Experiences and perceptions of nurses working night shift: a qualitative systematic review protocol

ABSTRACT

Objective:

The objective of this qualitative systematic review is to examine the available evidence on the experiences of nurses working the night shift within any specialty in the acute care, subacute, or long-term care setting.

Introduction:

Nurses are required for round-the-clock patient care, and night shift nurses can experience detrimental effects as a result of their work hours. Understanding nurses’ experiences when working night shift will facilitate the development of strategies to minimize the potential negative effects of working at night. In examining nurses’ perceptions of working night shift, there is scope to explore how to improve night shift nurses’ practice environment and job satisfaction, which will then translate to improved patient outcomes.

Inclusion criteria:

This review will consider qualitative studies that include registered nurses and licensed practical nurses who work night shift or rotate between day and night shift. Night supervisors and advanced practice nurses will be excluded due to the potential for dissimilar experiences and resources within those groups. The search will be limited to studies published in English from 1983 to the present.

Methods:

The search strategy is designed to locate both published and unpublished qualitative studies by searching academic databases for published studies, gray literature, and hand searching reference lists. The study selection, critical appraisal, data extraction, and synthesis for this systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.

Systematic review registration number:

PROSPERO CRD42019135294.

Introduction

Despite its importance, night shift nursing is one sector of nursing that has been largely unaffected by innovations in nursing practices in the previous two decades.¹ It continues to be the most challenging shift to work, and night shift staff are often invisible and undervalued.² More recently, researchers have examined the differences between a typical day shift and night shift in hospitals, and found less nursing and ancillary staff, more on-call personnel, newer staff, fewer services available, and less supervision on the night shift.³,⁴,⁵

The UK government defines night work as a shift of at least three hours between 11 p.m. and 6 a.m.⁶ The US Bureau of Labor Statistics defines night shift as between 9 p.m. and 8 a.m.⁷ In the United States, night shift for nursing occurs most commonly between 7 p.m. or 11 p.m. and 7 a.m.⁸,⁹ Of nearly 5.8 million registered nurses (RNs) and licensed practical nurses (LPNs) in the United States, the exact percentage of how many nurses work the night shift is unknown.¹⁰ Registered nurses and LPNs are required to work at night because patients in acute care, subacute, and long-term care settings require constant vigilance.

Evidence suggests that working at night disrupts nurses’ circadian rhythms and has consequences on their physical and mental health, with ramifications on job performance and satisfaction.¹¹ Drowsiness, fatigue, sleep deprivation, and poor sleep quality have been identified by those who work at night.⁹,¹²,¹³,¹⁴ In addition, nurses are at increased health risks when working at night. Recent studies have found that nurses who work at night have increased risk of cardiovascular disease and diabetes, and reported more depression than day shift nurses.¹⁴,¹⁵,¹⁶,¹⁷ Working the night shift also has an effect on workers’ mental well-being, can cause mood changes, and result in work-to-family conflict.¹⁸,¹⁹

This disruption to nurses’ circadian rhythms impacts performance, and nurses working at night have more work-related injuries and a significantly increased risk of drowsy driving incidents after working a night shift.¹²,²⁰,²¹,²² Sleep-related errors have been identified for night shift workers, and research has found that night-shift napping decreased sleepiness and improved performance.²³ Research studies also suggest that nurses working the night shift have more patient care errors.¹³

An abundance of research has been conducted that links features of a positive nurse practice environment to better nurse and patient outcomes²⁴,²⁵; however, information is lacking on the nurse practice environment specifically for night shift nurses.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted, and no current systematic reviews were identified addressing the experiences and perceptions of nurses working the night shift.

Although two related systematic reviews examining the relationship of the evening, night, and weekend shifts to outcomes were uncovered, the authors were unable to identify any reviews that explored the experiences of nurses working the night shift. The first review, a mixed methods systematic review of qualitative and quantitative studies, examined the evidence of how evening, night, and weekend shifts affected quality patient and employee outcomes in hospitals.²⁶ Sixty studies were included with 37 studies examining patient outcomes of mortality, length of stay, frequency of procedures, and treatment delays. Of the 19 studies that researched employee outcomes, seven studies focused on nights, finding that employees who work night shift had more injuries and greater fatigue than those who work day shift.²⁶ Lastly, four qualitative studies examined nurses’ perceptions about patient and employee outcomes, finding less staff, less supervision, and decreased resources, which fostered more independent thinking by nurses.²⁶

The second, more recent, systematic review examined the relationship between shift work and errors and performance.²⁷ Thirteen studies, including one qualitative study, covered a variety of fields including the health care (the majority), industrial, and transportation industries, as well as safety officers. This review concluded that working the night shift has an impact on employees’ health, which may be a factor in the increase of errors and decrease in performance.²⁷

It is important to better understand nurses’ experiences when working at nighttime, outside the regular routines of their families and society, in order to improve the night shift work environment and minimize the potential detrimental effects of working at night. A meaningful synthesis of qualitative evidence will assist staff, nurse leaders, and organizations in developing guidelines and interventions to create a better experience when working the night shift, which will positively impact patient outcomes.

The objective of this qualitative systematic review is to examine the available evidence on the experiences and perceptions of nurses working the night shift or rotating between day and night shift within any nursing specialty in the acute care, subacute, or long-term care setting.

