The good and bad of night shift

Hi again! I thought I'd write a post about the good and bad of night shift, since I see people ask on forums what it's like and all. I've been working nights exclusively since almost the start of my career six years ago, and there are distinct pros and cons to it. It's definitely not for everybody, and frankly it's not great for me considering my narcolepsy history, but I still love it and can't get myself to switch to days.

There are several things I like about night shift. For one, the pay. Night shift often gets a pay differential because of the impact it has on your personal life outside of work physically, emotionally, and mentally (I'll get to that in a minute). For me, I also just love the team on night shift. I often get time to have a short chat with nurses and techs working with me when patients sleep, which is great for strengthening team bonds. Teamwork is essential in nursing, and without a solid team you can depend on, you're destined for burnout. When I did day shift, I found that pretty much everyone was too busy to ever talk or help each other, and the stress seems to make a lot of day shifters a bit cranky... I'm not saying they all are, but it's a general pattern at least where I work. The third pro is related to this, and that is the slower pace. With way fewer procedures, doctors, visitors, and medications to give, the pace is significantly slower. As long as we do our hourly rounding and charting, there is often some "downtime" during the night when we can work on homework, chat, read, etc. I find people are in a better mood when there's less pressure and stress, so we get along really well. Occasionally, we get together at the nurses' station halfway through the shift to do some stretches together to help us stay awake, which often ends up with laughter. Please note, experiencing downtime is not the same as neglecting patients. Downtime is when the patients are trying to sleep so we don't disturb them, but we do still monitor them. With regular rounding, peeking in through windows, checking telemetry alarms, etc., we can experience a little downtime while keeping our patients safe.

Another pro in my opinion is the lower amount of managerial supervision and monitoring. I don't mean this in terms of getting away with breaking rules. I mean like it promotes a sense of autonomy and reduces the pressure experienced when performing job responsibilities under a microscope. I'll admit I also do enjoy the fact I can "get away with" wrapping up in a warm blanket while charting on night shift. Not that this is against an established rule, but it's probably more frowned upon as "unprofessional" in front of the doctors, visitors, and managers that are around during the day.

Night shift does not come without its cons though. It sounds "easy" when you first think about it. You may be thinking, "No supervisor, less to do, and better pay??? Sign me up!" The truth is, night shift can do some major damage to your health, physically and mentally. Normally when you leave work on day shift, you're actually leaving work. You aren't struggling to realign your circadian rhythm with the rest of the world, you aren't fighting sunlight while you try to sleep, you aren't functioning in a society where everyone around you is asleep. During the day on your days off, people are out and about, stores are open, you can meet friends and family, get errands done, and not struggle to wake up for appointments. When you do night shift, your days off can be pretty hard on you. There are lots of studies about how people who do night shift or shift work are more likely to be depressed, be socially isolated, have a weakened immune system, be fatigued, etc. I personally often experience those effects, I won't lie. Several doctors have insisted that I switch to day shift, mainly due to the effect on my mental health and narcolepsy, and I know they are right. But I honestly just love my night team so much, love the pace, and need the pay. So I have not been able to heed their advice.

Night shift itself has several challenges outside of the lifestyle effects as well. On night shift at the hospital, most of the doctors are asleep, most services are closed, resources are harder to come by, and response time when reaching out to diagnostics or doctors on call is slow. There have been a handful of times where I've had to activate an emergency team because the patient was declining rapidly, and the covering doctor wasn't replying quickly enough. A lot of times, we have to leave messages with a messaging system for a call back about a patient. At my hospital in particular, the hospitalists cover about 10 patients each on day shift, but about 400 patients each on night shift. When I reach out to a hospitalist, they usually are not familiar with the patient from the start because their job is to make sure everyone survives until morning, not make new treatment plans customized for the patient or attend to every concern that comes up. The attendings on day shift know their patients much more in detail, so they make changes to plans and medications and related things like that. As a result, most things that aren't directly harming the patient or dangerous to someone in some way are left for the day team. The number of times covering doctors have refused patient requests or needs and instead said "defer to day team" is astounding. And don't get me wrong, I'm not criticizing them for it. I feel like it's a system flaw to have one doctor be responsible for 400 sick people at once... Of course they don't have time to write a note for the patient's boss or order non-essential labs or medications or come talk to the patient about their questions. In fact, on rare occasions I've been snapped at for asking for something non-emergent. By now, I've learned what things are appropriate to handle at night and what things have to wait until daytime, but I didn't always know that. Every hospital is different, so some may have better staffing than others and are more capable of helping with less-emergent needs, but in general, I've learned that things like critical labs, unstable vitals, changes in patient condition, new admissions, etc. are appropriate, while abnormal but not-critical labs, iffy vitals, and trivial requests like for laxatives have to wait until daytime. In fact, my workplace has developed a matrix of what concerns to page the doctor about, chat the doctor about, or just defer entirely to day shift.

I think, aside from the inconvenience that often comes with not having many doctors or access to resources at night, it can sometimes be frustrating when day shift assumes we are "being lazy" because we didn't handle some of those trivial concerns. A great example is repleting or replacing electrolyte imbalances. If they are critical or dangerous imbalances, then there is no excuse for the nurse not to get an order for repletion and administer it. But if the lab values are "not ideal" but are also "not unsafe", doctors on night shift will almost always say no if we ask for orders to replete. I remember this one particular time, early in my career, where a patient had a potassium of 3.6 mEq. This is technically in normal range, but on a cardiac unit, we typically aim to keep it above 4 mEq. Rather than leaving it for day shift to deal with, little old me tried to be helpful and get it repleted on my shift. So I messaged the doctor by chat asking if they wanted it repleted. She replied, "Only message me about critical values" and then rage-quit the chat. I never made that mistake again, unless, for example, the 3.6 was causing abnormal heart rhythms. In my experience, a good rule of thumb when deciding whether or not to reach out to the doctor about something is to ask myself, Is this causing harm or potential harm to the patient now, or can it safely wait until day shift? I often feel bad about this, because I know it means more work for day shift... But, that's just sort of the way it is.

Now, let's talk about the patients on night shift... I'm going to make this a part 2 post. There's so much to say about patients on night shift, and the very real phenomena of "sundowning" and "sunrising".

To be continued...

• Bella, RN