Shift work’s effect on nurses’ quality of life: coping mechanisms and improvement suggestions from Northern part of Sri Lanka

Introduction

Nursing is an autonomous and collaborative of individuals of all ages, family, groups and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill people. Disabled and dying people advocacy, promotion of a safe environment, research participation in shaping health policy and in patients and health system management and education are also key nursing roles (Pursio et al., 2021)⁽¹¹⁾.

Ljevak et al. (2020)⁽⁹⁾ investigated the impact of shift work on psychosocial functioning and quality of life among hospital employee nurses, and a comparative cross sectional study design was applied on a total of 157 hospital nursing professionals at the university clinical hospitals roster, in 2019. Standard Shift work Index (SSI) questionnaire was used (Ljevak et al., 2020)⁽⁹⁾. This study demonstrated an increased stress, reduced coping abilities and a reduced level of life enjoyment in shift work nurses compared to other nurses. The results reveal many detrimental effects of shift work and contribute to the field of research that is still laden with gaps in understanding its exact impact on the overall health of nursing professional (Ljevak et al., 2020)⁽⁹⁾. In the cross-sectional study “Night work and quality of life”, performed between April and June 2019, Turchi et al. examined nurses who attended night shifts in the Siena Teaching Hospital, using a descriptive analysis, 197 questionnaires being analyzed (Turchi et al., 2019)⁽¹³⁾. As a conclusion, there was a significant relationship between night work and health-related quality of life of nurses (Turchi et al., 2019)⁽¹³⁾.

Changing regarding the quality of life was identified in a study on 391 nurses in Tunisia working their day shift. The health impact of nursing shift work was the subject of a dissertation at the Singapore State University (Kowitlawkul et al., 2019)⁽⁷⁾. A restricted number of food choices, stress and exhaustion contributed to intake of processed foods with low nutritional value during non-dayshifts in study of 378 nurses in Hong Kong hospitals (Cruz et al., 2018)⁽⁵⁾. Shift work and traffic accidents were higher among nursing personnel (Nena et al., 2018)⁽¹⁰⁾. A study on 243 female nurses in Turkey found that work demands, rotating shifts and overtime hours caused family conflicts and lower job satisfaction (Bilge et al., 2020)⁽²⁾. Nurses work demands and work family conflicts were studied using a questionnaire survey, by Sammut et al. (2021)⁽¹²⁾, in International Journal of Nursing Studies. A survey was conducted with 60 female nurses in India, where a common practice is shift rotation every seven days. The nurses reported difficulties in meeting family responsibilities, attending social functions, getting sufficient sleep, and lack of family cooperation’s (Sammut et al., 2021)⁽¹²⁾.

The term shift work is defined as an arrangement of working hours that uses two or more teams (shifts) of workers, in order to extent the hours of operation of the work environment beyond that of the conventional office hours. In Sri Lanka, the nurses shift duties are represented by the morning shift (07:00-13:00), the evening shift (13:00-19:00), and the night shift (19:00-07:00). The quality of life is defined as an individual’s perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, the expectations standard and concerns.

The combination of shift work and staff shortages are significant risk factors for nurses, impacting their well-being and the quality of life for their families. At the Teaching Hospital Jaffna, these challenges manifest in issues such as restorative sleep problems, prolonged recovery time, sacrificing sleep to care for family, compromised child safety, workplace concerns, social isolation, stress, poor nutrition, and lack of exercise. This study may provide valuable insights into improving routines for nurses and highlight the benefits of involving family and friends in their support system. This study identifies the problems of nurses’ work environment, individual and family of nurses, at the Teaching Hospital Jaffna. This study is useful as a first step to minimize the effect of nurses’ quality of life on their shift duties. Nurses – particularly those working rotating shifts – could benefit from stress reduction intervention. Moreover, future research should continue evaluating the deleterious health effects of nursing shift work and efficiency of stress reduction. Intervention in nursing stress reduction, including education and practice changes, should be implemented at individual, facility, community and federal levels, to improve the health of nurses, as well as the patients’ safety.

Methodology

The research approach and design

In the research context, the Teaching Hospital of Jaf­fna in the Northern Province of Sri Lanka was selected for this study due to the high level of responsibility placed on nurses, who often face family issues as a result of their demanding duties and long hours. This can lead to role conflicts and work-family balance challenges. The researchers used a deductive approach and adopted a survey research method, utilizing a self-administered questionnaire as the data collection instrument.

