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European Journal of Scientific Research

ISSN 1450-216X Vol.23 No.1 (2008), pp.70-86

© EuroJournals Publishing, Inc. 2008

Effect of Night Shift on Nurses Working in Intensive Care Units

at Jordan University Hospital

Raghad Hussein Abdalkader

Lecturer at Maternal and child health nursing department, Faculty of Nursing
The University of Jordan, Amman, Jordan
E-mail: raghadabdlkader@yahoo.com

Ferial Ahmed Hayajneh

Assistant Dean for Training, Assistant Professor, Clinical Nursing Department
Faculty of Nursing, The University of Jordan, Amman, Jordan
E-mail: drferial@yahoo.com


This descriptive exploratory study was conducted to describe the effect of night
shift on Jordanian nurses at critical care units. A convenience sample of Jordanian nurses
working at six critical care units in a teaching hospital (N=100) were studied using a
structured questionnaire developed by Sizeni Madide(2003) that describe the effect of night
shift among nurses working in critical care units. The findings showed that female nurses
had a significant difference on sufficient sleep, and interpersonal conflicts. In addition, the
results indicated that nurses experience health problem and their work performance
affected by the night shift. The study findings indicated that night shift affect critical care
nurses well being. Consequently, this study emphasizes and urges the need to design proper
nursing manager interventions that help nurses to improve nursing care quality.

Keywords: Night shift, critical care units, Jordanian nurses, circadian rhythms.

1. Introduction
Shift work is a reality for about 25% of North America working population. Interest in the effect of
shift work on people; have developed because many experts have blamed rotating shifts for human
error connected to a number of accidents and catastrophes related to disturbance of circadian rhythms
which result in an increased risk of accidents and injury. (Coffey, Skipper, & Jung, 1998).
The international council of nursing (ICN) recognizes that many health care providers' services
are accessible on twenty-four hour basis, making shift work a necessity, at the same time ICN is very
concerned that shift work may have a negative impact on the individual's health, ability to function,
thus affecting the services provided.
Nurses as health care providers are obliged to work during the day and during the night to cater
for the needs of sick people. While Intensive care nurses were vulnerable to a stressful environment
because of the complex nature of patient’s health problems that requiring an extensive use of very
sophisticated technology.
Furthermore, few researchers' studies the effect of night on critical care nurses for example
Mathew and Campbell (1990) stated that Nurses turnover is expensive. It affects the safety and
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 71

effectiveness of service in Intensive Care Units. And they hypothesized that frequent night duty is a
major factor influencing turnover therefore they conduct a study on thirty (30) nurses, who choose to
leave intensive care unit within last eight month, The results of the study support the hypothesis and
they found that 50% of the staff left intensive care unit, because of general dissatisfaction with a
variety of aspects of their job, specifically night duty.
Furthermore, in examining the influence of day, afternoon, night and rotating shifts on job
performance and stress on nurses, found that job performances and satisfaction was less on a rotating
roster than on a fixed roster. Although there has been a move towards studies of nursing turnover, there
is still a general absence of research that attempts to associate perceptions of night duty with job
satisfaction and ultimately staff turnover.(Ohida, "et al". 2001)
The literature revealed that there is various effect of night shift on workers, night work have
implications for the entire living sphere of mankind, thus health hazards and stresses of work itself, as
well as intervening factors from outside the working life may influence, and impair the state of health.
Literature agrees that the effect of night is due to disruptions in circadian rhythms. They also state that
these effects are associated with phase shifting in sleep and wakefulness cycles, and cause interferences
with daily routine at work and in family and social life. Effect of night on nurses particularly
highlighted, but few studies examine that effect on intensive care nurses and the consequences on
critical patient and quality of care.
Night shift term defined as work performed after 6pm and before 6am the next day, therefore,
the activity at night will be out of phase with the circadian body temperature and other coupled
rhythms. In addition, because individual biological rhythms, re-entrain to a time shift at different rates,
each time the work schedule rotates, for a period of time after the time shift, the circadian system will
be in a desynchronized state. This disorientation can lead health, psychosocial effect such as feeling of
fatigue and disorientation.
Conceptual definition of effect is: a change from original status. This study defines it as the
change in health, psychological, and social status of nurses after working at night shift
Jordan university hospital is a health institution in Amman-Al Jubaiha, it includes 650 beds.6
critical care units, and nurses take turns working the three shifts. Nurses might work in the evening, in
the middle of the night, or morning, their shift; the morning shift 7hours, evening shift 7hours, and
night shift is 10 hours. Furthermore nurses at Jordan provide continuous service personnel on twenty-
four hour basis for the provision of health. Therefore they susceptible to all hazards mention before

