Registered Nurses’ Experiences Taking Breaks on Night Shift: A Qualitative Analysis

Abstract

Background:

Fatigue mitigation strategies among night shift workers can include deliberate use of restful work breaks, taking naps, and consuming caffeine. However, nurses have frequently reported missing break opportunities, and the rationale for missed breaks remains unclear. The purpose of this study was to describe and interpret the lived experience of hospital night shift nurses taking breaks and the meaning of this phenomenon as it relates to the workplace.

Methods:

Registered nurses (n = 16) from a U.S. community hospital were interviewed about how they took rest breaks during their shift. Data were analyzed with methods consistent to interpretive phenomenology.

Findings:

Identified themes about the breaks included (a) breaks are a time to eat, (b) breaks are inconsistently supported by unit-level structures and processes, and (c) breaks are a luxury, not a right.

Conclusions/Applications to Practice:

Nurses in this study reported an absence of consistent and restorative breaks. Organizations should analyze gaps within systems and processes to optimize a consistent, restorative nature of the break experience among nurses working night shift.

Background

Circadian misalignment can occur when sleep-wake cycles are out of synchronicity with the biological night (Baron & Reid, 2014). Shift workers are at high risk for this misalignment, with night shift workers being at the highest risk. Health consequences to shift workers are numerous and include increased risk for cardiovascular disease, obesity, and psychiatric conditions (Baron & Reid, 2014). Some associated physiological effects of night shift include sleep loss, fatigue, dysphoric mood, accidental injury, and death (Flo et al., 2014). While in the workplace, nurses who work 12-hour shifts have been found to take fewer 30-minute breaks compared to day-shift nurses who work 8- or 12-hour shifts (Wilson et al., 2018). Night-shift nurses on 12-hour shifts also reported more sleepiness and show greater difficulties with on-the-job performance tests compared to day-shift nurses that worked 12 hour (Wilson et al., 2019). Increased risk of medication errors has also been reported for 12-hour nurses compared to 8-hour nurses (Witkoski & Dickson, 2010). Such hazards have been well-documented in the literature and can have a direct impact on patient care outcomes and nurses’ well-being (Caruso, 2014). Therefore, strategies to reduce risks to patients and workers’ health are needed, particularly regarding night-shift workers that work 12 hours.

Hospital-based nurses across the world commonly work 8- or 12-hour shifts to provide patient care over 24 hours of time (Centers for Disease Control and Protection: National Institute for Occupational Safety and Health, 2004). With these long shifts, employers have implemented recommended policies for controlled rest breaks for all health care workers (The Joint Commission, 2012). For the purpose of this study, we defined a break as a 30-minute lunch/dinner during an 8-hour shift. A 15-minute and shorter break is taken for every 4 hours worked according to standard practices by the U.S. Department of Labor and the policy of the health care organization where the research took place (U.S. Department of Labor, 2020). In the acute care or hospital workplace, breaks are variable in length and inconsistently enforced across countries and care settings (Centers for Disease Control and Protection: National Institute for Occupational Safety and Health, 2004). Currently, rest breaks are not part of any federal regulations, are dependent upon individual state labor laws, and less than half of states in the United States (U.S.) have legislations to provide rest breaks for workers (The Joint Commission, 2012).

Previous research has highlighted that rest breaks improve performance, reduce fatigue (McDonald et al., 2013), and are an accepted fatigue countermeasure in many industries outside of health care such as truck drivers and airline pilots (Satterfield & Van Dongen, 2013). Napping has not been well-studied in nursing populations (Geiger-Brown et al., 2016) despite recommendations to encourage napping of less than 45 minutes (The Joint Commission, 2012). One study reported that despite having break policies in place, nearly one-third of nurses report not taking on-shift breaks of at least 30 minutes, and more than 75% of nurses report not having a quiet place to take a break (Wilson et al., 2018). It is well documented that nurses do not take breaks, but the current literature does not accurately describe the reasons why nurses are not able to take restorative or restful breaks during their shift (Nejati et al., 2016).

The purpose of this study was to gain a better understanding of the barriers and facilitators for night-shift nurses to take their breaks. The specific aim of this study was to describe and interpret the lived experience of hospital employed nurses taking breaks on night shift to facilitate the understanding of the meaning of this phenomenon as it relates to their workplace.

