ORIGINAL RESEARCH

Night work and its meanings for intensive care unit nursing

Marlusse Silveira^I; Silviamar Camponogara^II; Carmém Lúcia Colomé Beck^III; Valdecir Zavarese da Costa^IV; Graziele Lima Dalmolin^V; Éder Luís Arboit ^VI.

^I Nurse, Master in Nursing, University Hospital of Santa Maria, Rio Grande do Sul, Brazil. E-mail lussisilveira@yahoo.com.br
^II Nurse; PhD in Nursing, Professor at the Federal University of Santa Maria. Rio Grande do Sul, Brasil. E-mail: silvia@ufsm.yahoo.com.br
^III Nurse; PhD in Nursing, Professor at the Federal University of Santa Maria. Rio Grande do Sul, Brasil. E-mail: carmembeck@gmail.com
^IV Nurse; PhD in Nursing, Professor at the Federal University of Santa Maria. Rio Grande do Sul, Brasil. E-mail: grazieledalmolin@yahoo.com.br
^V Nurse; PhD in Nursing, Professor at the Federal University of Santa Maria. Rio Grande do Sul, Brasil. E-mail: valdecircosta2005@yahoo.com.br
^VI Nurse, Master in Nursing, Professor at the University of Cruz Alta. Palmeira das Missões, Rio Grande do Sul, Brazil. E-mail: earboit@unicruz.edu.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.17416

ABSTRACT

Objective: to understand the meanings of night work for nursing professionals at Intensive Care Units. Method: analytical-descriptive study with a qualitative approach approved by the Research Ethics Committee, CAAE: 11467512.0.0000.5346. The participants were 13 nurses and nursing technicians at intensive care units from a university hospital in southern Brazil. The data collection lasted between October and December 2013, through recorded semi-structured interview; the data were submitted to thematic content analysis. Results: it has been highlighted that the meanings of night work consist of the interrelationship set between the satisfaction and the dissatisfaction at work, composed by personal motivations and characteristics of night work. Conclusion: time is an outline of personal motivations and work characteristics. Night work exceeds the work shift, infers personal planning, the project of personal wishes and goals concerning professional development for nursing professionals. It is a mechanism which responds to and materializes the personal life of the workers.

Keywords : Nursing; night work; critical care nursing; critical care.

INTRODUCTION

Human work assumes its relevance in guiding people in the development of societies. It contributes to the construction and transformation of the world, and organizes the conduct of people in society¹. It is one of the most important practices because it generates elements of subsistence and personal/professional fulfillment². This conformation goes beyond the financial value when it represents personal fulfillment and becomes a point of health balance and restoration.

In the health context, the work occurs in shifts due to the assistance provided in the 24 hours of the day³. Nursing develops its work activities in several spaces and in the morning, afternoon and evening shifts, a fact that is intensified in the hospital scenario, given the dynamics of care centered on the cure of diseases.

Nursing performance in these institutions has particularities, especially in the case of intensive care units (ICUs), which is an environment characterized by continuous patient care, qualified human resources, high-tech devices and the need for agility and strict attention in the care ⁴.

Such characteristics associated to the continuous stay of workers in the day or night shifts next to the patient can have implications to the life and health of these workers. In this context, professionals must adopt strategies to minimize the repercussions resulting from night work, as well as to reduce the rates of illness, as a way of contributing to the promotion of health and satisfaction in the work environment⁵ and qualifying the care provided to the patient.

In light of the above, the following research question emerges: what are the meanings of night work for ICU nursing professionals?. The objective is to understand the meanings of night work for nursing workers of intensive care units (ICUs).

LITERATURE REVIEW

The human being is a species with diurnal habits. Thus, organic, corporal, social and personal adaptations are necessary for the night work. The main purpose of the work in health institutions is to provide qualified care to the patient/user, who requires comprehensive and multidisciplinary assistance, aiming at the resolution of actions related to health promotion, rehabilitation and recovering and prevention and treatment of diseases, articulating with public policies at the municipal, state and federal levels.

Thus, the work performed at night has different meanings for each worker and its repercussions deserve to be the subject of further scientific investigation in the different institutional settings since night work is inherent to nursing work in the hospital environment³ and because of the changes it promotes in the personal, social, psychological and organic context of these workers.