2. Previous Research
literature has devoted much attention to the effect of night shift on the entire living sphere of mankind,
particularly nursing as profession had a lot of studies describe the effect of their working against the
physiological nature of the human being which affects their health, psychology, and social life, this
physiological nature created by Allah which is circadian rhythm, confirmation to this, Allah says in the
holly Quran "and made the night as a covering, and made the day as means of subsistence".
Circadian rhythm is determined by nucleus suprachiasmaticus in the hypothalamus. This
structure regulates the physiology and psychology functions of the body such as temperature. Reaching
its maximum at five pm and its minimum at five am. This basic principle underlying the rhythm
variation is catabolism and readiness for action during the day, and anabolism and rest during the night.
(Akerstedt, 1996).
According to Pheasant, 1999, the word circadian comes from the Latin" circa dies" which
means "about a day". Circadian rhythms are partly driven by the internal body clocks and partly
synchronized to external world by cues known as zeitgebers (German: ziet, time; geber, giver). These
rhythms are coordinated to allow for high activity during the day and low activity at night. Normally
the body uses cues from its processes and from the environment such as clock time, social activities,
the light/ dark cycle, and meal times to keep the various rhythms on track.
72 Raghad Hussein Abdalkader and Ferial Ahmed Hayajneh

The problem with a night shift working is that, the human race is diurnal, who are functions
during day time. Night workers report a number of health problems. (Crofts.1999). Therefore these
negative effects have consequences not just for individual, but also for work place, as decreased
alertness and reduced job performance that could endanger human lives and affect the quality of care at
intensive care unit. (Koller 1996; Brown & Erkes, 1998).
Moreover Lushington and Dawson (1997) stated that Night shift has physical and social effects
on the life of an individual including nurses, the long hours that they work interfere with their health
and their safety. Night work can even be more negative impact for female nurses who also have family
responsibilities such as pregnancy and child rearing.
Studies show that shift workers accident rates are more than day workers. Thus the findings do
not conclusively indicate that night shift workers are more prone to accidents. There are also
discrepancies with research on this issue because of the fact that working conditions are not the same
on different shifts. For example, the nature of workload, the backup system available, and the amount
of supervision can make comparisons inaccurate. Nonetheless, lack of sleep heightens the decline in
performance. Research has shown that the optimum mental performance level for workers occurs
between 2-4pm, maximum general awareness is between 1-7pm. Performance levels are lowest
between 3:30-5:30am (Coffey, Skipper, & Jung, 1998).
Furthermore, a retrospective study on error rates by time of day was conducted, under three
continuous three shift schedules, they document error from the recording between 1921-1931.This
study revealed that the numbers of error over175.000 was against the time of the day. The highest
number of errors occurred between around 3am. (MOSER R,DUBRAVEC M,2001, Scott
Moreover, a survey study was conducted, by applying a questionnaire consisting mainly of
items concerning sleep disorders, on night shift work related problems and work performance on
young female nurses in 11 hospitals in Japan. Subjects were 620 female nurses average age 23.9. The
result indicated significant association between working on night shift and use of alcoholic beverages
to help induce sleep. Moreover, average hours of sleep were significantly associated with three related
sleep items: subjective sleep quality, difficulty in getting to sleep and daytime drowsiness. (Ohida,
"et.al", 2001).
In Japan the health and safety association published the results of medical examination of the
country salaried employees. This report includes the result of 600,000 employees in health and hygiene
sector. Nurses who work rotating shifts had complaints concerning fatigue and this was highest in the
night shift, followed by evening then morning shift. The symptoms reported by night shift nurses
include sleepiness, sadness, and difficulty concentrating, with numerous complaints about cumulated
fatigue and disturbed social life. (Ohida, "et.al", 2001; Behar, "et al", 1999)
While across sectional study in Germany used a standardized questionnaire of thirteen items on
sleeping disturbances and fatigue symptoms on sample size 3332 nurses on the effect of night shift
they found that night shift is associated to sleeping disturbances off duty but not to fatigue symptoms
on duty. They conclude that fatigue is primarily related to quickly alteration work schedules but not to
the fact of day shift or night shift. Also night shift is correlated to sleeping disturbance but it is unclear
if night shift leads to fatigue symptoms ((Behar, et al, 1990; Mckenzie,J 2001).
Costa (2001) indicates that women can be more vulnerable to shift- work in relation to both
their more complex circadian and infradian (menstrual) hormonal rhythms and extra demands related
to family life. This includes disorders such as menstrual pains abortion interference with fetal
development, premature and low birth weight.
Moreover exposure to light at night may increase the risk of breast cancer by up to 60%. Light
suppresses the normal nocturnal production of melatonin by pineal gland, which in turn could increase of
estrogen by the ovaries. (Davis, "et al" 2001; Horowitz, "et al" 2001). Also retrospective study was
conducted on 763 women with breast cancer, and 741 women without the disease, found that women
who regularly worked night shift for three years or less were about 40% more likely to have breast
cancer than women who did not work such shifts. Women who worked at night for more than three
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 73