Methods

The methodology of interpretive phenomenology was selected for this study because little has been documented about night-shift nurses’ experiences using their break time (Creswell & Creswell, 2018). Interpretive phenomenology is a qualitative research methodology based on philosophical work of Heidegger (1927/1993) and Gadamer (2013), to capture the everyday experience of phenomena (Mackey, 2005).

Participants were selected through purposive sampling. The sample included 16 registered nurses working in a community hospital in a rural/suburban area of the Pacific Northwest of the U.S. Participants were recruited using organizational email, flyers, and word-of-mouth advertisement through co-workers and nurses involved in the research. The following inclusion criteria were used to determine whether the participant was eligible to participate: a registered nurse who provided direct care to patients on the night shift, in the hospital setting, worked exclusively 12-hour night shifts without rotating shifts, spoke fluent English, and was willing to be digitally voice recorded.

Each interview lasted from 30 to 90 minutes in length. Participants were provided a small gift certificate to a local company as an honorarium. Interviews were audio recorded and transcribed by a professional transcriptionist with participant identifiers removed.

By employing the method of interpretive phenomenology, one-on-one interviews were completed and then transcribed for group interpretation (Vandermause & Fleming, 2011).

The interview began with one opening query: “Please describe your experience with taking rest breaks while working night shift at this organization.” Unstructured interviewing techniques allowed for additional prompts to encourage conversation with the participants. Such prompts included, “Tell me about an experience that you had when you were able/unable to take your breaks and your lunch/dinner.” The Washington State University Institutional Review Board and the health care organization where the research took place deemed this study as exempt from review.

Data Analysis

Each recorded interview transcription was shared with a group of content experts in nursing practice from the health care organization. The main interviewer led an interpretive team to analyze the transcripts. Each interview was read by at least three of the six members of the interpretive team. The team met once a month for 4 months to review interviews and themes. Consistent with phenomenological methods, validity and rigor were confirmed through group interpretation and consensus among the transcripts, and no software was used for analysis (Vandermause & Fleming, 2011).

Results

Sixteen registered nurses were interviewed. Fourteen were female and two were male. The average age was 37.8 years. All participants worked 12-hour night shift at the same organization, yet practiced nursing in various specialties throughout the acute care setting including intensive care units, labor and delivery, medical-surgical, psychiatric units, and the emergency department.

Three main themes emerged from the analyzed interviews. The first theme identified that the primary purpose of breaks was eating. The second theme highlighted that the ability to take breaks depended on unit-level structures and processes such as patient load, patient acuity, and availability of break support resources. The third theme emphasized that breaks were perceived as a luxury, not as a restful experience or a working person’s right. Nurses preferred social interactions during their breaks, not napping and there was a perception among those interviewed, that napping would increase tiredness instead of improving tiredness.

Primary Purpose of Breaks: Eating

Every participant shared an experience describing the primary purpose of a break was eating, not resting. When asked about taking a break, all the participants identified eating a meal. None of those interviewed viewed the break as a restful time, but as a time to quickly eat. Participants were more concerned about surviving the shift without hunger or hypoglycemia, not symptoms of circadian misalignment related to not taking a restful break.

The participants spoke primarily about needing to eat to do their work. If they were unable to eat, this was considered a “bad” or “busy” shift “[ . . . ] there’s been times where I haven’t eaten, drank any water, or gone to the bathroom, and it was four am. I think those are the days where I don’t want to come back” (Participant B).

Many of those interviewed recalled shifts in which they were unable to eat, let alone take a full restful break. If a participant had a moment of down time, they were quickly getting food in their mouth to make it through their shift to, “[ . . . ] take ten or fifteen minutes to grab some food, go potty, and come back” (Participant G). One participant even shared that breaks were generally not taken at all and that if you got to take a break, it is for eating:

I know we’re supposed to get a thirty-minute lunchbreak and depending on the volume of nurses, if we have enough nurses to cover and how acute the patients are. If you can afford to step away, you’re given a lunchbreak. Other than that, you just don’t typically get it. And breaks are not something we actually even consider or talk about. (Participant P)

Among the participants interviewed, breaks were being used for eating food. Although those interviewed were aware of the break policy, they were allowed to take breaks and the unit was staffed appropriately for their shift. Breaks were not used to their fullest capacity by those interviewed.