In this context, night work is part of the nursing profession. Although it causes problems in workers' health, it must be developed, since the assistance, the service and the work are continuous, and the use of strategies that allow the reduction of the consequences in the worker's health is essential ⁶.

However, night work is not seen by nursing workers only as a cause of illness and imbalances to their well-being. It is also related to positive factors such as: greater interaction between team members and patients; reduction of the number of examinations and the flow of people in the unit compared to the day shift; quieter and more silent environment; availability of daytime hours to study or perform other activities; more time to raising children; possibility of greater financial gains with additional night remuneration and/or other jobs⁷.

METHODOLOGY

This is an analytical-descriptive research with a qualitative approach ⁸ performed with adult and cardiac ICU nursing workers from a university hospital in the south of Brazil. This unit was chosen because of the characteristics of the work.

A total of 13 night workers were interviewed, comprising three nurses, nine nursing technicians and a nursing assistant. For the definition of study participants, the proportionality criterion between the two units and the data saturation were observed⁹.

The inclusion criterion was the minimum time of work of 12 consecutive months at night. Time infers that the worker already has conditions to establish relationships and elucidate the meanings about night work. Those who performed activities in alternating shifts (day and night) and those who were on leave of any nature during the period of data collection were excluded.

Data collection took place between October and December 2013 through a semi-structured interview. The interviews were carried out in a private place, with an average duration of 15 to 55 minutes, being recorded and then transcribed. Participants were identified by letter I for interviewed followed by numerical order (I1, I2, I3,…).

For the data treatment, content analysis thematic modality was used ⁸. The data were organized and transcribed into text files. The theoretical-empirical categories were formed after the exhaustive reading of the data, constituting the thematic category Satisfaction and dissatisfaction related to night work in intensive care units . The ethical aspects of the research were respected, according to the directives and norms of research involving human beings¹⁰. The research project was approved by the Research Ethics Committee, CAAE number: 11467512.0.0000.5346. All participants signed the Informed Consent Form.

RESULTS AND DISCUSSION

The participants were seven women and six men, aged from 31 to 40, with a time of work 5 to 10 years in nursing and in intensive care. Five participants have completed high school, five were attending higher education course, and three have graduate degrees. Also, 12 interviewees stated they worked overtime, which ranged from 12 to 84 hours a month, mostly during the night.

In relation to sleep habits, two participants reported that they do not sleep after completing night shift, five of them sleep from 3 to 4 hours, five of them from 5 to 8 hours and only one worker sleeps more than 8 hours. Eight of the interviewees practice physical activity and consider it fundamental for their life. Eight also report not having diseases or doing continuous use of medications; the others reported being carriers of hypertension, hypothyroidism, hyperlipidemia, hyperinsulinemia, tendonitis and herniated disc.

Individual characteristics such as age, sex, physical fitness and type of circadian system can also influence night work, since the organism behaves differently during the day and at night¹¹. A comparative study between day and night workers identified a high risk (67%) for cardiovascular diseases in night workers, with a higher prevalence of hypertension ¹².

A study conducted with day and night nursing workers showed that the latter had worse levels of attention when compared to the former¹³. Memory impairment and the ability of the night worker to concentrate may be resulting from deficits in sleep, fatigue and exhaustion, since exchanging night for day, in relation to sleep and work habits, leads to loss of the body's internal synchrony. Another study revealed that workers also showed mood instability and irritability¹⁴.

Satisfaction and dissatisfaction related to night work in ICU

The meanings of night work for nursing workers consist in the established interrelationship between satisfaction and job dissatisfaction, which is compounded by personal motivations and job characteristics of night work. The meaning of satisfaction comes from the reference to the available time that the night worker has to dedicate to their personal issues regarding personal organization, availability for the family, expansion of economic resources, organic adaptation to the shift, personal and professional qualification and qualification of the care provided.

Participants who reported organizing their lives in relation to night work mentioned that the chronological and biological organic adaptation contributed to staying at night. Other routine factors cited by nursing workers include commuting from home to work and the service needs.