years were 60% more likely to develop breast cancer. Furthermore another longitudinal study on
78,000 nurses from 1988- 1998.it found that nurses who worked rotating night shifts at least three
times a month for one to 29years were about 8% more likely to develop breast cancer. For those who
worked the shifts for more than 30 years, the relative risk of breast cancer went up by 36 %.
(laden,"et al" 2001)
The nurse's health study found that women who worked night shifts at least three times per
month for 15 years or more had a35% greater risk for intestinal cancer, including 41% greater risk of
right colon cancer, 22% greater risk of left colon cancer, and 51% greater risk of rectal cancer than
women never worked rotating night shifts. (Brigham and women's hospital, 2003)
Lipkin, et al (1998) stated that shift workers are more likely to suffer cardiovascular and
digestive disorders. Shift workers also experience headaches, muscle pain respiratory infection and
general malaise these in turn result in higher rates of absenteeism employee turnover and higher costs
associated with recruiting and training replacement employees. Nonetheless, Steeland, and Fine.
(1998) studied the effects of shift on worker who do not rotate, to determine whether current shift or
recent change in shift was a risk factor for ischemic heart disease, they conduct a nested case control
study of heart disease death at work within a cohort of 21,000men.they found that there was little
evidence of any difference in heart disease risk by current shift. there was some indication that recent
change from afternoon or night shift to day shift had a protective effect initially which decrease over
time on the other hand no corresponding negative was found for change from first to second third, but
analysis were limited by small number of worker on night shift.
Sleep is one of the main reasons why irregular hours cause ailments and disorders extended
waking leads to tiredness and reduced functional capacity. After the first 24 hours without sleep the
functional capacity may be halved and after two sleepless days, the functional capacity is at its lowest
and risk of falling asleep is ever present. With prolonged exposure, the individual cannot manage to
keep awake, and can't make complex decisions which require thinking (Akerstedt, 1996). Nonetheless
non experimental research design conducted to examine the effect of sleep on short term memory recall
in day shift versus night shift nurses Revealed that there is no effect of lack of sleep on cognitive
process of short-term memory recall. (Allen C (, 1999)
A study was conducted in 2002 found that men who worked an evening or rotating shift were
more likely to report stress, relationship problems and feeling little control over their life. As well, 45
percent of men working an evening shift were daily smokers, compared with 27 percent of daytime
worker sand men working an evening rotating or irregular shift had higher odds of reporting a
diagnosis of a chronic condition (they reported back problems ulcers, heart conditions, and high blood
pressure) in the next four years than their male daytime counterparts or women with anon standard
schedule. (CBC news online staff, 2002)
Also job performance and job related stress of nurses was examined on 463nurses working
rotating shift. The study revealed that the overall job performance was highest for nurses on day shift
followed by the night, afternoon, and rotating shifts. Rotating shift nurses experienced the most job
related stress, followed in turn by the afternoon day and night shift nurses. (Coffey, "et al",1998)
A study conducted to examine shift related differences in chronic fatigue and the contribution
of sleep quality anxiety and depression to chronic fatigue among a random sample (142) of female
critical care nurses. Twenty three percent of this sample met the criteria for clinical depression, day and
night nurses did not differ in their reports of chronic fatigue. Night nurses reported more depression
and poorer sleep quality, depression and anxiety, depression and sleep quality were the most relevant
to the explanation of chronic fatigue. This study suggests the need for studies of strategies to promote
sleep and improve mood in critical care nurses. (PERKINS, 2001). Moreover effects of shift work on
mood changes were studied on 1608 Japanese female nurses, working on rotating shift schedules,
revealed that there were prominent changes of subjective fatigue, activity and confusion were observed
especially when shift changes occurred. However the mood changes were observed even after
adjusting for the effect of sleep hours, indicating that irregular sleep pattern is not the only cause that
affects mood. (Hartel C. 2000)
74 Raghad Hussein Abdalkader and Ferial Ahmed Hayajneh