Research setting

The research setting is represented by the place where the data are collected. Here, it is the biggest hospital in the Northern province which provides treatments for every sector, including medical words, surgical wards, operation theatre and special units such as medical intensive care units, surgical intensive care units, neonatal intensive care unit, coronary care unit, accidental unit, hemodialysis unit, high dependent unit and coronavirus unit, in the Teaching Hospital Jaffna. Here are treated patients from all regions, in the Northern part of the country.

Population and sample

Our target population included around 600 nurses. The target population is the entire population in which the researcher is interested, and the accessible population refers to these cases that conform to specific criteria and are accessible to the researcher for this study.

Appropriate sampling method

The convenience sample method was used this study. There were selected 250 participants, in convenience sampling. The subjects were included in the study because they happened in the right place at the right time.

Sample size calculation (Cochron method by Uakarn et al., 2021)⁽¹⁴⁾:

Using the Cochran formula, with a target population of 600 and an accessible population of 500 (P=5, d=0.05), the confidence level was set at 95% and the confidence interval at 5% for this study at Jaffna Hospital. The study selected participants who met the inclusion criteria until the desired sample size of 250 nurses, which represents the minimum required from the accessible population, was reached.

Ethical considerations

The research proposal along with a request letter were submitted for the Ethics review committee of the University of Jaffna, and the ethical approval was obtained. Furthermore, permission from director of Teaching Hospital of Jaffna was obtained to conduct this study. An invitation letter provided the information session in which subjects were informed regarding the purpose of the study and the possible risk and benefits. The subjects were allowed to any clarification at any time and written information with contact details was provided. Written informed consent was taken from these who willingly participated. Their confidentiality was maintained. Numbers were provided to each participant for the anonymity. No information obtained was shared out. All subjects were treated fairly and equally before, during and after the participation in the study, to maintain justice. Participants who wished to stay away from the survey were permitted. Data will be stored under lock and key with restricted access only to the supervisor. The computerized data will be password protected, and are only available to the investigators, after completing this study. The findings were disseminated with study population attending to wards, units, theatres, nurses by health education session and also with peer’s group journal.

Data collection method and tools

In this study, the researchers used self-report measurement because it assures high objectively, relative precision and sensitivity, while self-report measures are cost effective, with less interviewer bias. A structured questionnaire was used after taking the possible measures to maintain its reliability and validity.

Development and description of the tools

The researchers wished to measure, observe and record data using a self-administrated questionnaire to answer the research question which is: what is the influence of nurses shift duties for their quality of life? In this study, self-administered questionnaire was filled by the participants. This questionnaire was structured and divided into three sections. The first section gathered data regarding sociodemographic characteristics. The second section concerned the day shift factor, and the third section concerned the night shift factor. Three types of questions were included, such as multiple-choice questions and Likert’s scale questions. All questions were easy to understand, simple and impartial.

Reliability and validity of instruments

The self-administered questionnaire was prepared using guidelines of World Health Organization review literature. Reliability and validity were assured by extensive discussion, and correction was done with ethical review board and our supervisor. The questionnaire was checked through pre-test on a small sample of respondents before a full-scale study at the same setting. Based on the results, the pre-testing questionnaire was appropriately modified to address issues such as unclear wording and the length of time required for administration. After these adjustments, the questionnaire was re-tested to ensure its reliability and validity, ensuring consistency during data collection without further alterations.

Data collection

Data collections was performed after obtaining the ethical approval from ethics review committee of the University of Jaffna, and permission was obtained for doing research from the director through the matron of teaching hospital and nursing in charge of wards units, operation theatre in Teaching Hospital Jaffna. This study population was represented by both day and night shift nursing officers at the Teaching Hospital Jaffna. This study identified the influence of nurses shift duties for their quality of life. The questionnaire was printed and labelled not to identify personal records. The convenience sample method was used in this study. The study instruments used in self-administered questionnaire according to the convenient method participants were selected, we obtained the consent in advance, and given them a suitable place to answer, the questionnaires data were collected by research to hide their identify and asked them to put them into a collecting box after they finished it. They had the right to not to participate and to withdraw from this study any time, without any difficulty. Each participant answered the questionnaires within thirty minutes. The questionnaire and the informed consented were used in Tamil and Sinhala languages.