I find it difficult to work during the day, mainly because of my sleep schedules and activities that I have during the day. My biological clock has already adapted to this scheme of working at night. (I3)

The main reason is because I live in another city and, for me, the night shift is better. It facilitates regarding the bus schedules and since it consists of ten shifts and a half, I need to come less times to the hospital . (I10)

The workers referred to the preference for the night, as it provides and increases the availability of free time during the day or the number of monthly breaks that allow them to devote to their personal and family matters. They point to the family as an important factor to be considered, as evidenced:

Eu não tinha mais empregada para ficar com as minhas filhas durante o dia, aí eu vi que a noite seria a melhor alternativa, para a gente em casa se organizar. (I1)

Trabalhar à noite possibilita mais folgas para que eu possa me dedicar a outras coisas. (I3)

Nursing workers referred to the preference for the night because it provides and increases the availability of free time during the day or the number of monthly rest days that allow them to dedicate to their personal and family matters. They point to the family as an important factor to be considered, as evidenced^15,16, since among the reasons that led them to choose night shift, respondents reported having more time with the family, mainly due to the fact that they spend less time to commute from home to the hospital.

In addition to the family aspect, economic issues are mechanism of personal satisfaction established by night work, which is the possibility of increasing financial gains by combining night work with a second job and/or working overtime hours.

It is done by necessity or by earning extra money at the end of the month. (I9)

Workers also referred to the possibility of professional qualification, since they use the day to study and/or to improve knowledge in the work area, which is in line with personal or professional motivations.

When I arrived here, I was able to work at night and continue my studies during the day. (I4)

Moreover, the speeches revealed the meanings of job satisfaction focused on the characteristics of the night work itself. This meaning is still associated with time; however, it is also related to care. Workers reported that night work allows providing adequate care with more attention to the patient. In other words, the time in the night work favors quality in the accomplishment of procedures, resulting in the improvement of the quality of care provided in that shift.

At night we can give more attention to patients, make the procedures with more time and calm; that is why I like the night shift. (I2)

During the day there are a lot of people around the patients; when we want a medical record, we cannot find it; we want to reach the patient to make a medication, but there is a lot of people around. On the contrary, at night, it is only the physician, the nurse and the patient; we can do the routine procedures. It is quieter. (I1)

A study carried out with day-care workers evidences that due to the intense, daily and complex routine of hospital work, little time is devoted to touching, listening and talking with patients¹⁶. This causes distress and suffering to workers because they feel they are not doing their work as they should.

For the participants of this study, night work favors the nursing work, since the environment is calmer, with less flow of people and bureaucratic issues. This allows nursing work to expand its focus to direct patient care.

Studies have shown that the work performed during the night shifts gives the workers feelings of reward, of accomplished duty by the twelve hours they have been there. In other words, the feeling of pleasure intensified due to the worker's identification with the characteristics of night work, of the intensive care units and of their unique routines^1,7,17.

The characteristics of night work - less flow of procedures, of bureaucratic procedures and of personnel - make the work dynamics more pleasant, insofar as it favors tranquility for the development of work, which brings the pleasure of accomplishing it as well as the quality of care provided.

The characteristics of night shift stand out when allied to the characteristics of the intensive care environment, since they require attention and concentration by the worker. These elements allow us to infer that the development of night work is favorable to the worker and to the patient, since it increases professionals' level of satisfaction and the quality of the care provided by them¹⁷.

The opposite represents the overload of nursing work, considering the different demands that emerge from an environment with many people, each one with their requests and that, in most cases, goes through the nurse, causing excess work and decreasing attention time to the patient. In this way, a calmer and more tranquil environment, favored by the reduced number of people, can be configured as a generator of job satisfaction and is directly related to the quality of care provided to patients. On the other hand, limiting the flow of people and procedures at night favors interpersonal relationships and contributes to teamwork among team members ¹⁷.

The interpersonal relationship was another issue mentioned by the majority of the participants, since the night work was constituted by mutual cooperation between team members for the development of their work. According to the participants, night shift favors the formation of bonds of friendship and trust, which are established by solidarity actions among the team members in the development of their activities, that is, the night shift brings together colleagues and creates more intimate social bonds.

The night shift staff is more united; they help each other more often; there is timing. During the day, the work is more individual, perhaps because there are more people in the unit. (I7)

There are people here I consider as close friends, not only colleagues; those who will be with me in every moment. This is very important and the night shift allows the formation of bonds, because we spent 12 hours together. I feel valued as a person and as a professional. (I3)

The cordial and trustful relationship among team members is crucial for the work, and is a source of satisfaction and well-being for the workers. Similar data were found in a study that identified co-operation among participants as essential in order to succeed in the work activities ¹⁴.

