being rostered to work during social events was an obvious issue, the emotional effects of exhaustion could also diminish the quality of time spent with family and friends.

It's antisocial shift work, so you you're not having that regular contact with your friends as much because they've got their own nine to five jobs usually. – 23/VIC/ Nurse

4.4.1. Increased risks to safety

Sleep deprivation and fatigue were seen as impairing shift workers' ability to think clearly, presenting a risk to workers and patients, both during and after shifts. During work hours, participants told of how being sleep deprived negatively impact medication administration, patient management and interactions.

It's difficult to make drug calculations, it's difficult to think quick … Sometimes, even taking a blood pressure, and you're trying to think to yourself, ‘my God, is that right?’ You're just stupid. You feel like an idiot … but you're so fatigued. You're brain‐dead. We used to do like late, early, late, early sometimes and … you'd be totally screwed … I don't understand why they want to fatigue their staff so much, to the point that you are at such high‐risk of making a fatal error. – 113/QLD/Registered Nurse

Participants were also concerned about risks post‐shift. Worker's commuting was a particular concern, especially where participants had to drive home fatigued. In roles where driving was a requirement of the job, tiredness and fatigue brought this risk into the workplace.

I did have a job where it took me an hour and maybe 15 minutes, and on those drives home it was very difficult at times. I had nodded off, yeah. Which gave me a fright. I'd also driven up the next‐door neighbours' driveway, thinking that it was my house, but it wasn't. – 65/VIC/Registered Nurse

Unfortunately, this sense of increased risk often came with a level of psychological stress. For some workers, the implications of fatigue and risk of making an error or having a car accident lead to feelings of anxiety and worry.

Oh, all the time. Constantly. You go home from work, and some shifts are worse than others, but you'll go home from work, and you think: ‘have I done everything?’, ‘did I check everybody?’, ‘was everybody still alive when I left?’. You know stuff like that, it can play on your mind. – 65/VIC/Registered Nurse

4.5. Coping strategies

Intra‐shift strategies relied on trying to stay alert and taking time to recover wherever or however possible during their shift, while inter‐shift coping strategies relied more heavily on the development of routines and structures outside of the workplace to sleep and recover. However, there was no one‐size‐fits‐all approach as strategies did not work for everyone. Therefore, participants tried to devise the most effective techniques they could overtime by trial and error over.

It's kind of just like figuring out what best worked for me, trying kind of like trial and error … obviously there was some suggestions from peers and stuff like that [who] had been doing a bit longer than I have when I first started. So yeah, probably a bit of a trial and error and also advice from colleagues around how to manage. – 146/NSW/Paramedic

4.5.1. Diet

The most common intra‐shift strategy used by participants revolved around food. Most participants depend on caffeine to keep themselves alert at work:

Coffee's been the big changer for me in … getting the energy to get through the shift and stay awake and focus. – 96/VIC/Midwife

While others used high sugary foods to get energy and cope with shifts, especially night shift.

We eat a lot. I'm not a great coffee drinker, but I do tend to eat overnight snacks. I love chocolates and cakes and all of those sorts of bad things. I don't eat healthy food at night. – 65/VIC/Registered Nurse

We eat a lot. I'm not a great coffee drinker, but I do tend to eat overnight snacks. I love chocolates and cakes and all of those sorts of bad things. I don't eat healthy food at night. – 65/VIC/Registered Nurse

4.5.2. Exercise

Strategies relating to the maintenance of general health (combination of both diet and exercise) and ensuring that there was adequate time to ‘wind down’ were between shifts were also mentioned.

I exercise, you know, before a shift you know and take some time out for myself as well. – 111/VIC/Nurse

Eat properly where you can, keep exercising, keep a good BMI … keep your strength, because … it's not just your mental health, it's your physical health. – 44/SA/Paramedic

4.5.3. Co‐worker support

Participants often also relied on co‐workers for support, by either helping them to help identify if they were getting fatigued or being affording time for rest and recovery within a shift.