Ability to Take Breaks Depended on Unit-Level Structures

Night-shift nurses’ ability to take a break depended upon the acuity of their assignment and support structures in place to allow a break, “If we have a really critical baby, nights tend to go by really fast, sometimes I find myself thinking I haven’t even had a glass of water” (Participant N). Participants described their priority was a responsibility to their patients, sharing, “[ . . . ] we had a demise recently, and it just wasn’t an appropriate situation to have another nurse who hadn’t been with that patient to go sit in the room with her” (Participant C).

Before taking their break, participants felt their responsibility was to their patient first.

If the patient was critically ill, in active labor, dying, or another similar crisis, the participants described that breaks were skipped to provide continuity in the nursing care for the patient:

Nights that I just have a super sick patient, or two of them, and is where I feel it the most is just physically. It usually hits me around there or four, and I’ll feel nauseous and I’ll feel like my brain function is depleted. (Participant J)

While break policies were in place, a consistent system for how, when, and where to take a break was inconsistently reinforced for every unit represented by the participants interviewed. “We don’t have a formal assigned buddy [ . . . ] if I do choose to take a thirty-minute break, then that means I would have to stay over for my shift” (Participant K). Participants wanted to finish their work and go home on time, so breaks were not taken or enforced by the current work unit structures.

As a result, the decision to take their break and how advocate for themselves was at the discretion of the nurse, “There is no organized practice for small breaks when patients are just so unstable and they’re requiring so much care that there’s not any opportunity to really step away” (Participant A). While several participants did share that they were able to take their breaks with appropriate staffing and patient load, unstable patients continued to cause disruptions in many participants’ ability to take restful and reliable breaks. The participants described limited organizational support to take their break, instead of having structures that encourage or create a safe, restful place to take a break away from the unit.

Breaks Were Perceived as a Luxury

The final barrier to nurses taking breaks was that a break was viewed as a bonus, taken only when the nurse’s shift was “going well” or tasks were up to date. Breaks were considered a luxury, not as a restful experience or a right for a working person. Participants expressed that taking a break was secondary to all other parts of their work:

I’m there if we had an emergency. If there was code. If there was something, then at least I’m there if needed. Because on nights if we don’t have the resources, you don’t have that extra staff that can show up. We are it. (Participant D)

In addition to the earlier mentioned theme of eating for one’s break, participants also shared that they would often consume food at the nurses’ station during their break. The majority of participants interviewed told about eating food at the nurses’ station:

We all sit at the nurses’ station where we can still see our patients and hear the alarms and watch the monitors [ . . . ] we really don’t take those breaks; [ . . . ] they’ll (nurses) go and get food and then they’ll sit at the nurses’ station where they can watch their alarms, watch their monitors. (Participant M)

While despite this practice is against hospitals’ policies, participants felt that this was the safest option when staffing was lower on the nightshift. Eating at the nurses’ station allowed the nurses to see call lights or ensure available help for staff, in the event of emergency. All of the nurses who shared that they ate and took their break at the nurses’ station understood the inappropriateness of their actions. However, none of the nurses acknowledged that this was not a restful break but rather an opportunity where the nurse could sit and eat while continuing to do their work. Moreover, the participants interviewed indicated that eating at the desk was what they considered a break.

Discussion

The main themes from the data suggest that night shift nurses do not use their breaks to the fullest extent for restoring or improving their health. Nurses use their breaks as a method to survive the shift meeting their basic needs while remaining available to their co-workers and patients. Taking a break is a time for eating and socializing, not resting or napping. Furthermore, the results of this study highlight inappropriate breaking practices such as eating and drinking at nursing station, while continuing to work. When a break away from the unit is used, it is considered a luxury, when there is sufficient relief staff and lower patient acuity.

Napping was never used or seen as an option as a way to combat tiredness by any of the participants. These findings align with other studies of nurses describing napping as not a commonly accepted practice within their allotted break time at work (McMillan & Fallis, 2011). In contrast, a research study conducted in Brazil found that 94% of nurses surveyed stated that they were authorized to sleep or rest during their shift, and the average duration for a break/nap was 2-hour during a 24-hour shift (Silva-Costa et al., 2013). Important next steps should examine whether cultural beliefs or unit culture related to rest breaks can be altered by organizational efforts.