About the prevalence of extended work periods and their effects on patient safety. Logbooks
completed by 393 hospital staff nurses revealed that participants usually worked longer than scheduled
and that approximately 40 percent of the 5,317 work shifts they logged exceeded twelve hours. The
risks of making an error were significantly increased when work shifts were longer than twelve hours,
when nurses worked overtime, or when they worked more than forty hours per week (Rogers, "et al

The main purpose of the study is to describe the effects of night shift on nurses and to evaluate the
impact of these on the health and well-being at intensive care nurses, in an attempt to provide
applicable recommendation to decrease stress produced by working conditions, and promote the best
patient care.

The current study may help both nurses and administrators to understand some of the underlying
effects of night shift on nurses, and their impact on nurse’s life, clinical practices. The study will help
the manager by giving them direction as to what steps should be taken to protect nurses from
occupational stress that caused by night shift in attempt to decrease nurses turnover, which negatively
affect safety and effectiveness of services provided in intensive care units, and in the other hand it is
cost expenditure through advertising interviewing and orientating new hired nurses. Furthermore it is
significant for nurses because it will improve their quality of life and coping with night shift.
Study finding may also provide a knowledge base for further research that addressed after
studying all aspects of nurses work shift and its relationship with other factors in the clinical and other
world environment.

3. Research Questions
Q1. What are the effects of night shift on health aspect among intensive care units nurses
according to the gender?
Q2. What are the effects of night shift on psychosocial aspect among intensive care units
nurses according gender and civil status?
Q3. What are the effects of night shift on work performance among intensive care nurses?
Q4. What are the effects of monthly night shift schedule on health aspect on nurses in
intensive care unit?

4. Research Methods
4.1. Design
This research design is of descriptive exploratory design, it describes the Phenomenon as it exists in
the current time; it is more practical in the implementation, economical in cost, and easy to manage.
The study utilizes the data to recognize the level of knowledge and attitudes of the nurse toward night
shift work, therefore the study is designed to describe the effect of night shift on nurses.

4.2. Population and Sample

The study population consist of all staff nurses and practical nurses in critical care units at Jordan
University Hospital, so these are the target population. Sample inclusion criteria is intensive care
nurses who are working shift schedule, exclusion criteria is nurses fixed at morning shift such as head
nurses and aid nurses. For the purpose of sample size determination the convenience sample of 100
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 75

nurses (staff and practical) were chosen, from the six units along three weeks duration, Selecting a
convenience sample willlimit the extent of generalization, it is inexpensive and accessible, and they
usually require less time to acquire than other types of samples.

4.3. Setting
This study was conducted at the Jordan University Hospital at six critical care units; Surgical intensive
care unit SICU(1st floor), Surgical intensive care unit SICU(3rd floor), Coronary care unit CCU,
Medical care unit MICU, Neurology intermittent care unite NICU, Pediatric care unit PICU.
Jordan University Hospital is a major teaching hospital in Amman, it includes 650 beds total,
eight floors, six critical care units that contains 41 beds, and nurses take turns working the three shifts.
There shift-work schedule not typical three shift system, the morning shifts 8 hour, the evening shift is
7 hours, and night shift is 10 hours duration .each Intensive Care Unit capacity is 6 to 8 beds in
general, the system of all the units are opened system except C.C.U, which is a closed system, single

4.4. Data Collection and Instrument

Participation in the study is voluntary and based on the nurses ability to give an informed consent, all
data and information’s gathered will be strictly confidential and will not be accessed by any other
without prior permission from the participants, moreover, the participant has the right to withdrew at
any time if he can not complete the questionnaire.
To study the Effect of night shift on nurses, a questionnaire was developed by Sizeni Madide
who is a master science student graduated from Lule University of Technology in Sweden, this
questionnaire obtained from his thesis, Reliability and alidity of this questionnaire is not known related
to miscommunication between me and the author, instructors, and University Dean, despite frequent E-
mails, that may be related to language barriers.
Therefore face validity for the questionnaire was done by 4 experts-nursing- researchers: Dr
Fathieh, Dr Amal, Dr Ferial, at University of Jordan and Mona alekue(R.N Master degree in nursing)
from Al Hussien Centerfor cancer. Internal consistency reliability “Cronbachs alpha coefficient”
calculated as the most approach to estimate internal consistency which based on interrelation of all
items in the scale.

