1. The Bewitching Hour: Confessions From the Night Shift
Mary Eisenhaur RN BSN CCRN
Staff Nurse III
Boston Children’s Hospital
Thank you for the opportunity to share my experiences in the charge role with you

3. 8 South
0710
8 South
1910
Boston Children’s CICU is a 29 bed unit. This is a snap shot of the unit at 7:10 am and again at 7:10 pm.

4. S: “Where is everyone? Is anyone working?”
B: The staffing level in the CICU changes at 7pm
A: Patients receive exceptional care at night
R: Appropriate use of resources
S: “Where is everyone? Is anyone working?”
B:The staffing level in the CICU changes when the shift changes at 7pm. These changes are visible to patients, families and staff
A:Patients receive exceptional care at night
R: Appropriate use of resources
We do not work with a skeleton crew!

5. Day Shift (18) Night shift (8) Three medical teams
7 Fellows/NP, Senior fellow
3 Cardiac Medical attendings
Respiratory/ ECMO specialist
Social worker
Child Life Specialist
Administrative Assistants
Three teams divided in 2
2 Fellows/NP
1 Cardiac Medical attending
Respiratory/ ECMO specialist
No ICU social worker
No Child Life Specialist
Administrative Assistants
What are the differences between the day shift and the night shift? During the day our patient population is divided into three teams. Team A with 11 patients, Team B with 12 patients and Team C with 6 patients. These teams are covered by 7 fellows and or Nurse practitioners and a senior fellow. Each Team has an assigned cardiac medical attending. The team C attending is also responsible for the bed flow.
At night there are 2 fellows or a fellow and an NP and one attending. Team A and B are unchanged. Team C patients get divided between the fellow/NP. The fellows/NP at night is now responsible for patients as opposed to the 5-6 they would be responsible for on the day shift.
Respiratory/ECMO specialist staffing does not vary from day to night shift.
There is no social worker available after 7 pm in the CICU. There is an ED social worker available until midnight.
There is no child life specialist on at night.
The administrative assistant staff is scheduled for day, evening and night shift.

6. Day Shift Night shift Nursing staffing Charge Nurse role
More experienced staff
1 educator and 1 CNS
Resource nurse
2 Clinical assistants
Charge Nurse role
Permanent role
Bed management
Nursing staffing
Less experienced staff
No educator and 1 CNS
Resource nurse
1 Clinical assistant
Charge Nurse role
Permanent role
Support to clinical staff
Nursing coverage is based on our census, complexity and available staffing. Our staffing is based on the synergy model, matching the skill set of the nurse to the unique needs of the patient. Our goal ratio is 3 under the census for day and night shift.
In 2013, Hickey and associates found that mortality was increased when nurses with 2yrs of clinical experience or less represented greater than 20% of staff on that shift. (Hickey, Gauvreau, Curley, & Connor, 2013, p. 641)
We are cautious about allowing new staff nurses to go to permanent night shifts and maintain a balance of experienced and inexperienced staff on the night shift.
Experienced nurses are strategically placed among the less experienced staff.
There is no educator currently on the night shift. There is a Clinical Nurse Specialist available most week nights until 12am.
The resource nurse role is essential for the day and night shift.
There is a clinical assistant available until 11pm
The night charge nurse role in the CICU has evolved over the past few years. There is less movement of patients out, and we are seeing more post op patients arriving on the night shift. We are the conduit between nursing staff, fellows and attending physicians.
The night charge nurse participates in the rounds of the entire unit, not just one team.

7. S: “Mary, my patient’s mom would like to speak with you
S: “Mary, my patient’s mom would like to speak with you. She is NOT happy!”
B: Nurse was in a double assignment. Patient self extubated
A: Staffing ratio and complexity was appropriate for this patient assignment
R: Meet with nurse, then parents
S: “Mary, my patients mom would like to speak with you. She is NOT happy!”
B: 18 month old transferred from another facility for evaluation. 4 hours post cardiac catheterization patient self extubated. Nurse was in a double assignment.
A: Staffing ratio and complexity was appropriate for this patient assignment
R: Meet with nurse then parents
This SBAR represents another facet of the charge role.
At night there is no social work, patient relations, director or clinical coordinator in house. The charge nurse must handle all concerns and escalate up the chain of command if necessary. Either or director or clinical coordinator are always available by phone.
This scenario was easily resolved by just listening to the mother. She had trust issues with nursing from the referring facility. She was easily reassured.
Assignments are based on the complexity of the patient paired with the skill set and experience of the staff nurse.
This also depends on the resources available. For example is a CNS on and did staffing allow us to assign a resource nurse.

8. Role of the Night Charge Nurse
Consultant for patient situations
Advise, educate and support staff, families and fellows
Arbitrator in disputes
Expert in unit operations
Absence of nurse director/clinical coordinator
Assignments
The charge nurse is responsible for the flow of the unit at night, ensuring patient safety and maintaining clinical standards. We are the advisors, educators and support for staff patients, families and fellows. We are often the arbitrator in disputes. The charge nurse is the expert in unit operations in the absence of the unit director and clinical coordinator. The charge nurse is also responsible for the assignment of patients on the following shift.