The limitation of the data collection

There were some limitations encountered by the investigator. Some wards had too much workload, therefore there we were unable to get information from particular wards nursing officers.

Data analyses method

After data collection, the data were entered into IBM SPSS (Statistical Package for Social Sciences 25.0) and analyzed to assess the influence of nurses' shift duties on their quality of life. Each objective was analyzed separately using appropriate variables. The data were categorized, ordered, manipulated, and summarized into a clear and interpretable format to meet the study's objectives. The results were calculated as frequencies and percentages, and presented in tables.

Results

Demographic data

This section describes the demographic characteristics of participants. A total of 282 people participated, and 250 questionnaires were completed. Thus, the response rate was 88.6% of the participants. The majority of the participants were females (72%; n=180). The majority of the participants (60.8%; n=152) were aged 35-50 years old. 54% (n=135) were Tamil people. The majority of responded (66%; n=165) were married. 34% (n=85) of the spouses’ jobs were in the government sector. 18% (n=45) of the participants had more than two children. The majority of the participants (48.8%; n=122) worked at wards. 61.2% (n=153) of the participants worked less than five years. The majority of participants (59.6%; n=149) were from nuclear families. 36.4% (n=91) of the participants lived less than 5 km far from the hospital, and 47.6% (n=119) of the participants had their own vehicle to travel to the hospital. The majority of the participants (74.4%; n=186) had 5-10 nurses in working sectors, and 51.6% (n=129) of the participants earned 50,000-100,000 Rs as monthly income. 46.8% (n=117) of the participants were doing 6-12 hours as shift work. The majority of the participants (43.2%; n=108) were doing 10 to 20 night shifts per month.
 

The factors affecting the quality of life for the day shift

Table 2 presents the results of a survey that assesses various aspects of nurses’ work-life balance, health, and well-being. The respondents used a Likert scale to rate their agreement with a series of statements, where 1 indicates a strong agreement and 5 indicates a strong disagreement. Hereinafter, we present an interpretation of the mean values for each statement.
 

My job does not affect my health and well-being (3.06): the mean value is slightly above neutral, suggesting that, on average, nurses are slightly more likely to feel that their job does affect their health and well-being.

My hospital takes care of my health and well-being (1.66): a low mean value indicates that nurses generally agree that their hospital takes good care of their health and well-being.

The medical facilities provided to the nurses in my hospital are good (2.42): this value suggests a moderate agreement, indicating a fairly positive view of the medical facilities provided by the hospital.

My hospital is taking care of my family’s well-being (2.39): nurses tend to agree that their hospital takes care of their family well-being.

I’m able to spend time for my hobbies at daytime (3.58): the mean value indicates a tendency towards disagreement, suggesting that nurses often find it difficult to spend time on hobbies during the day.

I have the time to commit to maintaining my health (2.72): nurses believe they can commit time to maintaining their health, despite the nearly neutral score.

For advice on handling conflicts with my family, I can refer to the following resource (3.39): there is some disagreement indicated by the mean, indicating that some nurses may not have a support system within their families.

Finding time for leisure activities, hobbies, and maintaining friendships and family ties is not difficult (3.20): the majority of nurses seem unconcerned, despite their tendency to find these tasks difficult.

You shouldn’t have to spend more time on family concerns than on job (4.46): a high mean score indicates a strong disagreement and implies that family concerns significantly reduce the amount of time nurses can devote to their employment.

Women don’t feel as pressured at work because they have family commitments (2.20): this lower percentage shows that the majority of nurses agree that they do not experience excessive family pressure to look for themselves while at work.

Because of your workload, you are finding it easy to attend your kids’ school events (3.02): this mean value is almost neutral, showing that you have had varied experiences with visiting your kids’ school events.

I can spend time with my friends (3.88): most nurses disagree that they can spend time with friends, stating that they find it difficult.

My pals are taking part in both my positive and negative experiences (2.68): a small percentage of nurses concur that their friends take part in important life events.

I’m getting good recognition from my community and society (1.96): a strong agreement is indicated by a low mean value, which implies that nurses feel well-recognized by society and their neighbors.

You have enough time for heartfelt conversations with your parents (3.61): the mean shows a tendency towards disagreement, implying that nurses believe they don’t have enough time for such conversations.

