Most participants were unmarried (79.2%) women (83.3%) with a Bachelor’s degree in nursing (70.8%). Their mean age was 29.0 years (SD = 3.7; range = 24–36 years). Participants had an average of 4.8 years of experience (SD = 3.4; range = 10 months to 14 years) as registered nurses and typically worked 8-hour shifts (91.7%). The working units included a medical and surgical unit, an intensive care unit, a neonatal intensive care unit, an emergency room, and a psychiatric unit. Participants reported working for a mean of 47.3 ± 5.7 hours per week (range = 40–60 hours).
Three main themes were identified: (1) Unsatisfactory work schedules, (2) impact of shift work on nurses’ lives, and (3) impact of schedule-related fatigue on nurse’s performance. Themes and subthemes are presented in Table 1.
Theme 1: Unsatisfactory work schedules among rotating-shift nurses
All participants experienced dissatisfaction with their work schedules. While experiences varied, most nurse reported that their work schedules and shift patterns were unfavorable. They also frequently noted that this was closely related to nurse staffing shortages. Furthermore, the absence of clear hospital scheduling practice regulations led to high variability, depending on the working unit and nurse managers. This resulted in unequal work schedules. Participants also indicated that their monthly work schedules were usually generated and received with just a few days’ notice, and often changed during the month. The main causes of unsatisfactory shift work were unpredictability, instability, and the inability to request a specific schedule. Participants are referred to by group (G) and participant number (P).
“When the work schedule needs to be changed in my unit, the notice is posted in the group chat to inform the employees of the change. The employee’s personal commitments are not taken into consideration. Even if an employee already has plans or commitments, or really wants that time off, the nursing manager will cancel their time off and change the shift without consulting them. The employees have no choice but to follow through” (G2, P4).
Significantly, most nurses asserted that they could not recover from fatigue with the current work schedule. In fact, due to the high number of consecutive working days and insufficient days off, their fatigue was progressive. One participant commented that he worked six consecutive days once every two months and was extremely tired during and after his shifts. Due to the inadequate downtime between shifts, and overtime hours, nurses did not feel sufficiently rested and experienced greater fatigue. Although overtime hours varied (depending on the number of years worked and the unit type), most participants expressed that working overtime was both common and unavoidable under the current conditions.
Nurses described these extended work hours as physically and emotionally overwhelming. Furthermore, staffing shortages and organizational culture were said to make it difficult to take sick leave. Indeed, more than half of the nurses had worked when they were extremely sick, and some expressed guilt about taking time off.
“I think the worst part of our job is that somebody has to work in my place if I take time off. Other office workers or employees can just use their annual leave and take a day off when they are sick [P1, P4, and P6 nod] — but I know that if I take time off, someone else who was supposed to be off would have to cover for me. So, I just choose to go to work, unless I am unbearably sick” (G4, P5).
“I had to go to the emergency room during my shift, because of enteritis. Even at that time, I could not stop thinking about the patients that I had left behind. The doctors at the ER told me to wait until the blood reports were in to ensure that everything was fine, but I insisted on going back to work. It was very tough to work in such a condition, but I had to endure it because I could not dare to ask for time off” (G3, P6).
Theme 2: Impact of shift work on nurses’ lives
Nurses expressed that they were often extremely tired after work; when they worked overtime (or worked on a particularly busy day), they felt exhausted. Many recounted falling asleep on the bus or subway and missing their stop, or falling asleep while driving home after work. They also noted the development of health issues, including digestive problems, body aches, headaches, and reproductive problems (e.g., polycystic ovary syndrome) following the commencement of their careers as rotating-shift nurses. Most commonly, participants reported sleep impairment and circadian rhythm disruption. To manage these issues, some adopted a “no-sleep strategy” before working night shifts, while others were prescribed sleep aid medications to adjust to shift changes.