4.5. Procedure
Data collections were along three weeks duration, two inter raters were involved in data collection
process. First of all, a list of the six unit's staff and practical nurses names were got. Then started to
distribute the questionnaires in the three shifts, and collect it by hand when they finish. This study
approved from Jordan University Hospital by applying a proposal about the study to the Dean of
Nursing in the University, in turn they facilitate the approval, also an e-mail had sent to take the
permission from the authors to use his questionnaire

4.6. Data Analysis

Descriptive statistics will be computed using the statistical package for the social Science / personal
computer (SPSS / version12), data analysis will include descriptive statistics to describe the study
sample via mean, median, range, and frequency. Cross tabulation and mean test will be used to study
effect of night shift on health aspect among nurses, according to gender. Tow way ANOVA will be
used to study the effect on psychosocial aspect among intensive care nurses according to gender and
civil status. Descriptive statistics via means and standard deviations will be used to describe the effect
on work performance.
76 Raghad Hussein Abdalkader and Ferial Ahmed Hayajneh

5. The results of research questions

In order to meet the demand for an improved efficiency of dealing with the extended hours of work in
some industries, there has been an increasing drive towards the use of shift- workers. The main purpose
of this descriptive study was to identify the effects of night shift on Jordanian nurses working in critical
care units.

5.1. Sample characteristic

One hundred questionnaires were distributed to critical care nurses in Jordan university hospital. The
overall return rate (response rate) of the questionnaires was 100%. The sample consisted of eighty
seven registered nurses (87%) and eleven (11%) practical nurses. Moreover the largest number of nurse
respondents were single (71%) and in the age range from 21 years to 30 years old. Nearly half of them
female nurses (56%) and (44%) male. Regarding sample distribution among the six units: 26% of
sample from surgical intensive care unit SICU first floor. (17%) seventeen percent from coronary care
unit, (20%) twenty percent from medical intensive care unit, (10%) ten percent from Neuro Intensive
care unit and nine percent (9%) from surgical intensive care unit (third floor) see table 1.

Table 1: Sample Characteristics

5.2. Results of Q1 The influence of gender

The influence of gender has its own highlights in this study. Male regardless of marital status
respondents requested to work on a day shift. This is probably due to fact that they need to be with
their families or their young age. The married male nurse regarded night shift as strenuous, this was in
contract to the suggestion made by the unmarried male nurse. Who regarded night shift as comfortable
and had enough energy to perform his duties, but did not have enough sleep when on night shift. thy
needed to induce sleep by reading. Night shift affected the social life of male nurses but did not
seriously affect their health. However, they complained about feet ailments. This could be associated
with theatre work, where there is a lot of static standing. Rotating shifts can be very strenuous for a
female nurse with children and other family responsibilities. For these nurses other patterns of shift
schedules are not only strenuous but also dangerous since they involve transport problems. Traveling
or driving at night Crofts L (1999)), in his study, he strongly endorsed the need to take into
consideration nurses scheduler for shift work. he argue that the personal, socio-cultural and
environmental perspective of the nurse need to be given attention by the various stake holders involved
with rostering. Night shift is not suitable for life style for both married and unmarried nurses.
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 77

5.3. 1. Results of Q2: the effects of night shift on psychosocial aspect.

It is important to note that even though nurses make a request to work on a night shift, they still regard
it as being strenuous. This study examined concentration as one of the psychological concepts of night
shift, any shifts revealed that 28% of respondent felt that their concentration is law, 64% felt that their
concentration is normal, and 8% felt that is almost high even on night shift. The nurses experience
physical and mental workload since their job involves standing, walking, bending, lifting and making
decisions about patient care and other administrative work. All this leads to exhaustion, which disturbs
concentration. This means that a tired person is unable to think clearly. The study by Allen C (1999),
examined whether nurses can work a 12-hour working system, the results concluded that the system
had less significant physical workload but greater mental workload. 78% of nurses whose age less than
30 year, have night shift effect on psychosocial aspect, 56% of them are female and 43% male.

