快速輪班對於護理人員日夜認知功能、焦慮、睡眠、賀爾蒙之影響及改善策略

The circadian changes and effects on cognitive function, anxiety, sleep and hormone in nurses working on fast rotating shifts and the improvement strategies

張鈺姍(Yu San Chang)

指導教授 ： 劉景寬

高雄醫學大學/醫學院/醫學研究所博士班/博士(2015年)

https://doi.org/10.6832/KMU.2015.00009

摘要

目的： 國內醫療體系之護理人員大都以8小時為一輪的快速輪班制，
本研究主要之目的為，在快速輪班制下，探討護理人員1) 連續不同天數值大夜時認知功能之表現，2) 對於認知功能表現最差之夜班日數採取介入措施並評估效果，3) 連續不同天數值大夜後，白天認知功能、焦慮程度、睡眠傾向及與睡眠有關之荷爾蒙變化，4) 從連續不同天數值大夜時之適應性與連續不同天數值大夜後白天之適應性，探討護理人員於快速輪班制下，適當之大夜班連值天數，5) 在適當之大夜班連值天數後，休假1天是否足以調回白班之型態。
方法: 本研究招募20-30歲高雄市立凱旋醫院輪值三班之女性護理人
員，排除條件為目前有使用安眠藥、習慣性喝咖啡、精神疾病史、重大生理疾病史與睡眠障礙者，所收集之資料包括年齡與教育年限。所評估之項目包括：維持清醒能力測試 (Maintenance of Wakefulness Test)、情境特質焦慮量表 (State-Trait Anxiety Inventory)、史丹佛嗜睡量表 (Stanford Sleepiness Scale)、威斯康辛卡片分類測驗 (Wisconsin Card Sorting Test)、台灣大學注意力測試 (Taiwan University Attention Test)、 數字符號替換測驗 (Digit Symbol Substitution Test)、符號尋找測驗 (Symbol Searching Test)、多次入睡潛值測試 (Multiple Sleep Latency Test)、腎上皮質素 (cortisol)、泌乳激素 (prolactin, PRL)、甲狀腺刺激素 (thyrotropin, TSH) 與生長激素 (growth hormone)。
夜間適應性分三階段：第一階段比較連續值2、3、4天大夜者各21、20、21名，於最後一天上大夜3 - 4 a.m.時之認知功能。第二階段比較休假日組23名9 - 10 a.m.時、第1天值大夜21名與連續2、3、4天值大夜各21、20、21名於最後一天大夜3 - 4 a.m.時之認知功能。第三階段比較休假日組21名9 - 10 a.m.時、第1天值大夜有、無小睡30分鐘各21名於3 - 4 a.m.時之認知功能。
白天適應性分三階段：第一階段連續值2天大夜之護理人員20名，於下大夜後白天每隔2小時執行評估項目並檢測與睡眠有關之荷爾蒙。第二階段比較休假日組23名與20名連值2天大夜下大夜後該二組；休假日組23名、20名連值2天大夜與16名連值4天大夜下大夜後該三組，白天認知功能、焦慮程度、睡眠傾向及與睡眠有關之荷爾蒙變化。第三階段比較休假日組21名與18名連值4天大夜後休息2日之護理人員於第2天休息日，白天認知功能、焦慮程度、睡眠傾向之變化。
結果: 就夜間適應性而言，快速輪班制度下，大夜工作會影響知覺行動能力與訊息處理速度，第1天因突然改變日夜週期導致睡眠減少而表現最差，但至第4天可恢復至基本水準，於第1天值大夜時實施小睡，注意力的表現並不具統計上之差異，但在訊息的處理速度上具中等效果量。雖然連續4天值大夜後呈現夜間適應之現象，就維持清醒能力、知覺行動能力與訊息處理速度及學習效應而言，1天休息日仍不足以調整回白班之工作。
就白天適應性的認知功能而言，護理人員連值夜班下大夜後，白天客觀評估睡眠傾向並未有變化，但年齡增加維持清醒能力下降也不易入睡，另常高估了自己認知功能的表現以及維持清醒能力，若愈快速的輪值制度，下大夜後因焦慮度上升導致過度覺醒狀態，進而影響了知覺行動能力與訊息訊息處理速度及其學習效應之表現。就賀爾蒙而言，護理人員連值夜班下大夜後，白天TSH上升，隨著TSH上升，知覺行動能力與訊息處理速度跟者改善，不同連值大夜天數對TSH並無影響，但愈快速的輪值制度下，有可能影響了PRL。
結論: 建議應以連值4天大夜為佳，避免少於4天時，大部分的護理人員在夜班工作均處於功能不良之狀態，但連續4天值大夜後，休息日1天仍不足以調整回白班之工作，對於表現最差的第1天大夜班，實施30分鐘小睡仍有助於訊息的處理速度之效果。愈快速的輪值制度，下大夜後因調整睡眠「體內平衡-日夜週期」二機制的不穩定，易造成白天焦慮與影響注意力表現，以及有可能影響了PRL分泌。

