Fight fatigue in nursing and midwifery

Managing fatigue is a real challenge when we work stressful rotating shifts in busy pressured environments, but with the right tools and strategies, it’s absolutely possible to get a handle on your fatigue and feel better! Here’s what we can do:

Shift work is a known risk factor for poor sleep.

We know that sleep is important for health and wellbeing, but when life gets really busy its often the first thing we give up. Compared to the average population, sleep can be more difficult for us, as most of us work rotating shifts — in fact, a 2020 survey of nurses showed that 55% suffered from insomnia.

The effects of sleep loss can be insidious, and we may not always notice when we are sleep deprived, according to research. By the end of a workweek, we may have accumulated sleep debt, which impacts the way our brain functions.

For nurses and midwives, following the usual sleep recommendations don’t always work, leaving us feeling frustrated, hopeless, and confused.

Dr Lisa Matricciani, a sleep researcher and lecturer in nursing, explains:

“A lot of sleep recommendations focus on set fixed sleep and wake up times. For nurses and midwives working rotating shift work, and even other disciplines, that’s just not possible. One day you might be working a late shift and you finish at 9.30pm at night. Other times you might be working a night shift, so forming that consistent sleep schedule is really difficult.” — Healthy sleep and nursing, AJAN - The Australian Journal of Advanced Nursing

Taking control of your roster, as much as possible, is critical to reducing fatigue. Having agency over your schedule is important. Research shows that having a certain degree of choice and flexibility with your roster helps to increase wellbeing.

Here are some key strategies: 

• Avoid overtime. If you decide to work overtime, try to work it when you have at least one day off the following day to recover.
• Reduce late/early shifts. These shifts are known to cause fatigue as enough time isn’t allowed between shifts for sleep and recovery.
• Plan and submit preferences for your roster, including night shifts, in advance. If you work too many days in a row, you are much more likely to experience fatigue which can take longer to recover from on days off.
• Swap shifts to enhance your pattern of work.
• Direction of rotation of shifts: if possible, forward rotating schedules are better than backwards rotating ones. As an example, working a day, then evening, then night shift as opposed to a night shift, evening, day shift. This allows more time for sleep and rest in between shifts.
• Working more than three night shifts in a row is not recommended, as per the ANMF’s night shift policy.

We know it’s not always easy to take control over your roster and many people struggle to successfully negotiate a workable solution with an employer who is asking too much of them.

Nurses and midwives tell us that they feel a sense of guilt, obligation, pressure and responsibility to work overtime, extra shifts, and take on too much at work. A recent study found that nurses’ strong sense of duty is a key barrier in fatigue risk management.

“Part of the emotional fatigue is you don’t want to leave stuff for your coworkers, you want them to think you’re doing a good job. You don’t want them to be like, “uh I got to follow (name) again” cause she never got her work done. You want to be part of the team and be somebody that other people respect and want to work with.” — Nurse, Fatigue in hospital nurses - 'Supernurse' culture is a barrier to addressing problems: A qualitative interview study

By saying no, we may feel that we are letting others down, upsetting others, or fear being judged or criticised, but it’s important to remind ourselves that over-giving can leave us feeling stressed, overwhelmed and fatigued. In these circumstances, we will not be able to offer our best to our patients or colleagues.

Here are some resources to help you advocate for your needs.

Boundaries are a critical part of self-care, and something a lot of us struggle to implement. Boundaries help to protect our health and wellbeing. Wendy McIntosh, RN specialises in setting professional boundaries. She explains that overgiving can be an addictive lure, so she has developed the phrase “that’s enough now” to help nurses and midwives learn when to say no.

“It is a great enticement to keep giving more and more. It is almost like an addiction. I give more, I feel good, so I will keep giving more. Like any addiction, chasing the rush you get from giving more can lead you further and further from what is good and healthy for yourself and your own wellbeing”.

Check out Wendy’s guide to self-advocacy: “That’s enough now”— professional boundaries fortify self-care

Here’s a summary of her advice on how to set boundaries:

• Value yourself: Know you have a right to take care of yourself. Your health is number one.
• Plan ahead: If you know you may be asked to work overtime/extra shifts, have a script in your mind about how you will say no.
• Set boundaries early on: Starting this early in your career will help to sustain you in the long term.
• Seek out clinical supervision: This can you understand why you may have difficulty setting boundaries, and strategies for developing stronger ones.

Many of us don’t find it easy to be direct in our communication, but assertive communication is an important skill to develop:

“It is based on mutual respect and targets problems rather than people, with a mutual goal to solve a concern or crisis. This communication style has been found to neutralise incidents of workplace bullying, reduce the stress experience in complex situations and boost self-empowerment.”

Check out our guide to help you develop this integral skill.

Australian law regulates what can be expected of shiftworkers, but it’s not always easy to find out exactly what the law (or your contract) allows. Here are some resources you can reach out to help you understand your position:

• Your local ANMF branch
• Fair Work Australia
• The Employee Assistance Program (EAP) at your workplace
• Our team at Nurse & Midwife Support

Research tells us that people over 40 find shift work harder to tolerate, particularly shifts at night or longer than 8 hours. As we get older, the circadian rhythm weakens, sleep in general starts to deteriorate and chronic illness is more likely, making it harder to adjust to irregular working hours.

If you are over the age of 55 and have worked with your employer for at least 12 months, you may be eligible to apply for a flexible working arrangement — find out more: Flexible working arrangements - Fair Work Ombudsman.

You may also consider transitioning into a new position within the profession that allows you to establish a more regular schedule. Check out our newsletter on Career transition and development.

Once you’ve optimised your roster to maximise your potential for rest, you can also work on finding a research-backed routine that helps you sleep better once you get home. But remember — change can take time.

Finding and sticking to a routine that works for you can be difficult, so give yourself grace as you figure it out. Sleep specialist Dr David Rosen says:

“When evaluating sleep habits, the challenge becomes figuring out how to break the bad habit and having a plan in place if you falter. That plan must include forgiving yourself if you have slip-ups and making sure you only start with 1 or 2 routine changes at a time.”

Here are some strategies to try:

• Consider your light exposure:
  • Get sunlight, particularly early in the day. If this isn’t possible before work, try to get outside on your break
  • Avoid bright lights and stimulating activities 1–2 hours before sleep, as this disrupts your circadian rhythm.
• Find a relaxing wind-down routine before bed: take a warm shower, listen to soothing music, practice yoga or meditation.
• When you’re working night duty, wear sunglasses on the way home from work, eat a low GI protein-based meal before bed, and sleep in a very dark, cool, quiet room. Think black out curtains, ear plugs, and keeping the heat off or low.
• Try not to drink alcohol or caffeine later in your day.
• Give your body sufficient time to sleep. Say no more often and spend less time on social media.
• Prioritise sleep: ask your family/housemates to support you when you need rest. Protect your sleep by planning for it each day. Ask not to be woken unless it’s an emergency.
• Maintain a similar sleep schedule for each shift type — keep bedtime X for AM shift, bedtime Y for PM shifts. Aim to sleep 7–9 hours at a time.
• Allow yourself to nap: 20 minute naps taken at least 4-6 hours before sleeping can help improve alertness and reduce fatigue.

If you’ve had a hard day after a late or night shift and need to debrief you can give us a call on the way home. This could help your mind from racing and ruminating while you’re trying to sleep. Reach out on 1800 667 877 — we’re here for you 24/7, free, confidential, nationwide.