Clinical Voices July 2023

Jul 10, 2023

Added to Collection

In this issue, read articles on interventions to reduce night-shift errors and fatigue; masks, music and earplugs for better patient sleep quality; CVD risk based on race and ethnicity; and more. Plus, read a new President’s Column and the story of a nurse who's retiring after 47 years in practice.

Shining a Light on Night-Shift Fatigue

The study finds that 40 minutes of bright light intervention before a night shift reduced errors.

Bright light before a night shift leads to fewer nursing mistakes, less fatigue and improved mood, notes a study involving 57 full-time hospital nurses on rapidly rotating shift schedules.

“An Evening Light Intervention Reduces Fatigue and Errors During Night Shifts: A Randomized Controlled Trial,” in Sleep Health, tests whether nighttime light exposure and morning light avoidance improve circadian alignment for nurses in an intervention group. Nurses in a separate control group changed their diets to boost alertness and reduce sleep disturbances.

Healthy nurses, ages 18 to 65, from three hospitals participated in the study, led by McGill University Health Centre in Montreal. Participants worked directly in patient care, had at least a 70% full-time workload and were assigned to rotating schedules with consecutive night shifts.

Findings reveal that 40 minutes of bright light intervention before a night shift reduced errors, ranging from giving the wrong medication dose to accidental needle pricks by 67% compared with 5% in the control group. Nurses in the intervention group also reported less fatigue on workdays.

In a related article in Newswise, study author Jay Olson, a postdoctoral fellow at the University of Toronto, says, “Healthcare workers are experiencing high levels of fatigue due to staffing shortages, difficult schedules, and heavy workloads. Further, the cost of medical errors has been estimated at tens of billions of dollars per year in North America.

“Our study shows that feasible changes, such as getting light exposure before the night shift, may help reduce fatigue and its effects on performance at work, something which could benefit both the nurses and their patients.”

Study author Mariève Cyr, a McGill University medical student, adds that the findings are “relevant to a large population of workers, since between a quarter and a third of the world’s employees do some form of shift work.”

Eye and Ear Interventions for Sleep in ICU

Nurses can use these interventions to improve the sleep quality of critically ill patients.

A review of 24 clinical trials involving more than 1,500 ICU patients reveals that eye masks, music and earplugs, used separately or in combination, improve sleep quality to varying degrees.

"Effectiveness of Sound and Darkness Interventions for Critically Ill Patients’ Sleep Quality: A Systematic Review and Component Network Meta-analysis,” in Nursing in Critical Care, reports the best intervention occurs when eye masks, earplugs and music are used together. Separately, eye masks have the best relative effect on sleep quality, followed by music, quiet time and earplugs.

“This study provides recommendations for interventions that nurses can use to improve critically ill patients’ sleep quality,” notes the review, which advises further research using bedtime music, nocturnal eye masks and quiet time.

In a related matter, the American Thoracic Society convened a workshop of multidisciplinary experts to identify priorities regarding sleep and circadian disruption (SCD) in the ICU. “Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement,” in American Journal of Respiratory and Critical Care Medicine, covers “gaps and next steps” in developing sleep-promoting interventions such as light exposure, music therapy, pain control, noise mitigation and medication use.

“Translating fundamental circadian knowledge to bedside clinical care poses logistical challenges,” the statement adds. “The many abnormal circadian signals present in the ICU environment must be carefully tracked (e.g., light, feeding, sleep, and immobility).”

One topic involved personalizing a patient’s sleep preferences by treating preexisting sleep disorders and adjusting conditions such as room temperature, bed position, lights, blankets and pillows. But while “personalization of sleep promotion interventions is novel and potentially beneficial,” it also “adds complexity to already encumbered protocols.”

Still, workshop members agreed that “asking patients about sleep and showing empathy regarding inadequate sleep is helpful. Doing so may also raise team member awareness of ICU SCD.”

Recommendations to Improve Nurses’ Mental Health

We need substantive changes in healthcare policy to promote health equity for nurses.