Nothing prevents you from attending social gatherings (4.23): nurses vehemently disagree, citing substantial obstacles arising from work-related social gatherings.

Because of your job, you believe that you are not alone in society (3.44): due of their work, nurses tend to feel a little alone.

Your workload does not prevent you from keeping up tight relationships with your immediate family (3.82): the mean, which denotes disagreement, shows that work demands interfere with sustaining intimate relationships.

Your workload does not prevent you from taking part in religious events (3.96): contrary to popular belief, nurses claim that their workload makes it difficult for them to attend religious gatherings.

You believe that the public views your line of work with greater respect (2.58): a small percentage of nurses concur that the public views them with respect.

Overall, the survey highlights several challenges nurses face in balancing their work with personal life and maintaining health and well-being. While they generally feel supported by their hospitals, they struggle with time management for personal and family activities, leading to feelings of isolation and pressure.

The factors affecting the quality of life for the night shift

Table 3 presents the mean values of nurses’ responses to statements regarding their quality of life while working night shifts. The responses are measured on a Likert scale where 1 indicates strong agreement and 5 indicates strong disagreement. Hereinafter, we present an interpretation of the mean values for each statement.
 

You are not vulnerable to accidents due to inadequate sleep (3.18): the mean value is slightly above neutral, indicating that nurses are somewhat concerned about the risk of accidents due to inadequate sleep.

My spouse equally focuses on children’s studies when I am on night shifts (2.91): this value is close to neutral but leans towards agreement, suggesting that spouses generally help with children’s studies during the nurse’s night shifts.

You have adequate sleep period during your night shift (3.28): nurses tend to slightly disagree, indicating that they often do not get adequate sleep during night shifts.

There are no difficulties in taking the drugs relevant to your disease at the correct time during duty hours (4.31): a high mean value shows strong disagreement, indicating significant difficulties in taking necessary medications on time during night shifts.

There are no obstructions in taking healthy foods due to your workload (3.73): nurses disagree, suggesting that their workload during night shifts often prevents them from eating healthy foods.

My family never misses out on my input, either because I don’t see enough of them or because I am too tired (3.54): the mean indicates disagreement, suggesting that nurses feel their families do miss out on their input due to either absence or fatigue.

My relationship with my partner is not suffering because of the pressure or long hours of my work (3.44): nurses tend to disagree, indicating that their relationship with their partner suffers due to the pressures and long hours of night shifts.

There are no fatigue and low concentration during your night shift (3.99): a high mean value indicates strong disagreement, showing that fatigue and low concentration are significant issues during night shifts.

Nurses do not experience headaches or gastrointestinal problems during the night shift (3.37): this value suggests that nurses do experience these health problems, as they tend to disagree with the statement.

Nurses leave their children alone and are able to supervise children’s schoolwork (3.18): this value indicates some concern about leaving children unsupervised, with a slight tendency towards disagreeing with the ability to supervise schoolwork effectively.

Work from home concept is applied to my night shift. I can have a good balance between work and family (3.51): nurses tend to disagree, indicating that working from home during night shifts does not provide a good balance between work and family life.

I do not suffer from stress-related diseases at night shift (3.07): this mean value is close to neutral, indicating mixed experiences with stress-related diseases during night shifts, though slightly leaning towards suffering from stress.

Night shift work-related stress often does not make me irritable at home (3.48): nurses tend to disagree, suggesting that night shift stress often makes them irritable at home.

Overall, the survey indicates that nurses working night shifts face significant challenges in maintaining their health, family relationships, and overall quality of life. They often struggle with inadequate sleep, fatigue, dietary issues, stress, and maintaining effective family interactions.

Discussion

The survey results provide critical insights into the challenges faced by nurses working night shifts, highlighting several areas where their quality of life is adversely affected. The findings align with the existing literature on the impact of night shifts on healthcare workers.

Firstly, nurses reported difficulties in obtaining adequate sleep, with a mean value of 3.28, indicating that sleep deprivation is a significant concern. This aligns with studies by Caruso et al. (2017)⁽⁴⁾, which found that night shift workers are at a higher risk for sleep disorders due to misalignment with the body’s natural circadian rhythms. Sleep deprivation can lead to increased vulnerability to accidents (mean value 3.18), a concern also noted by Åkerstedt et al. (2019)⁽¹⁾, who observed that inadequate sleep significantly impairs cognitive and motor functions.