5.3.2. Effects of night shift on social life

Some of the problems of night shift and the dislike of this shift emanate form the social difficulties
encountered by nurses. Adaptation to night shift could be influenced by the social status of the
individual within the community. For instance, the marital status, family needs, societal values and the
lifestyle of the individual within the community influence the nurses attitude towards night shift. Night
shift causes an imbalance between desired lifestyle and work, women have a major role to play in the
domestic life and they compromise their sleep to undertake the domestic chores such as care to their
children and family chores. To find out whether night shift affects the social aspect of nurses or not
,see table (2), 60% of respondents stated that their social life is sometimes affected, 33% stated that
always their social life is affected that is mean 93% of the nurses are affected and 7% not affected. The
aspect of social life involves nurses families, work relationships and other social groups.

Table 2: Social life

78 Raghad Hussein Abdalkader and Ferial Ahmed Hayajneh

5.4. Results of Q3 the effects of night shift on the Work performance

Nurses regarded the time of 10 hours allocated for night shift is too long (see figure 2: caouses of
complain). 78% of nurses feel that night shift has a heavier workload than the day shift, nevertheless
their present shift either morning, evening or night. They attribute this to the fact that there are fewer
nurses working at night, 73% of nurses revealed that the ratio of nurses to patient is not appropriate.
The temporary supporting night nurses not as competent as permanent staff to deal with peculiar
problems encountered in specialized units. This makes it necessary for night nurses to work extra hard
to keep their sections functioning to the desired health care standards. The workload of the night nurses
is dependent on the intake of patients during a particular day. Management is facing a problem of an
unpredictable patient influx on each day.

Figure 2: Causes of complain

The results revealed that 64% of nurses sometimes increase the conflict at their Work(see figure
3 the effect of complain). Poor attitudes could irritate patients, lead to conflicts between staff and
patients and even among staff. There will also be a low motivation towards work and errors in
administering health care. Performance goes along with motivation, which is the drive towards
productivity. Productivity is essential to save human lives health care.
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 79
Figure 3: Effect of complain

5.5. Results of Q4: The effects of night shift on health status of the night workers
Regarding health status of the respondents during night shift (see figure 1), 74% of the nurses felt that
their health is affected, 26% had no health problems and11% did not know whether night shift affect
them or not. Amongst the respondents, 61% are troubled by frequent headaches, 49% by backache,
36% by persistent tiredness, and44% by insomnia and 23%suffered from feet ailments. The prevalence
of these ailments indicates that health risks exist with shift work and night shift as stated in literature.
Sleep problem dominated in ailments of all age groups of the respondents.Another health related
problem was that of exposure to occupational injuries and diseases. The results show that 56% of the
respondents sustained either a needle stick injury NSI or a back injury. 50% of respondents indicate
that the incidents occur on night shift. NSI can occur if the nurse is too busy, drowsy or tired where she
is likely to loose concentration and cause an accident. NSI predisposes nurses to infections such as
Human Immune Virus (HIV), Acquires Immune Deficiency Syndrome (AIDS), Hepatitis B, and other
viral infections. Lack of knowledge and skill exposes nurses to such harmful conditions and other
hazards such as back injury. In general, backache can result from exposure to psychological hazards.
According to previous studies stress is a psychological problem which manifest itself with aches and
pains of neck or back pain depending on the biological structure of the person. Orientation of newly
employed nurses and in-service training, and procedure manuals are tools that assist managers in
educating and development of staff thus reducing hazards. According to Lipkin et al.(1998), nurses
form a high-risk group for the chronic fatigue syndrome possibly due to occupational stressors, such as
exposure to viruses and stressful shift work that interfere with their biological rhythm. Finally 63% of
nurses demonstrate a problem during C shift that does not occur usually, with monthly C shift pattern.
Health problem nurses usually experience to night shift
80 Raghad Hussein Abdalkader and Ferial Ahmed Hayajneh
Health problem nurses usually experience to night shift

Health problem nurses usually

experience to night shift

frequent headaches persistent tiredness loss of sleep others
backache feet ailments muscular strain