Night work has characteristics that favor coexistence among workers, allowing us to infer that interpersonal relations play a fundamental role in the conception of night work, since it involves coping with the difficulties present in the care, such as dealing with the daily routine of diseases, and often with death¹³. Other studies have reinforced the importance of interaction between members of the nursing team for the adequate development of the work in the night shift ^15,16.

Certainly, motivating factors of satisfaction in the night work depend on the individual characteristics of the workers, the circumstances and experiences that they go through. Thus, job satisfaction is a complex phenomenon and difficult to define because it is a subjective status ¹⁴.

On the other hand, other factors emerged from the speeches, evidencing the meaning of dissatisfaction with night work. Regarding work environment, participants mentioned the characteristic of closed unit of the ICU, which brings feeling of isolation, especially in relation to the other sectors of the institution. They reported individualism and anxiety, using expressions such as prisoners, suffocated, considering the characteristics of the environment and the length of the working hours. The following statements illustrate the data:

I feel very isolated, we go in here and work alone, unrelated to what is happening in the rest of the hospital. On the other hand, during the day, we can have more contact with the staff from outside the unit, we take the patient for exams, we can go to the pharmacy or the cafeteria, but at night we do not have that. (I5)

I feel like a prisoner, suffocated; I count the hours to seven in the morning and to see the world outside, and I think it is one less night of work. (I11)

Another factor abstracted from the workers' statements, which gives meaning of dissatisfaction in night work, corresponds to the individual responsibility of nursing workers. The individual attention of the worker to the patient redoubles in the night, demanding a constant condition of alert, that is, the worker intensively disposes their physical and cognitive strengths to conduct the care in the night shift.

We have to have more attention, to be more alert, to see what is happening and to notice any change in the patient. (I1)

The patient does not want to know if it is night or day, they remain unstable. And they are all serious patients. This is the difficulty I have at night work. We do not want to be calling [the physician] all the time, not to be labeled as an annoying person. And also we do not have that partnership between professionals as during the day; it ends up overloading the nurse. During the day, there are many more people looking at the patient, the physiotherapist, the intern, the physician. (I8)

Working at night is very tiring and in ICU it is a double responsibility, I think it is because of the environment, by the seriousness of patients. (I11)

At night, the nurse is responsible for evaluating the patient more carefully. For me, it is extremely exhausting, both due to responsibility and due to overload. (I12)

Reports from workers showed that responsibility redoubles in night work in intensive units and leads to overwork. These findings corroborate another study¹⁸ that evidenced that nursing care provided during the night shift is complex, since there is a shortage of care services and physical and psychological overload. In addition, health work develops from the relationship of trust between the subjects and from the valorization of potential resources of the nursing team members; so, workers mentioned dissatisfaction with the feeling of loneliness, experienced in many situations, in which they would like to have a support from the multidisciplinary team.

These data show that night work, for certain participants, comprehends the meaning of dissatisfaction, essentially due to some characteristics of the night shift and the work environment. It is relevant to understand the meanings satisfaction and dissatisfaction on night work, since the balance between them is fundamental for both the worker's health-illness process and for the qualitative dynamics of the care provided.

Satisfaction and dissatisfaction are meanings that express night work and, in this study, are closely associated with the characteristics of the ICU. These feelings can directly affect the health of workers and the quality of care¹⁸.

Importantly, there is inevitably an interaction between the individual and the work environment, in a process in which the worker influences and is influenced by it¹⁹. In this sense, nursing workers should be encouraged to identify and understand the duality of suffering and pleasure in their working hours, building a more satisfying work and that promotes care with better quality ²⁰.

CONCLUSION

This study allowed us to understand the meanings of satisfaction and dissatisfaction of night work for ICU nursing workers. Satisfaction is related to greater availability of time, attention to the family, to the economy, to the organic adaptation of the worker to this shift, to the possibility of qualification and to the better quality of care provided. Also, the favoring of interpersonal relationships due to a longer period of coexistence in the shift was highlighted.

On the other hand, night work is also a source of dissatisfaction, especially because of the intense individual responsibility that the worker assumes in the care of the patient. The overload of activities was also highlighted as an aspect of dissatisfaction.