A consensus statement focused on addressing nurses’ mental health and substance use issues offers several recommendations to promote better outcomes.

American Academy of Nursing Expert Panel Consensus Statement on Leveraging Equity in Policy to Improve Recognition and Treatment of Mental Health, Substance Use Disorders, and Nurse Suicide,” in Nursing Outlook, stresses the need for substantive changes in healthcare policy to promote health equity for nurses and destigmatize mental health issues: “There is a tension between our obligation to safeguard the public by ensuring nurses are safe in their practice and our obligation to care for nurses who face mental health challenges.”

In a related video and article in MedPage Today, statement co-author Judy Davidson, a nurse scientist at University of California San Diego, assesses the prevalence of mental health disorders among nurses along with the occupational hazards that prevent them from seeking help. This combination of inequities manifests itself in a higher suicide risk, Davidson says, “issues we have never before raised publicly in nursing.”

The statement notes that the pandemic “exacerbated an existing but rarely acknowledged mental health crisis in the nursing profession,” including suicide, drug overdose and depression, adding that “the deterioration of mental health of the nursing workforce with the pandemic is disturbing given that nurses were previously found to be at greater risk of suicide than the general population prior to the pandemic.”

In her video, Davidson makes specific recommendations, including reexamining the legality and appropriateness of credentialing questions on mental health, as well as mandatory reporting requirements and disciplinary processes; using an encrypted, anonymous suicide prevention screening program; and addressing leave-of-absence policies to allow nurses to heal and retain their careers. “It is inequitable that nurses routinely lose their job and surrender their license to receive mental health treatment for substance use disorder,” she says.

AACN adds that If you or someone you know needs mental health assistance, call 988, which is available 24/7, visit for an online chat, also available anytime, or go to for additional resources.

Women’s Risk of CVD Based on Race and Ethnicity

The statement from AHA addresses the risk profiles of different racial and ethnic groups.

Cardiovascular disease (CVD), the leading cause of death for American women, can present with varying risk factors based on racial and ethnic differences, which also can affect preventive therapies.

Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement From the American Heart Association,” in Circulation, notes the range of risk factors expands beyond traditional ones to include sex-specific biological factors as well as social determinants of health (SDOH), and behavioral and environmental factors. “Equitable access to guideline-approved, evidence-based cardiovascular preventive health care based on available data should be available for all women regardless of race and ethnicity,” the statement notes.

The statement from AHA addresses the risk profiles of different racial and ethnic groups for traditional risk factors such as diabetes and smoking as well as nontraditional ones such as mental health and social conditions. “Adverse social factors such as health care access, migrant status, language barriers, discrimination, acculturation, and environmental racism (the disproportionate impact of environmental hazards on people of color) are common in communities of underrepresented races and ethnicities and pose a significant challenge in the diagnosis of CVD and the application of treatment modalities,” the statement adds.

The AHA breaks down common risk factor profiles (e.g., hypertension, dyslipidemia) for non-Hispanic Black, Hispanic/Latina, American Indian/Alaska Native and Asian women. It also examines several pregnancy- and menstruation-related factors as well as SDOH factors, such as adverse environmental exposures and the “physiological impact of stress on the body, to the combined weight of racism and sexism.”

An analysis of the AHA statement in American College of Cardiology examines the 10 key takeaways on the effect of race and ethnicity, and provides guidance for clinicians on community-specific risk factors. “A greater focus on addressing adverse levels of all CVD risk factors among women of underrepresented races and ethnicities is warranted to reduce future CVD morbidity and mortality,” the analysis notes.

Comparing Continued Enteral Nutrition and Fasting Before Extubation

The trial was conducted with more than 2,000 patients at 22 ICUs in France.

Discontinuing enteral nutrition in the hours before attempting extubation for ICU patients did not reduce the risk of failed extubation compared with the usual practice of fasting and gastric suctioning.