There were several limitations to the study. Those interviewed worked at the same hospital, with the same organizational policies. So, the results may not represent nurses at different hospitals with different policies. The majority of participants were also women. Future research should focus on a more diverse selection of participants from a variety of hospital types, geographic settings, and participant backgrounds. Another limitation to the study was that it was supported by the hospital organization. Because of this, participants may have felt inhibited to speak openly about their break practices. However, the majority of participants shared their break practices that were not supported by hospital policy.

Employees who work 12-hour shifts report having poor sleep quality and those on night shift are less likely to use allotted break times (Wilson et al., 2018). While some organizations have developed policies supportive of taking breaks and napping, research of U.S. working nurses suggests that this may be insufficient for employees to change their break time practices (Wilson et al., 2018).

Implications for Occupational Health Nursing Practice

Night-shift nurses from our sample shared their belief that their workflow is structured differently than dayshift. A high priority to the nurses interviewed was providing adequate relief staff and environments that assure patients’ needs are attended to during breaks. Several participants shared their opinion that because of the unreliability of night shift workflow, relief staff were commonly not considered worth the cost of additional staff. Consequently, the night-shift nurses in this study identified lack of a reliable structure and additional staff to support restful breaks.

Compounding this issue is the differing desires expressed by night shift nurses regarding how to best facilitate breaks. For instance, some nurses feel like a buddy system would be helpful, while others do not, citing fear of leaving a critically ill patient or guilt in assigning tasks to a buddy. It is reasonable, then, that different solutions for facilitating night shift nurses to take restorative breaks are needed. Occupational health nurses should explore how to support night shift nurses and patient needs using the resources available for restorative breaks.

Recommendations for restorative breaks included fresh air, nature, and natural light (Nejati et al., 2016), yet outdoor access is often unsafe and natural light is scarce during nocturnal hours. Some institutions have reported using meditation, tai chi, yoga, and other relaxation exercises for their night-shift staff members (Nejati et al., 2016). Alternatively, it has been suggested that organizations should support restorative breaks by providing staff with a quiet, dark room to nap in for their scheduled breaks (Pryce, 2016). Occupational health nurse can investigate solutions with the input of night shift workers. A multi-dimensional plan is ideal that addresses both organizational and individual barriers and facilitators to restorative breaks are needed.

Another consideration for occupational health nurses is to assess how to facilitate restorative break opportunities for nurses who are caring for critically ill patients. The nurses in this study indicated that they felt being uncomfortable leaving the nursing unit when caring for critically ill, high-acuity patients. Instead taking a restful break, they prefer to skip their break completely. Units and departments should analyze this issue as a probable cause for missed breaks, particularly for nurses caring for patients in isolation or mandated and/or complicated personal protective equipment. The development and enactment of a plan or protocol has the potential to provide protected, restorative break opportunities for all working nurses, despite the complexity of their patient or the shift they are working.

Conclusion

Break policies appear to be the norm for hospital-based nurses, yet there is inconsistent organizational support to take these breaks. A change in nursing workplace culture regarding breaks is needed to empower nurses to participate in restorative breaks. Evidence suggests that taking regular, restorative breaks may improve the overall health of night-shift nurses. Nurses in our study report a desire to take restorative breaks but may need support from organizations, occupational health nurses, and unit-specific leaders to address unique night-shift barriers.

Applying Research to Occupational Health Practice

Nurses who work in shifts, particularly night shift, face the risk of negative health consequences associated with shift work. Despite this known risk, night-shift nurses do not consistently take restful or restorative breaks while working. This study reports themes related to night shift registered nurses’ break practices. We observed that the primary purpose of breaks was for eating and breaks depended heavily the nurses’ responsibilities toward their patients. Occupational health nurses can address the unique needs of night shift nurses by supporting development of structures to encourage reliable breaks and physical places for restful breaks to occur away from the unit. In addition, occupational health nurses should consider ways to minimize health risks for nurses who miss their breaks to care for patients.