5.5.1. Problems of night shift

There is a diversity of problem encountered by nurses in a normal working situation. Some of these
may be physical, physiological, psychosocial and social. Night work intensifies problems since the
individual is working when the body clocks is naturally telling the majority of the people to rest.
Problems vary with each individual since the biological structure is different. The findings revealed
that 57% of nurses have experienced a problems to fall a sleep. and most of nurses 92% of sample
stated that night shift doesn’t suit their life style(see figure 2). Furthermore 94% stated that night shift
is uncomfortable and doesn’t pay better salary. 5.5.2. The influence of circadian rhythm on the night
workers As previously, mentioned differences in the circadian rhythm make other people to be at their
peak in the evening and some to reach their peak in the morning Meckenzie J(2001) The study also
examined if nurses felt more energetic when working on night shift. The results showed that 67% of
the nurses did not feel energetic. Tiredness may be due to insomnia, changes in sleeping patterns,
variations in length of shift periods, and circadian rhythms. The fact that about 20% of the respondents
experienced persistent tiredness implies that their performance could be impaired. This inefficiency in
performance could have deleterious consequences on the health care of patients.

5.5.2. The influence of circadian rhythm on the night workers

As previously, mentioned differences in the circadian rhythm make other people to be at their peak in
the evening and some to reach their peak in the morning Meckenzie J(2001) The study also examined
if nurses felt more energetic when working on night shift. The results showed that 67% of the nurses
did not feel energetic. Tiredness may be due to insomnia, changes in sleeping patterns, variations in
length of shift periods, and circadian rhythms. The fact that about 20% of the respondents experienced
persistent tiredness implies that their performance could be impaired. This inefficiency in performance
could have deleterious consequences on the health care of patients.
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 81

5.5.3. Sufficient sleep

The major problem faced by night shift workers is the lack of sleep or insomnia (table 3). 72 % of the
respondents working on day shift indicated that they do not get enough sleep when on night shift.
Among the whole group of respondents, 49% sleep for less than 5 hours, another 44% of respondents
sleep for 6 to 7 hours. Among day and night nurses of all age groups, only 7% sleeps for eight hours or
more, after night shift. The data obtained from the survey showed that 75% of the nurses have a
problem with falling asleep after night shift, implying that 23% did not have a problem. Insomnia is a
prevalent ailment that affects all categories of nurses who participated in this survey. Yamanchi h, et
al,2001), have noted differences in the biological make-up of individuals. These differences can create
difficulties for some people when they are expected to adjust from a diurnal working schedule to
working on a night schedule. This is in line with suggestions by some nurses who have no problems
with working on a night shift. They indicated that they were more energetic when they work on night
shift. This evidence collaborates that of Rodgers et al., 1986 who pointed out that some people are
“evening types” whereas others are “morning types”. Preferences towards shifts have an influence on
each individual towards adaptation to night shift.
Sleep is a major concern since it affects the health and the performance of nurses who are
dealing with human lives. The health care workers in this study have indicated that they are exposed to
such hazards and mistakes. Any mistake or accident resulting from fatigue or stress can cost a life of
the next person, resulting in law suites and claims from patients.

Table 3: Effect on sleep

get enough sleep after night Yes 72 72%

duty? No 28 28 %

How many hours do you Less than 5h 49 49 %

sleep after night duty 6hrs_8hrs 44 44 %
More than 7 7%
. After night shift work do Yes 42 42 %
you experience any problem No 57 57 %
to fall a sleep?

is night shift comfortable Yes 6 6%

No 94 94 %

5.5.4. Strategies to induce sleep

An important factor to note is that 54% of respondents use some form of strategy to induce sleep (chart
1). The respondents, who indicated that they have no sleeping problems when on night shift, have to
use some form of strategy to induce sleep as well. Several options to induce sleep were mentioned and
these included the use of beverages, reading and music. From the medical point of view, continued
intake of medication or sleeping tablets affects the physiological and psychosocial well-being of the
individual. It is not advisable to take medication without consultation with the medical doctor. An
important fact to remember is that induced sleep is not restful and tablets can be habit forming.
82 Raghad Hussein Abdalkader and Ferial Ahmed Hayajneh
Chart 1: Ways in which nurses induce sleep