“I was pretty healthy in general, but I started taking zolpidem two years ago as I was having a hard time sleeping. I feel skeptical about taking sleeping pills for work as I have to do rotating-shift work [P1 nods], and I wonder, ‘when am I going to need these pills to fall [a]sleep?’ ” (G4, P3).
In addition to physical symptoms, most nurses experienced psychological problems, like depression and low energy. It is noteworthy that nurses attributed this impaired psychological well-being to physical fatigue. In fact, one participant described fatigue as a physical, mental and emotional condition. Nurses also expressed that states of high stress and fatigue hindered their concentration and their professional performance suffered.
“You definitely lose your focus at work when you are tired. In fact, I also tend to feel depressed when I leave work, especially if I finish late. Sometimes I can only manage to finish work after staying at the hospital for 12 hours or even longer. It is emotionally very stressful” (G2, P3).
Along with the physical and psychological effects of shift work, the subtheme of work-life balance emerged. All participants indicated that the monthly work schedule controlled their everyday patterns and destabilized their lives. Nurses frequently faced challenges in managing their shift work and their social lives. Irregular, frequently changing work schedules undermined their ability to make plans with family, enjoy recreational activities, and devote time to personal development. One nurse even observed that it was difficult to engage in religious activities due to the shift work schedule. Another added that the quality of her engagement with family and friends decreased because she was too tired to engage in activities with them. Other nurses similarly reported conflicting demands between work and family roles. Approximately 20% of participants were married, and three were mothers. The participants found that maintaining the balance between parenthood and nursing was made more difficult by extended hours or unexpected schedule changes.
“When you have kids, you have to prepare breakfast and watch the kids after you finish your night shift, and that is very exhausting. It disrupts both the work and the ability to take care of kids” (G1, P1).
Participants also identified rotating shift work as a factor prohibiting the sustainability of their current position. Similarly, many of their colleagues left their units because of the negative consequences of shift work. In particular, older nurses indicated that adjusting to shift work and night shifts became harder as they aged, and expressed their intention to leave.
Theme 3: Impact of fatigue (due to shift work) on nurses’ performance
Nurses also discussed the challenge of providing high-quality care while fatigued. Most recounted falling asleep on duty due to inadequate rest time; this was more frequent during night shifts. Participants agreed that when they were physically and emotionally exhausted (due to insufficient sleep and circadian rhythm disruption), they were unable to complete their professional tasks.
Furthermore, when fatigued, they often lost their concentration and experienced compromised assessment and problem-solving abilities. This jeopardized patient safety in relation to medication errors, falls with injury, patient identification errors, and omitted nursing care. One participant stated that she made a dosing error when mixing liquid medications while extremely exhausted. Another added that she often experienced near misses on the final day of five consecutive day shifts or during night shifts.
“At one time, while I was taking a blood sample during the night shift, I thought that I had clearly checked the patient and taken a blood sample from Patient A. When I looked at it again, after an additional blood test was prescribed for Patient A, I found out that I had taken Patient A’s blood sample for Patient B’s blood test. Luckily, I realized my mistake in time and it did not lead to a medical accident, but the patient had to undergo another invasive test. Looking back, I think I was in a trance and was not completely aware of what I was doing. My performance was not up to the mark that night” (G2, P4).
Nurses also described several examples of regrettable professional communication with patients and other healthcare professionals while fatigued. One participant, who worked in a psychiatric unit, said she failed to carefully listen, or promptly respond, to patients’ requests when she was sleepy. Other nurses regretted their irritability when they were working while sick. Participants agreed that when they were not fully rested, they tended not to assist colleagues and to snap at others.
“If I am fatigued…I start talking bluntly, not just with the patients but also with my coworkers and newly graduated nurses, when I could have talked politely [P4 and P6 nod], and my manner becomes gruff when I tell things to the doctors. This can hurt their feelings and create problems by having a negative effect on their emotional state. I try not to behave in this manner, but I am sure a lot of people can relate to this” (G4, P5).