Continued Enteral Nutrition Until Extubation Compared With Fasting Before Extubation in Patients in the Intensive Care Unit: an Open-label, Cluster-randomised, Parallel-group, Non-inferiority Trial,” in The Lancet Respiratory Medicine, notes that similar extubation failure occurred among patients in either protocol, suggesting that continued enteral nutrition until extubation is safe and “thus represents a potential alternative in this population.”

Conducted at 22 ICUs in France from 2018 to 2019, the trial included 1,130 patients in the intention-to-treat population and 1,008 in the per-protocol group. Units were randomly assigned to begin fasting protocols six hours before extubation or to continue enteral nutrition.

Extubation failure occurred in 101 (17.0%) of 595 per-protocol patients who received continued enteral nutrition, compared with 74 (17.9%) of 413 fasting patients. It also failed in 106 (17.2%) of 617 intention-to-treat patients compared with 90 (17.5%) of 513 fasting patients. A secondary outcome, pneumonia within 14 days, occurred in 10 (1.6%) patients receiving continued enteral nutrition and 13 (2.5%) fasting patients.

A related article in MedPage Today notes that aspiration is a primary justification for the fasting protocol but occurred rarely in either group. “The whole issue here is it’s a very infrequent reason for reintubation, so it’s not a good rationale,” added trial co-author Stephan Ehrmann at the Society of Critical Care Medicine Critical Care Congress.

An accompanying editorial in The Lancet Respiratory Medicine notes the risks of low caloric intake for patients in the fasting protocol (311 the day before compared with 637 in the continued enteral nutrition group) and the benefits for nurses. “In times of post-pandemic staff shortages, any practice change resulting in less work for nursing staff is very welcome and should be embraced as soon as possible,” the editorial adds.

Cinnamon: Could It Add Spice to Brain Function?

Most reviewed studies note that cinnamon might help prevent and reduce cognitive impairment.

While cinnamon is a known antioxidant, this spice and its key components can improve memory and learning, and might help prevent or reduce cognitive function impairment.

Cinnamon and Cognitive Function: A Systematic Review of Preclinical and Clinical Studies,” in Nutritional Neuroscience, finds that cinnamon’s properties could influence brain function by decreasing amyloid plaque in the hippocampus and phosphorylation of tau protein, which is linked to Alzheimer’s disease.

“This function is accomplished by different mechanisms and pathways including antioxidant, anti-inflammatory, and anticholinesterase activity as well as neurotrophic effect, neural maintenance and insulin signaling improvement,” the review explains.

In 2021, researchers at Birjand University of Medical Science in Iran researched various databases to collect 2,605 studies regarding how cinnamon and its key components — eugenol, cinnamaldehyde and cinnamic acid — affect memory and learning. After the investigation, 40 studies were eligible for the systematic review, including two clinical studies, 33 in vivo studies and five in vitro.

One study with adolescents ages 12 to 14 showed a positive effect on memory using cinnamon chewing gum for 40 days. But another study involving adults ages 60 or older reported no significant changes in memory using cinnamon administered orally (single dose of 2 grams).

The review acknowledges variations among the 40 studies, noting that “the ineffective result of some studies may be due to the short duration of their experiment or the lower dosage of cinnamon/its components.” Additional and larger studies could produce valuable results about dose dependency, the review notes.

“Also, because of the limited number of clinical studies in this field, it is necessary to perform more clinical studies on this subject,” the review adds. “It is also beneficial that in vivo studies in this field propose the probable mechanism of cinnamon affecting the brain to specify the related pathways more precisely.”

President’s Column: Rising Together

As AACN President Terry Davis begins her term, she discusses the profound sea change nurses have experienced and says there is more change to come. “Someone must drive that change. If not us, then who? Rising Together we will lift each other up and manifest the future of healthcare.”

Read Now

Nurse Story: A Legacy of Nursing Excellence

Saramma George, a cardiac surgery ICU nurse, recently retired after 47 years. The milestones in her professional history include being the student of three AACN founders and a proud AACN member since 1974. “My patients inspired me to show up each day. Some of my transplant patients have kept in touch for 30 years.”

Read Her Story