10. S: “Mary, can you help me? I called the fellow about my glucose and I’m not comfortable with the order she wrote.”
B: Newborn hypoglycemic. First year medical ICU fellow ordered inappropriate dose of glucose not consistent with unit protocol
A: Nursing staff uncomfortable with glucose order from a first year fellow. Nurse utilized her chain of command
R: Have a conversation with fellow
S: “Mary, can you help me? I called the fellow about my glucose and I’m not comfortable with the order she wrote.”
B: Newborn hypoglycemic. First year medical ICU fellow ordered inappropriate dose of glucose not consistent with unit protocol.
A: Nursing staff uncomfortable with glucose order from a first year fellow. Nurse utilized her chain of command in notifying the charge nurse
R: Have a conversation with fellow

11. Outcome Fellow not receptive to conversation
Multiple conversations occurred over one hour
Fellow to bedside nurse
Bedside nurse to charge nurse
Charge nurse to fellow
Chain of command was utilized
Attending notified
Glucose was not treated, repeat was normal
The fellow was not receptive to this conversation.
Multiple conversations occurred over hours between Fellow and bedside nurse, Bedside nurse and charge nurse, and Charge nurse and the fellow.
After 1.5 hours and much frustration I utilized my chain of command and the Attending was notified and was readily available to intervene.
The glucose was not treated and an SBAR was initiated to address the issue with the fellow. The issue being a safety issue.
Ultimately, This conversation never should have gone on as long as it did.

12. S: “Why are night shift nurses excluded from everything
S: “Why are night shift nurses excluded from everything? How do THEY expect us to learn and grow?”
B: Night shift nurses feel there are more educational and advancement opportunities during the day shift.
A: Committee meetings and education opportunities limited for night shift.
S: “Why are night shift nurses excluded from everything? How do THEY expect us to learn and grow?”
B: Night shift nurses feel there are more educational and advancement opportunities during the day shift.
A: Committee meetings are held during the day. Educational offerings are available during huddles and nursing rounds on the night shift. Monthly nursing M&M and education available for the night shift.

13. Recommendations Nursing Huddle Clinical Nurse Specialist utilization
Night shift educator/education committee
Timing of education
Net Learning
Seek opportunities to educate peer
The nursing huddle was initiated by our clinical coordinator and a day charge nurse after a focus group identified that our nursing staff was frustrated with a lack of education and a feeling of isolation in our large expanding ICU. The huddle occurs each shift and takes about minutes and is run by the charge nurse or the resource nurse. O'Brien and colleagues determined that this forum provides necessary education, enhances teamwork and alleviates communication issues. (O’Brien, Small and Ahern 2010)
Staff are encouraged to seek guidance from the CNS before they leave at midnight.
Availability of a night shift educator is a role that is greatly missed. There are a few permanent night staff nurses trying to gather the momentum and develop a night shift education committee.
Timing of education on the off shift is essential to the retention of information. The National Sleep Foundation reports that a person’s internal Circadian clock regulates the timing of periods of sleepiness and wakefulness; the strongest sleep drive in adults occurs between 0200 and 0400, or at the end of a long night shift. Continuing education offerings need to occur before the Circadian cycle dip, and before fatigue sets in.(Mayes & Schott-Baer, 2010) Our huddles, rounds, and nursing M&M’s generally occur before 0200.
Net learning is hospital assigned education via powerpoint. Participation is mandatory for some material and optional for classes and workshops.
Advancement at Boston Children’s is an option available to all staff as their practice develops. Because meetings and formal classes are all offered on the day shift, the night nurse often has to juggle her schedule to attend these offerings as she works towards advancement. The day shift also has to plan accordingly to attend these meetings.

15. S: “Why do bad things happen to my patients at night
S: “Why do bad things happen to my patients at night? Did you lift this patient for Xray?”
B: Attending surgeon arrived in the CICU as his post op patient was arresting and being cannulated to ECMO.
A: Surgeon was concerned that his patients receive suboptimal care at night
R: Post operative patients external stressors are minimized. Redirect the surgeon to the patients immediate needs.
S: “Why do bad things happen to my patients at night? Did you lift this patient for Xray?”
B: Attending surgeon arrived in the CICU as his post op patient was arresting and being cannulated to ECMO.
A: Surgeon was concerned that his patients receive suboptimal care at night
R: Post operative patients external stressors are minimized. Redirect the surgeon to the patients immediate needs.
The night shift is cognizant of the stressors that can have a negative impact on a patient in low cardiac output state. Efforts are made to minimize these stressors by not bathing patients or lifting them for Xray when cardiac output is at its lowest. This is a practice change as nurses are trained to bathe patients and change their linen on the night shift to help the day shift.
Data spanning from Oct 2013 to Oct 2014 demonstrates that there is difference in the number of arrests on the day shift (25) compared to the night shift (22). There are slightly fewer arrests on nights than days in the past year.

16. Conclusion Expertise can vary at night Effective communication
Care is not impacted
Effective communication
SBAR
Night shift nurses
Team work
Conflict resolution skills
Night nurses are proactive in seeking and providing learning opportunities
Expertise can vary at night
Care is not impacted
Measures taken to support the junior staff
Less support staff/ expertise
Effective communication
SBAR
Escalate in a timey
What can day shift nurses learn from night shift?
Team work
More time to review patients anatomy and plan of care
Less distractions/interruptions
Night nurses need to be proactive in seeking and providing learning opportunities for each other. Plenty of opportunities for advancement on the night shift.

17. Thank You!