關鍵字

輪班工作 ； 認知功能 ； 睡眠傾向 ； 護理人員 ； 與睡眠有關之荷爾蒙 ； 焦慮 ； 小睡 ； 日夜周期變化 ； 適應性

並列摘要

Objective: A three-shift system with faster rotation is common in the medical field in Taiwan. Under the three-shift system with faster rotation, the goals of this project were to investigate: 1) the differences in cognitive performances during the night shifts (NS) in nurses working different con- secutive night shifts (CNSs), 2) the effect of adaptation strategies applying to the poor performances during the NS, 3) the changes in cognitive func- tion, anxiety state, sleep propensity and sleep-related hormone in the daytime after completing different CNSs, 4) the suitable CNSs in nurses to adapt the NS and readjust their circadian rhythms, 5) whether one day off was enough to readapt back to a daytime schedule after adaptation the NS.
Methods: All participants were aged between 20 - 30 years working in the acute ward of Kaohsiung Municipal Kai-Syuan Psychiatric Hospital. The exclusion criteria were current use of hypnotics, regularly drinking coffee, psychiatric illness, major systemic disease, and sleep disorders. Demographic data included age and years of education. The measures included the Maintenance of Wakefulness Test, State-Trait Anxiety Inventory, Stanford Sleepiness Scale, Wisconsin Card Sorting Test, Taiwan University Attention Test, Digit Symbol Substitution Test, Symbol Searching Test, Multiple Sleep Latency Test, and the sleep-related hormone (cortisol; prolactin, PRL; thyrotropin, TSH; growth hormone).
The project consisted of three stages for adaptation to NS: 1) to com- pare cognitive function during the NS in nurses working the last night of two (n=21), three (n=20), and four (n=21) CNSs at the time of 3 - 4 a.m.; 2) to compare cognitive function during the NS in nurses working on the first NS (n=21), the last night of two (n=21), three (n=20), four (n=21) CNSs at the time of 3 - 4 a.m., and on the off-duty day (OD) (n=23) at the time of 9 - 10 a.m.; 3) to compare cognitive function among nurses on the OD (n=21) at the time of 9 - 10 a.m., working on the first NS at the time of 3 - 4 a.m. with (n=21) and without (n=21) taking a 30-min nap.
There were also three stages for daytime adaptation: 1) to explore chan- ges in the above measurements during the daytime after completing two CNSs (n=20); 2) to compare changes in the above measurements between during the daytime after completing two CNSs (n=20) and on the OD (n= 23), among during the daytime after completing two CNSs (n=20), four CNSs (n= 16) and on the OD (n=23), respectively; 3) comparing changes in the above measurements (excluded sleep-related hormone) during the day- time after four CNSs followed by one day off (n=18) and of the OD (n=21).
Results: Regarding adaptation to NS, nurses working on fast rotating shifts have more impaired perceptual motor abilities during the end of CNSs. Those working on the first NS associated with sleep loss, leading to a decrease in information processing and the accuracy of visual attention tasks. The adaptation to CNSs was showed on the fourth day as demonstrated by improvements in perceptual motor abilities during NS. There was no difference in the visual attention performance between those taking and not taking a nap during the first NS, however the effective size was medium in the information process. Although the adaptation occurs after four CNSs, one day off is not sufficient to readapt back to a daytime shift in term of the ability to maintain wakefulness, perceptual motor abilities and the learning effect during the daytime.
Regarding adaptation to daytime, nurses during the daytime after CNSs, there was no change in sleep propensity, but increasing age was related to both of maintaining wakefulness and falling sleep difficulty. In addition, nurses also overestimate cognitive function and the capacity of maintaining wakefulness during the sleep restriction daytime. When rotating NS too quickly have more emotionally stressful, and may result in a state of hyperarousal that could contribute to decreases in both perform- ance of attentional tasks and the learning effect. As for sleep-related hor- mones, the level of TSH was elevated during the daytime after CNSs. When the TSH levels were elevated, the performance on perceptual motor coor- dination improved. The daytime levels of TSH was unaffected by the number of CNSs worked. However, rotating NSs too quickly may have an impact on PRL levels.
Conclusions: We suggest that at least four CNSs should be used in a three- shift work schedule with faster rotation to prevent nurses from working not as many CNSs during which the impairment in night performance is greatest. However, one day off is not sufficient to readapt back to a daytime shift after four CNSs. There was a medium effective size in information process when implantation a 30-min nap during the first NS which had the worst performance. Accordingly, destabilization of the homeostatic-circadian two-process model of sleep regulation would be expected to be more pronounced in rotating NSs too quickly, which may cause anxiety and decreased attentional performance, and may impact PRL levels during the daytime after NSs.

並列關鍵字

shift work ； cognitive function ； sleep propensity ； nurses ； sleep- related hormone ； anxiety ； nap ； circadian ； adaptation

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