DEBRA GRICE-SWENSON, PhD, RN, NEA-BC

1. THE SUBCULTURE OF NIGHT NURSING DEBRA GRICE-SWENSON, PhD, RN, NEA-BC

2. BACKGROUND • Institute of Medicine’s reports: address patient safety and workforce issues such as environmental safety, staffing, organizational culture and workforce characteristics. • Recommendations: • that federal agencies and private foundations support research in areas that will provide healthcare organizations with the information they need to strengthen nurse work environments • Specifically: • “studies and development of methods to better describe, both qualitatively and quantitatively, the work nurses perform in different care settings…” (IOM, 2004, p.257).

3. PURPOSE OF STUDYRESEARCH QUESTIONS • (1) What is the role of a night nurse in a hospital? • (2) What does a typical night entail for a night nurse? • (3) What are the shared behaviors, norms, rituals, communication, hierarchies, and nursing care patterns in the hospital at night?

4. LITERATURE REVIEW • Role Theory • Role and Nursing • Role and Socialization • Socialization and Nursing • Culture • Role and Culture • Culture and Nursing • Night Nursing

6. STUDY DESIGN &METHODOLOGY • Ethnography: Used to describe how a culture/ sub-culture works, and to explore its beliefs, language, and shared behaviors • Ethnonursing developed by Madeleine Leininger(1970) • Developmental Research Sequence (Spradley 1979; 1980). • Content Analysis: Observation Notes and Interviews

7. SETTING, PARTICIPANTS, DATA COLLECTION • 5 units in two acute care settings • Eligibility criteria: registered nurses who were currently working on the night shift, and had been working the night shift for at least 2 years • IRB Approval & Informed Consent obtained • Observations: approximately 100 hours • Interviews: 8 participants selected from observations; formal semi-structured interviews conducted individually in private settings • Hospital Document review

8. SUMMARY OF CHARACTERISTICS OF FIELD & PARTICIPANTS • Types of Units: 2 critical care, 2 med-surg, 1 oncology • Bed-base of Units: Range from 12-36 beds • Average number of RN’s per night : 6-8 • Age of participants: 26-66 • Education: 1 Diploma, 3 Associate, 3 Bachelors, 2 Masters • Years in nursing: 3-47 • Years in nursing at night: 3-45

9. DATA • Field notes, memos, and reflexive journal entries by the researcher • Transcripts of in-depth interviews of informants • Documents such as position descriptions, policies, meeting minutes, vision statements and procedure manuals for content analysis

10. METHODOLOGICAL RIGOR • Credibility • Transferability • Auditability • Dependability • (Lincoln & Guba, 1985)

11. Results • Cultural patterns that night nurses share as a group include: entry, specified roles, rituals, hierarchies, and insider/outsider perspectives. • The data reinforced the description of night nursing as a subculture • 8 Domains identified from Observations and Interviews (Content analysis)

12. Role of a night nurse • Patient-centered and encompasses both physical and emotional care. • What was once considered a predominantly supervisory role of monitoring sleeping patients is no longer true. • While sleep is encouraged for patients, there are many interruptions.

13. Ebb and Flow of the Ocean

14. Identification of Cultural Themes • Four Major Themes emerged from analysis of interviews and observations: • 1 Camaraderie and Teamwork are the Pillars of Night Nursing • 2 Learning to Critically think abounds on the Night Shift • 3 Sleep Mindedness permeates Night Nursing • 4 Night Nurses are Undervalued

15. Theme 1: Camaraderie and Teamwork: the pillars of night nursing

16. Theme 2: Learning to Critically Think abounds on the Night Shift • “I find that the skill of a night shift nurse is far greater than the day shift because out of necessity you develop better skills…you can’t call anybody to put your NG tube in or start your IV.” • “I think night nurses are more independent…they’re more the trouble-shooter type. I have found night nurses devise great things to make things work…that drain has a leak, what can we do to improvise to make things work since we don’t have the stockroom people here…we use our critical thinking to make things work, you know?”

17. Theme 3: Sleep Mindedness permeates Night Nursing • “I feel like we obsess about our sleep! I don’t hear day people asking each other how much sleep they got…you know?” • “I think there is always that background fatigue…that you almost can’t pay back anymore…there are still times where I’ll fall asleep anywhere…sleeping is one of the most important things!”

18. Theme 4: Night Nurses are Undervalued • “I think the day shift doesn’t always understand a lot of what the night shift does. ……that’s frustrating” • “No one would believe that this is really happening in the middle of the night, unless they were here to experience it!” • “ We have a great nurse manager but she never comes in to meet with us during the night. That’s one thing that drives me crazy. It’s just a quick ‘hello’ in the morning and then ‘goodbye’. It would be nice for us to be recognized…that’s all!”

19. Conclusions The study findings supported literature on: • sleep disturbances and high teamwork scores among night nurses • limited opportunities for formal education at night • Night nurses not as valued as their peers on the day shift The study findings did not support the literature on: • night shift in a hospital is quiet • patient outcomes may be worse on weekends and nights.

20. Conclusions • Subcultures are often present in every layer and division of an organization and can either weaken or strengthen the culture of the larger group as a whole • Subcultures with strong self-identities have the potential to become ethnocentric and this may impede further growth for the larger culture

21. Implications for Nursing Practice • Nurse managers need to be visible and accessible to their night nurses • Current routines need to be examined; holding on to certain rituals and outdated practices may no longer be feasible • Capitalize on the teamwork and camaraderie • Provide the resources necessary for the formation of nursing practice councils or research committees that meet on the night shift

22. Implications for Nursing Practice • Ensure that a safe quantity of staff and appropriate mix of skill sets are working on a nightly basis • Ensure a minimum of two nights off in between scheduled shifts • Permit and encourage napping during break times , especially during the known peak of circadian rhythm sleepiness, between 2 a.m. and 4 a.m. • Promote adherence to scheduled breaks during the night shift to improve alertness and reduce the incidence of fatigue-induced errors.

23. Implications for Administration • Promote involvement of night nurses to make them feel more valued as contributors: • Establish formal communication with night nurses on a regular basis. • Ensure that night nurses are involved in nursing department decision-making and in practice or policy changes.

24. Recommendations for Future Research Further exploration of : • the dynamics of inter-shift relationships between nurses on nights and nurses on days • teamwork dynamics of nursing units • nursing practice environment of a night nurse And • Increased use of ethnographic methodologies to gain valuable insight when seeking to redesign healthcare environments

25. Limitations • Excluded unlicensed assistive personnel- nursing assistants, patient care technicians • Openness of the observations may have resulted in some participants being guarded in their interactions • Some interviews were conducted on the units where the participants worked: not known if this might have influenced the responses of the participants

26. Thank you!