6. Summary and Conclusion

Study shows that all age groups are subject to exposure to physiological and psychological hazards
brought about by night shift as indicated in their subjective response. The recent developments
regarding shift work is aimed towards improvement of health of shift workers, the physical and
psychosocial well being as stated by International Labor Office ILO. ILO has highlighted that
recommendation should be relevant to specific groups and work systems. Noted is that each sector has
its own specific needs, especially health sector as it deals with patient care. The night shift worker is a
man at odds with his own body rhythms as stated in Pheasnt,(1991) when managers are planning shift
schedules should be aware of these biological rhythms as explained by other research's. Literature has
explained that there is no perfect schedule; the main factor is consideration of the inputs from the
participants in shift work. Shift work environment should be comfortable, safe and free from hazards
such long hours at work. Further studies are required to find out the extent of night shift effect.
Management will benefits with further research in this area. The purpose of this study to describe
hazards affecting nurses working on night shift and to make recommendations based on the finding.

7. Recommendations
The findings of this study suggest that it may valuable to replicate this study with larger and more
heterogeneous randomly selected sample and well-defined valid instrument that fit and sensitive to
Jordanian culture Assessment of advantages and disadvantages of shift system should be done based on
objective criteria. Adjustment of physiological function to night work, level of well being, health
problems, and disturbances in personal life, accident rate and performance efficiency, are all taken into
consideration in shift work design.
Upon the study findings, I recommended that nurses need a continuous medical screen. That
supported by International Labor Office (1990), which was adopted that permanent and rotating night
workers are generally a population at risk and are to be included in medical screening, and should be
given special attention as they are exposed to work load and extended working hours.
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 83

Other recommendation to managers include, appropriate health services for nightand shift
workers, first aid facilities, option to transfer to day work for health reasons,measures for women on
night shifts, and special maternity protection.Schedule planners should avoid quick change over from
night to day on the same day or from morning to night. Every shift system should include some free
weekend with at least 2 successive full days off. Time of recovery, and rest breaks must be considered
schedule to be regular and predictable.
However, managers must have responsibilities toward nurses, like to let nurses have a freedom
of choice regarding shifts, and to formulate strategies to assist the nurses who find it difficult to work
at night, identify the existing occupational hazards that affecting nurses, and they will be able to
forecast on possible strategies that can help to reduce hazards in hospitals.
Considerations of nurses needs for a particular shift and involvement is important for
motivation and acceptance of shift schedules and work. Motivation could improve adaptation of the
nurses to awkward hours of night shift.
It can not be possible to meet all the needs of different nurses when planning Schedules, on the
contrary, it is possible to make adaptations that can reduce the strain of the long hours worked on night
Other recommendations is encouraged to provide a psychologically supportive environment to
the nurses. Rest room should be provided to relieve psychological stressors. Music, reading materials,
and games provide relaxation to nurses.
The comfort of the environment and the furniture used for resting is essential and conductive to
complete rest. Those who feel tired can benefit from a separate resting area at the Cafeteria or the work

Tips are recommended for shift workers, to be in health and good manner
Plan your sleeping time, keeping a steady schedule. Make and keep rules, train your children’s not to
disturb you when you are sleeping. Do not work too many nights in arrow. At least, not more than four.
Develop a good sleeping environment, have a dark cool, and comfortable room, black out light with
heavy curtains. Eye-shades and ear–plugs can be used by those who are comfortable wearing them,
turn telephone volume to off. If under stress, relax before going to bed, light exercise is one of that.

Care about what you eat and drink, choose light healthy meals before going to bed. Avoid heavy,
gassy, greasy or fatty meals during night shift. Avoid coffee or caffeine at least four hours before going
to bed Herbal tees and warm milk are good before bed. Avoid using intoxicants or sleeping pills to get
84 Raghad Hussein Abdalkader and Ferial Ahmed Hayajneh

in sleep, except in most unusual circumstances; the sleep architecture is altered thus sleep is less restful
and you may be hung over poor performance at work

Do not lose your connection with your family life, do not forget that your family is for whom you do it,
and do not lose your spouse or significant other. Grocery shopping at off peak hours will be of benefits.
Finally of recommendations, identifying effect of night shift on circadian rhythm among nurses
working in critical care units can contribute to critical care nursing curriculum that can address
psychological and physiological needs of nurses, which ultimately reduce stress level from night shift
and improve the quality of nursing care.
Effect of Night Shift on Nurses Working In Intensive Care Units at Jordan University Hospital 85

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