Some of my colleagues have said: ‘can you just drive? I'm tired, it's three in the morning’, … so you just drive for them. You go and get a coffee. You poke them in the eye. Whatever you need to do to keep them awake. So, with the driving it's all about just working together. – 44/SA/Paramedic

We're very good at that in Emergency, we tap each other out sometimes. Like, I will say to my colleague: Hey, I need to tap out for a couple of minutes. – 104/VIC/Registered Nurse

4.5.4. Medication

However, even though the establishment of consistent routines and structures at home, centred around meal preparation, was important, sleep was the only cure, with many resorting to medications to aid in sleep.

Phenergan is really good. It's an antihistamine that also clears your sinuses and makes you really drowsy and if you don't use it on a regular basis. It's really good, sort of once in a blue moon, to have that and really … knock you out. – 23/VIC/Registered Nurse

4.6. Advice and recommendations for change

Most participants agreed that education around the realities and specific challenges of shift work was important. This could be delivered either at the university or within the workplace; however, very few participants reported receiving such education. Rostering was also seen as exacerbating the issue of fatigue and transparency and fairness of the rostering was identified as another area for improvement.

4.6.1. Sleep education

What was common with all participants' recommendation was the need for more information on how to better manage fatigue and get enough sleep. However, participants were often given no guidance on how to cope with their shift work schedules. In particular, participants identified that education consisting of strategies to cope and manage their sleep and shift work were not taught during their training.

I don't think, even now, it's included in the university education. I don't think they have any education about how to care for yourself. And because it's a job that's very giving, it usually attracts giving people… so it usually that means you put your needs aside. I think it's important to give people permission to look after themselves, as well as look after others. – 3/WA/Clinical Nurse

I don't remember ever having a lecture on sleep or shift work when I was a nursing student. I mean, I spent four years learning about bloody nursing, diagnosis, and useless stuff … they should have taught us this because this is‐ this is probably the biggest part of our job. – 104/VIC/ Nurse

But if they were given the skills and knowledge, it would be beneficial, especially early in their careers.

No one really teaches us about sleep, and I feel that if it could be taught to us that it would be a massive benefit. – 1/QLD/Paramedic

However, many commented that the difficulties they experience would be hard to adequately communicate to the uninitiated and that preparation for shift work would benefit from actual experience, received in placements or on‐the‐job.

You can talk to students whilst they're in university, but it won't become real until they actually experience it. It's a bit like, you know, teach one, see one, do one. So, you can teach them about it, but it won't become meaningful to them until they're actually a part of actually doing it. – 3/WA/Nurse

4.6.2. Sleep management policies and rostering practices

Throughout the interviews, the responsibility for fatigue management was highlighted. While it was acknowledged that appropriate coping strategies were the responsibility of employees, participants felt that the workplace also required certain practices and protections for shift workers, such as fatigue management systems and safe rostering practices in place.

I know it can't be helped all the time, but … people who roster the night shift in other wards or areas can do it very well and, where I work, I don't think it's done very well at all. – 111/VIC/Nurse

While it was acknowledged that those in charge of rostering had a difficult job, it was also felt that it was the task of staff doing the rosters to consider the effects that a combination of shifts had on staff.

Issues around the transparency and consistency of rostering meant that some workers felt unfairly burdened.

There's still a lot of organisations now, especially in nursing, that still do the late‐earlies which, you are lucky if you get five hours sleep. And then you've got to be back on, and you've got to make, you know, lifesaving decisions. – 113/QLD/Nurse

I think the self‐rostering works to an extent, but then other people miss out. So, you get the people that will self‐roster their entire roster and then other people won't do anything, so they get all the leftover shifts. – 115/VIC/Nurse

5. DISCUSSION

Those who were willing to make the compromises that shift work required did so for several reasons. Workers enjoyed the lifestyle, the flexibility, and the financial rewards that came with working shift work, and often enjoying the work itself. However, fatigue and sleep deprivation seriously undermined these benefits, as both the quality and duration of time with family and friends was eroded. Risks to the public, along with the likelihood of immediate and long‐term health consequences for the workers themselves, were also concerns. This raises questions about how best to inform people working shift work in the healthcare industry to better manage their sleep and fatigue.

