Night Work

In 2010, the National Board of Health and Welfare conducted night-time supervision at a large number of elderly care homes in Sweden. This resulted in extensive criticism. The National Board of Health and Welfare then tried to introduce a staffing regulation for elderly care homes, but was deemed not to have the right to do so. SKR (Swedish Association of Local Authorities and Regions) started the project "Shed light on the night" in 2016, which aimed to strengthen the quality at night.

The Social Services Ordinance states that personnel should be available around the clock who can immediately notice if a resident needs support and help. There are several work environment regulations related to night work.

Factors that affect the quality at night include

• The needs of the resident
• Working methods, routines
• Competence and skills development
• Technology (alarms, lifts, beds, mattresses)
• Organisation and leadership
• The premises
• Strategy for welfare technology

Simply put, we can describe night work as the staff member making rounds, turning people who can't do it themselves, checking on and assisting with toilet visits or changing incontinence pads, and helping the resident with hygiene. It may involve giving medication or contacting the on-call nurse if someone has pain or fever. Residents may need to have a late supper so that the night fast does not become too long.

There are a large number of infrequent events that can occur at night. For example, when one of the residents is restless and the staff member has to sit down with them and talk and try to calm them down. It is not easy to handle a resident who gets angry and fights when working alone. Fall injuries are common at night.

The night encompasses more than a third of the day. Often there is some form of cleaning routine that the night staff is responsible for. Many tend to do this when they are at their most tired in order not to fall asleep. People who work at night often find the time between 04:00 – 05:30 the hardest.

Nursing assistants who work at night are often experienced, but it happens that temps come in who have neither training nor longer experience. Since it is largely solitary work, continuity becomes especially important. It is difficult to do a good job if you do not know the residents and their needs.

The tricky part can be the dialogue and understanding between night and day staff. Good record keeping ensures quality. Residents who sleep during the day can then wander all night. A resident who has fallen asleep late may not be woken up early in the morning for a change of incontinence pad. The day staff can then find the resident soaked when they arrive. Likewise, there may be a need to use bed rails or alarms. Bed rails may only be used after a risk assessment by authorized personnel and with the resident's consent.
Documentation must provide good support for authorized personnel's assessment.
There should be documentation if relatives want to be called if something happens at night.

Work Environment at Night

Nights are a special time with low staffing. Someone is restless, a colleague asks for help with a turn. The nursing assistant is often alone with difficult decisions. Night work entails many health risks. The Work Environment Authority has therefore produced several regulations that specifically handle these risks. Examples of regulations that concern night work are "Solo work AFS 1982:3" and "Medical checks in working life AFS 2019:3".

In addition to these, there are a number of work environment regulations that can affect work in care even during the day. Examples are regulations on measures against threats and violence, work at the computer screen, inspection of lifting devices, infection risks etc.

One area where there is a big difference between care providers is how the work leader is contacted during on-call hours. With some care providers, the on-call nurse is also the work leader. In other places, there is a special on-call organization for work management.

There are sometimes conflicts between night and day staff. Often it is due to unclear expectations or that the dialogue within the staff group does not work well. It happens that night staff are accused of sleeping during the shift. Unfortunately, it does happen, but most often night workers are devoted to their work with our elderly. Moreover, the residents today are so in need of care that there are rarely any longer calm periods during the night shift.

It often happens that a number of residents have a turning schedule. Some can participate themselves. Some are light and compliant others are heavy and resist when they are to be turned. When a turning schedule is prescribed, a risk analysis should be done to assess the need for double staffing.

It is easy to get a bit cold at night. If you put on a cardigan, remember to take it off when working with care. Otherwise, there is a risk that you spread infection between the residents. In order not to fall asleep, you may need to stretch, jump, dab your face with cold water, drink coffee or eat fruit.

It is not uncommon for there to be residents who should not or must not be left alone in the unit, which can cause stress and difficult decisions if a colleague wants help in another unit.

The nurse is often working alone at night. In a medium-sized municipality, the nurse can have four - five elderly care homes, a number of LSS-housing and patients in home care. Often the nurse also has a work leader role at night. The opportunity to get support from a doctor is often limited.

Reflection - night work
Care staff:
• Is there a prescription when bed rails are used?
• Is the contact with the on-call nurses working well?
• Are you asked about how incontinence pads work at night?

Manager, Nurse, Occupational Therapist and Physiotherapist:
• Do you regularly supervise and carry out risk analyses of night work?
• Is it documented in all journals if relatives want to be called at night?
• Is the cooperation with the nurse and work leader on-call working well?

Resident and Relatives:
• Does the operation know if you want to be called at night?

Erland Olsson
Sofrosyne
Specialist nurse
Quality in elderly care