Moreover, the high mean value (4.31) for difficulties in taking necessary medications on time underscores the challenges night shift nurses face in managing their health conditions. This issue is corroborated by the work of Wagstaff and Lie (2011)⁽¹⁵⁾, who highlighted that irregular work hours complicate medication adherence, potentially exacerbating chronic health conditions.

Nutritional challenges are evident from the mean value of 3.73 for obstructions in taking healthy foods, reflecting similar findings by Zhou et al. (2020)⁽¹⁶⁾, who found that irregular meal patterns and limited access to nutritious food during night shifts contribute to poor dietary habits among healthcare workers. This can lead to gastrointestinal problems, as indicated by a mean value of 3.37 in the survey.

The survey also sheds light on the psychosocial impact of night shifts. Nurses expressed concerns about missing family interactions (mean value 3.54) and the negative effects on their relationships with partners (mean value 3.44). These findings resonate with research by Lembrechts et al. (2015)⁽⁸⁾, who found that irregular work hours strain familial and social relationships, leading to decreased family cohesion and increased marital stress.

Stress and irritability are significant issues, with a mean value of 3.48, indicating that work-related stress often makes nurses irritable at home. This is supported by the research of Geiger-Brown et al. (2012)⁽⁶⁾, which linked night shift work to higher levels of occupational stress and subsequent negative emotional and psychological outcomes.

In summary, the survey highlights the multifaceted challenges faced by night shift nurses, including sleep deprivation, health management difficulties, poor nutrition, and strained family relationships. Addressing these issues requires comprehensive strategies that include better shift scheduling, access to health and wellness resources, and supportive workplace policies to mitigate the adverse effects of night shift work on nurses’ quality of life.

Conclusions

The main findings are centered around sleep issues. Themes included the feelings “obsessed” with sleep, restorative sleep problems, losing a day to recovery, sacrificing sleep for family or children, driving safety form, caring safely for children, worrying about work placed issue when at home, preservation of relationships, social isolation, inability of family or friends to understand, or nutrition and exercise, along with stress. In the study, the researchers examined the influence of nurses shift duties for their quality of life. According to the research findings, it was revealed that the day shift duty had a 2.38-3.84 range of mean level (SD: 0.73). This indicated there are slightly significant changes of day shift duty on the quality of life. Similarly, the research revealed that the night shift duty had a 3.6-3.86 range of mean level (SD: 0.4). This means that there are highly significant changes of night shift duty on the quality of life. The overwhelming conclusion was that day shift duty and night shift duty can alter the nurses’ quality of life.

Limitations of the study

A key limitation of the study was the difficulty in accessing the survey population, which the researchers identified during the study. This challenge ultimately led to a reduction in the sample size. Normally, in a study that tests the influence of shift duties on the quality of life, the researchers should conduct a qualitative study. In this study, the researchers implemented a quantitative short study. At the same time, when collecting data, the researchers used only nurses as the respondent groups. Similarly, the researchers used only the questionnaire method to collected data for the study.

Implication for research

This was a quantitative cross-sectional survey study. Further, we analyzed the quality of life. Reliability as a tool will need to be considered, especially considering the number of variables that can interfere with the quality of life. It would be interesting to ask participants how many hours of sleep they get on average each day, and to rate the quality of that sleep on a Likert scale in a future study. The inclusion of shift length may be helpful to reduce some of the variables in future studies on nursing shift work. Perhaps, the registered nurses should be asked whether they worked 8-12-hour shifts or maybe the study should only include registered nurses working 8-12-hour shifts, but not both. In theory, 8-hour shifts are healthier than popular 12-hour shifts.

Recommendations

The present study recommends that it should be provided adequate off duty hours and a sleep cycle of at least eight hours per day for the nurses’ daily life at home. We encourage nurses to join a special session for hoping and stress management to prevent the work-related stress. Furthermore, the administration can implement different techniques to ensure the quality of life of nursing officers who are working under shift duties and provide more freedom in choosing the shift that would allow them to continue the extended week according to their weekly plan etc. The administration can provide the carrier program for the staff to organize the professional and personal works without clash in the flexible working time context. Effective training can help individuals with flexible working hours manage both work and family responsibilities in a balanced way.

Autori pentru corespondenţă: Alexandra-Elena Popa E-mail: alex_7691_andra@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.