While participants highlighted many positives to working shift work, these were diminished by the negative effects. Besides the potential convenience of working outside of the normal 9–5 h and the financial rewards of shift work, these workers had to manage a range of physical and mental impacts, such as feeling too exhausted and fatigued to be able to do anything after work. This is a concern for the longevity of healthcare shift workers, with many burning out and quitting the industry (Wisetborisut et al., 2014). Statistics show that the healthcare industry has the highest turnover rates in Australia, with between 12% and 38% of workers leaving (Hayes et al., 2012; Pressley & Garside, 2023), with poor sleep and burnout being major reasons (Pressley & Garside, 2023). Low retention rates are also costly to the organization, as the cost of advertising, onboarding and training new employees, and the loss of productivity in between hiring (Mills et al., 2016; Roche et al., 2015), is estimated to cost upwards of $100–150,000 per hire in Australia (Roche et al., 2015) (Bae, 2022). Therefore, it is important that healthcare shift workers can effectively manage and successfully cope with their shift work schedules.

Health intervention programs for shift workers commonly include healthy eating, yoga and mindfulness (Montayre et al., 2023), but often do not address the underlying issue of shift work, which is the loss of and/or impact on sleep. Knowledge of how shift work schedules impact sleep and fatigue is important. Lack of education means that healthcare shift workers are potentially learning strategies by trial and error, potentially leading to the development of poor sleep hygiene habits, diet and/or resorting to alcohol and medication as sleep aids to cope. Research shows that by learning how to adjust internal circadian rhythms to meet fluctuations in shift work schedules, such as timed caffeine intake, naps and bright light exposure, shift workers can reduce their sleepiness and fatigue and decrease the risk of sleep‐related workplace accidents (Berger & Hobbs, 2006; Di Muzio et al., 2019; Gander et al., 2020). Additionally, diet and poor food choices at inappropriate times can impact sleep such as eating difficult to digest foods, consuming caffeine or alcohol and eating high sugary foods (Shriane et al., 2020; Zhao & Turner, 2008). Sleep education and training that includes information on the biology of the circadian rhythm, good sleep hygiene principles, sleep strategies specific to shift work, behaviour change approaches (that reinforce healthy sleep and diet habits) and psychological support (that address sleep disturbances related to job stresses) have been shown to be effective in improving sleep and depression in nurses (Booker et al., 2022; Burton et al., 2016). In the current study. however, no participant said they were provided any education on how to manage shift work, sleep and fatigue, at either an academic or employment level.

In Australia, workplaces are required, under the Occupational Health and Safety (OH&S) Act (2004 and 2014), to provide (so far as is reasonably practicable) information, instruction, training and supervision necessary to enable employees to work in a way that is safe and without risks to health such as for managing fatigue risk (Australia, 2004). What this training should include is not defined. However, guidelines from the WorkSafe Victoria state that necessary training and information should include: body clock and sleep processes (including sleep hygiene and sleep disorders), risk factors for each type of fatigue (physical, mental and emotional), signs and symptoms of each type of fatigue in self and others, procedures for preventing fatigue, health and lifestyle factors that may contribute to fatigue or impede good quality sleep, and balancing work and life demands (Victoria, 2020). This study indicates that participants may not have received the appropriate training (by their employer or by academic organizations). Therefore, a review of the policies and guidelines of healthcare organizations, including implementation and adherence is needed. Training that incorporates sleep and shift work management strategies is required. This could take place as part of professional onboarding practices and/or during academic training, to equip healthcare shift workers with the skills required to manage the challenges of shift work from the start, thus improving shift workers' quality of life that and minimizing risk to patients.

Additionally, organizational changes could also be made to reduced shift work impacts, with shift work rostering practices being one area that could be improved (d'Ettorre & Pellicani, 2020). Issues around rostering practices were identified by several participants in this study including the amount of late/earlies being rostered and the lack of consideration of breaks in‐between. Research shows that the reduction of late/earlies (working an evening shift then doing a morning shift), implementing forward rotating shift work schedules (days, evenings, nights and then days off), introducing rest periods of at least 10 h between consecutive shifts, and at least one rest day off after night shift can be effective in minimizing the impact of shift work and in preventing the misalignment of sleep–wake rhythm due to shift work schedules. The demands of a 24‐h care cycle means that staff must work around the clock, therefore also ensuring the provision of amenities that facilitate the safety and recovery of these staff is important. For example, providing sleep facilities for staff, where appropriate, could help support the coping practices outlined by staff and be available both within and between shifts. The use of such spaces could also extend to those having to commute after long or late shifts. While napping at work can be culturally seen as controversial and discouraged by management, past research shows that napping during or after a shift is a successful strategy in decreasing the risk of work‐related fatigue (Martin‐Gill et al., 2018; Shriane et al., 2020), with improved performance and decreased fatigue during and after a shift (Martin‐Gill et al., 2018; Takahashi, 2003). Worker transportation was also a major concern, with commuting to and from work discussed as a particularly difficult or dangerous aspect of shift work. Initiatives such as bus services or closer accommodation (particularly in regional or rural settings) could help minimize this risk and free public transport.