Review questions

i) What are the experiences and perceptions of nurses working the night shift or rotating between day and night shift within any specialty in the acute care, subacute, or long-term care setting?

ii) What are nurses’ perceptions of the working conditions during the night shift?

iii) What are nurses’ perceptions of the duties that are unique to working the night shift?

iv) What do nurses perceive as the challenges of working the night shift?

Inclusion criteria

Participants

This review will consider qualitative studies that include nurses who work the night shift or rotate between day and night shift. Studies will be included when authors mention that participants work the night shift or any time period inclusive of the time between 11 p.m. and 6 a.m. Registered nurses and LPNs who work a full-time, part-time, or per-diem night shift or rotate between day and night shift will be included.

Administrative or night supervisors, nurse midwives, and advanced practice nurses will be excluded because their roles, experiences, and resources are different from those of direct care nurses.

Phenomena of interest

The phenomena of interest will be the perceptions and experiences of nurses who work the night shift or rotate between day and night shift.

Context

This review will consider qualitative studies that are within any nursing specialty in the acute care, subacute, or long-term care setting.

Types of studies

This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and qualitative descriptive work. Studies published in English will be included in this review as this is the primary language of the reviewers. Studies published from 1983, when the seminal work on hospitals that attract and retain nurses was published, to the present will be included.²⁸

Methods

The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.²⁹

Search strategy

The search strategy will aim to locate both published and unpublished studies by searching academic databases for published studies, sources of gray literature for unpublished literature, and hand searching reference lists for studies not identified through the search of databases and gray literature.

An initial, limited search of PubMed and CINAHL was done using the terms “night shift” OR “shift work” AND “nursing.” This confirmed that there is qualitative research on the phenomenon. The titles, keywords, and index terms from the limited search will be analyzed to obtain comprehensive search terms and a second, expanded search using all identified keywords and index terms tailored to specific databases will then be undertaken. A sample search strategy for CINAHL is presented in Appendix I.

Information sources

The databases to be searched include MEDLINE (Ovid), CINAHL, Embase, PsycINFO, and Web of Science. Unpublished or gray literature will be searched for using MedNar, Google Scholar, Virginia Henderson International Nursing Library of Sigma Theta Tau International, and ProQuest Dissertations and Theses. The reference lists of all identified reports and articles will be searched for additional citations. Additionally, conference proceedings from the past five years from Magnet, Eastern Nursing Research Society, and Western Institute of Nursing conferences will be reviewed to identify any presentations on night nurses’ experiences, and the identified authors contacted.

Study selection

Following the search, all citations will be collated and uploaded into EndNote X8 (Clarivate Analytics, PA, USA) and the duplicates removed. The titles and abstracts of articles identified in the search will be screened independently by two reviewers for appropriateness and the results compared. Any disagreements between the reviewers will be handled by joint review and discussion of the relevant title and abstract. The full text of potentially relevant studies will be retrieved, re-reviewed against the inclusion criteria, and eligible study details will be entered into the JBI System for the Unified Management, Assessment, and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in an exclusion table in the final paper. Any disagreements that arise between the reviewers at this stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.³⁰

Assessment of methodological quality

Papers meeting the inclusion criteria will be assessed independently by two reviewers for methodological validity prior to inclusion in the review using the JBI Critical Appraisal Checklist for Qualitative Research.²⁹ All studies will be appraised, and papers not meeting criteria 2 (congruity between the research methodology and the research question or objectives), 4 (congruity between the research methodology and the representation of the analysis of data), and 8 (participants and their voices are adequately represented) will be excluded without full review. Full appraisal will be conducted on all remaining articles. This will ensure that the methodological approaches were appropriate and that the voices and meanings of study participants were captured. Any disagreement between the two reviewers will be resolved through discussion or by a third reviewer. Authors of papers will be contacted to request missing or additional data for clarification, where required.

Data extraction

Qualitative data will be extracted from included papers independently by two independent reviewers using the standardized JBI qualitative data extraction tool.²⁹ Results will be cross-checked, and any differences discussed and clarified prior to entering data into JBI SUMARI. Initial extraction will include data relevant to the phenomena of interest, populations, study methods, and outcomes specific to the review questions. Findings will be verbatim extractions of the authors’ analytic interpretations (themes), along with relevant illustrations (participant quotes or fieldwork observations), if available, and page numbers of the findings. Each finding will be assigned a level of validity or credibility. Authors of primary studies will be contacted for missing information if necessary.

Data synthesis

Qualitative research findings will be pooled by the team using methods outlined in the JBI approach for qualitative systematic review.²⁹ The findings from studies regarding nurses who work the night shift and from studies with nurses who rotate between day and night shift will be analyzed separately and then analyzed together to determine common or varied findings. This involves the aggregation or synthesis of findings to generate a set of statements that represent that aggregation by assembling the findings (level 1 findings), rating findings according to their quality, and categorizing these findings on the basis of similarity in meaning (level 2 findings). These categories will then be subjected to a meta-aggregation to produce a comprehensive set of synthesized findings (level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.³¹ The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest, and context for the specific review. Each synthesized finding from the review will then be presented along with the type of research informing it, a score for dependability, a score for credibility, and the overall ConQual score.

Appendix I: Search strategy

CINAHL (EBSCOhost)

Search conducted on 12/14/2019 – Total results 1124