It is essential that hospital institutions develop programs to prevent diseases and promote the health and quality of life of nursing workers at the night shift. The establishment of institutional strategies to favor satisfaction at night work and minimize its negative effects is essential.

REFERENCES

1.Veiga KCG, Fernandes JD, Paiva MS. Factorial analysis of the correspondence of the social representations on nurse's night work. Rev bras enferm. 2013; 66(1):18-24.

2.Beck CLC, Prestes FC, Tavares PT, Silva RM, Prochnow AG, Nonnenmacher CQ. Professional identity of nurses working in municipal health services. Cogitare Enferm. 2009; 14(1):114-9.

3 Girondi JBR, Gelbcke FL. Nurses' perceptions of the effects of night work on their lives. Rev Nursing in Focus, [online]. 2011; 2(3):191-4.

4.Santos ES, Gastaldi AB, Garanhani ML, Montezeli JH. Receptional and education process in health to family members patients boarding in adult ICU. Cienc Cuid Saude. 2016; 15(4): 639-46.

5.Silveira M, Camponogara S, Beck CLC. Scientific production about night shift work in nursing: a review of literature. J. res.: fundam. care. online 2016; 8(1):3679-90

6.Luna GAS, Lima IMB, Passos TSA, Rodrigues APRA. Night work and the consequences for nurses' health: a literature review. Ciências biológicas e da Saúde. 2015; 2(3): 81-90.

7.Silva RM, Beck CLC, Guido AZ, Lopes LFD, Santos JLG. Quantitative analysis of the professional satisfaction of nurses working at night. Text Context Enferm. 2009; 18(2): 298-305.

8.Minayo MCS. The challenge of knowledge: qualitative research in health. 12ª ed.:São Paulo: Hucitec;2014.

9.Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Sampling in qualitative research: proposal of procedures to verify theoretical saturation. Cad Saúde Pública. 2011; 27(2):389-94.

10. Ministry of Health. National Health Council Resolution 466/2012: Norms for research involving human beings. Brasília (DF): CNS; 2012.

11.Lopes JE, Simony RF. Feeding habits and nutritional status of night workers of a steel industry in the city of Guarulhos, São Paulo, Brazil. Rev Simbio-Logias. 2013; 6(9):117-29.

12.Pimenta AM, Kac G, Souza RRC, Ferreira LMBA, Silqueira SMF. Night work and cardiovascular risk in public university employees. Rev Assoc Med Bras. 2012; 58(2):168-77

13.Oliveira B, De Martino MMF. Analysis of cognitive function and sleep of nursing staff on different shift work. Rev Gaúcha Enferm. 2013; 34(1):30-6.

14.Lisboa MTL, Souza NVDO, Santos DM, Fernandes MC, Ferreira REDS. Night work and its repercussions on the nursing worker's health. Rev enferm UERJ. 2010; 18(3):478-83.

15.Magalhães AMM, Martins, CMS, Falk MLR, Fortes CV, Nunes VB. Profile of the nurses of the night shift of the hospital of clinics of Porto Alegre. Rev HCPA. 2007; 27(2):16-20.

16.Gomes GC, Lunardi Filho WD, Erdmann AL. Psychological distress in ICU workers affecting with their way of living Nursing. Rev enferm UERJ, 2006; 14(1):93-9.

17.Silva RM, Beck CLC, Guido LZ, Lautert L, Tavares JP, Prestes FC, et al., Facilities and difficulties faced by nurses in night work: qualitative study. Online Brazilian Journal of Nursing. 2009; 8(2).

18.Silva MM, Moreira MC, Leite JL, Erdmann AL. Nursing work at night in palliative oncology care. Rev Latino-Am Enfermagem. 2013; 21(3):773-9.

19.Tavares JP, Beck CLCB, Silva RM, Beuter M, Prestes FC, Rocha L. Pleasure and suffering of nursing workers caring for hospitalized elderly. Esc Anna Nery. 2010; 14(2)253-9.

20.Souza NVDO, Correia LM, Cunha LS, Eccard J, Patrício RA, Antunes TCS. The FENF/UERJ nursing graduate in the working world. Rev esc enferm USP. 2011; 45(1):250-7.