Impaired sleep and alertness are putting the health and safety of workers and patients at risk (Berger & Hobbs, 2006; Di Muzio et al., 2019; Uehli et al., 2014). This study provides valuable insight into the struggles and concerns workers have and what strategies are being used to cope and manage their shift work schedules. It is hoped that this study helps to draw attention to some of the shortcomings in the how sleep and fatigue is managed, and occupational health and safety risks involved.

5.1. Strengths and limitations

This study explored the impact of shift work on sleep and fatigue from the perspective of healthcare shift workers. Drawing from those affected, this study provides a detailed insights into the real‐world concerns around sleep and fatigue and the strategies healthcare shift workers implemented to cope with the demands of their shift work schedules. Recommendations or changes outlined in this study may be helpful in guiding future policies and research. Caution is needed however, because, even though the themes were consistent across different healthcare professions (nurses, paramedics and midwives), the findings from this study may not necessarily be generalizable to all healthcare shift workers or other professions such as medical practitioners. In addition, territory training and knowledge may vary between States and University and other countries. Nonetheless, even though there are potential differences in occupations, workloads, tasks, etc. in this sample, their experiences of shift work schedules in general were similar. Shift work was difficult for everyone and how they coped, the concerns and experiences were comparable across the board.

5.2. Recommendations for practice

The alertness and cognitive function of healthcare shift workers is vital to maintain a healthy and safe workplace for themselves and their patients. This study provides a valuable insight into how healthcare shift workers manage their shift work schedules and identifying potential areas of concern such as the physical and mental health toll and safety concerns that need to be addressed. Future research is vital to look at what the best way to equip healthcare shift workers with the skills and knowledge needed to cope with their shift work schedules in a safe manner to minimize sleep deprivation and fatigue. For example, this study identified that more education was required and should include specific evidence‐based coping strategies to help healthcare workers manage shift work impacts. If this is at a territory education or employer level needs to be explored. Organizations also need to look at how shift work rosters are developed and also the work environment to help improve alertness and reduce fatigue of their workers.

6. CONCLUSION

Ultimately healthcare shift workers seem to be lured by the lifestyle benefits and the pay, and because they enjoyed the work they did and being of service to others. What workers needed was to be supported in these roles, so that the toll it took on them and their lives could be sustainably managed. It is hoped that outcomes from this study will help drive and guide organizational and policy level changes within the sectors.

AUTHOR CONTRIBUTIONS

LB, JF, JM, MB, JS, MDC, TS: Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; LB, JF, JM, MB, JS, MDC, TS: Involved in drafting the manuscript or revising it critically for important intellectual content; LB, JF, JM, MB, JS, MDC, TS: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; LB, JF, JM, MB, JS, MDC, TS: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

FUNDING INFORMATION

This project was funded by WorkSafe Victoria.

CONFLICT OF INTEREST STATEMENT

First author was supported by the funder. No other conflict of interest has been declared by the authors.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This research has been approved by the Human Research Ethics Committee, and written informed consent were obtained from all participants. All methods were performed according to the relevant guidelines and regulations.

Booker, L. A. , Fitzgerald, J. , Mills, J. , Bish, M. , Spong, J. , Deacon‐Crouch, M. , & Skinner, T. C. (2024). Sleep and fatigue management strategies: How nurses, midwives and paramedics cope with their shift work schedules—a qualitative study. Nursing Open, 11, e2099. 10.1002/nop2.2099

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not be publicly available due to privacy or ethical restrictions.