Introduction

Nurses working nights are a vital part of the healthcare workforce as patients depend on professional nursing 24 hours a day [1-3]. Unfortunately, working nights affects their well-being and self-esteem, family life, childcare and relationship with their spouse and significant others, including friends and extended family [4-6]. Working night shift negatively effects the total life situation of the nurse, but insight into the work situation may open for improvement.

Night shifts mainly have negative consequences, even though an Australian study showed that night shifts provided flexibility for family and social activities [2]. A phenomenological study with interviews of 21 American nurses found that nurses encountered difficulties getting adequate rest due to family responsibilities and/ or circadian rhythm disturbances [4]. Some even chose to give up sleep entirely to meet family obligations [4]. In addition, Books et al. [1]. reported that American nurses working nights had a high risk of family stressors. The same issues were seen across cultures and across gender roles [1-7]. A South African study by Phiri et al. [6].  showed that nurses working nights found limited family time and ability to resolve family conflicts. In their study, nurses reported having insufficient time to manage their personal and home responsibilities. They reported feeling moody and irritable, which occasionally triggered family conflicts [6]. Furthermore, a quantitative study with 50 Brazilian night shift nurses conducted by Cordeiro et al. [7] revealed that working nights influenced social life and could lead to health problems.

Serious health issues have been documented in relation to working at night [1,5-8]. Phiri et al. [6] and Books et al. [1] revealed that being overtired from work was a major challenge to leading a healthy lifestyle. Serious health issues have been reported, including a risk for increased sleep insomnia, sleep deprivation, anxiety, increased depression, burnout, increased Body Mass Index (BMI), hypertension, back pain, chronic fatigue, attention and concentration problems, feeling of discomfort, fatigue, mood swings, gastrointestinal and cardiovascular disease, and increased cancer risk [1,5-12].

Health issues may also influence nurses’ job performance [1,5-8]. When working nights, more occupational errors associated with sleep deprivation were reported. Working nights also threatened nurses’ own safety. For example, in a study based on focus group discussions with 103 nurses, Phiri et al. [6] showed that occupational accidents, such as needle stitch lesions, were more prevalent among nurses when they were working nights. Accidents often occurred early in the morning when nurses were exhausted. This increased their risk of being infected, which caused fear [6]. Another issue was an increased risk of driving accidents due to sleep deprivation when driving home [4,7-8,13].

Patients’ safety may be compromised due to night shift nurses’ sleep deprivation. Several studies have shown a significant inverse relationship between fewer hours of sleep and increased patient care errors [7-8,13]. Due to physical and mental fatigue, nurses had difficulty performing nursing procedures and they made medication errors or failed to respond to changes in patients’ status. Nilsson et al. [3] showed that

nurses struggled with concentration at night and therefore had to check medications several times. Performing a quantitative study with open-ended questions, Books et al. [1] reported that chronic lack of sleep could affect nurses’ ability to provide proper patient care, to critically assess their patients and to respond quickly and adequately to emergency situations, all of which were putting patients’ health at risk. The level of fatigue may be so high that it changes how the nurses engage with their patients, which influences job satisfaction negatively. In a qualitative study, Steege & Rainbow [13] revealed that almost half of the 22 nurses working night shifts experienced reduced job satisfaction. Nonetheless, some nurses stated that fatigue was a part of nursing and that they had to deal with that [13].

Working at night usually implies having several night shifts in the nurses’ rotation of the work schedule [11]. At night, nurses have to care for a larger number of patients than during day hours because fewer nurses are on duty during nights, and this may increase the mental and physical burden since tasks have to be accomplished by fewer hands. Nurses often work for longer hours than other shifts in hospitals; for example, a night shift is usually 10-11 hours (starting at 20:00-22:59) in Finland, 10 hours (starting at 21:00-21:59) in Norway and 8 hours (starting at 23:00-23:59) in Denmark [14].

Positive features like a strong relationship with colleagues [2] and the possibility for professional growth [2,5,15] have also been highlighted. Still, working night shifts overall has a negative impact on nurses’ life. Furthermore, Zannini et al. [15] found that night shifts have changed dramatically in recent years with a decrease in inactive periods and an increase in required competences. Because nurses can rarely avoid working at night, the price they pay for this transgressive shift it is problematic. Hence, literature, shows that working night shifts colonises nurses’ entire life including their social and family life as well as their physique. This complexity may hinder insight into how the burden of working night shifts can be eased. Therefore, we explore the nurses’ experience of living and working through the night time.

Method

The aim of the study was to gain knowledge about being a nurse working in the night by exploring nurses’ experience of living and working through the night time. The need for nurses to understand experiences of others’ makes phenomenology ideal as a research methodology for the present study [16]. According to Cohen et al. [16], a phenomenological approach offers useful guidance that makes researchers more alert to the individual’s perspective. This enables the meaning of the individual’s experience to further our mutual understanding [16], in this study of nurses’ experience of living and working through the night time. Phenomenology was developed to achieve an understanding of the lifeworld [17] and thereby gain insight into people’s world and the various ways they experience life [17]. According to Dalberg [18], when using this methodology, the aim is to capture the phenomenon and its existential meaning without reducing its complexity [18]. Building on the phenomenological tradition, we strived to allow the working during nnight time as experienced by nurses to show itself. Focusing on this particular phenomenon during data collection, we ensured that both interviewers and informants had knowledge about the phenomenon. 

Setting

The setting of this study was both in a somatic, paediatric, psychiatric, maternity, emergency wards in several hospital and a hospice in Denmark. The informants were 19 nurses interviewed by 19 nursing Master students who participated in an advanced phenomenology course and were engaged in the study of the phenomenon of working through the night time. The learning environment improves when engaging students in phenomenological investigation [19,18]. To ease the inclusion process, every student each found one willing informant among her nursing acquaintances. This made interviewing less challenging. The issue of being too close was discussed, and solved by asking for thorough descriptions, though fewer words may suffice due to the mutual acquaintanceship. The 19 nurses interviewed worked night shifts in different ways and at various wards, see (Table 1).

Data collection

Prior to the data collection, the students were taught to engage in phenomenological interviewing [18]; This implied to let the phenomenon show itself, and therefore, they worked with their own perception of working through the night time. This awareness of their everyday perception, also called natural attitude [20] was supported by letting the students interview each other. Their attitudes were discussed in class. As an example they realised that although most of the master students disliked working at night, some actually liked it. This experience was used to highlight the importance of letting the phenomenon show itself due the students’ awareness of their own perception, their so-called natural attitude and moving to a phenomenological attitude [21] also called a scientific attitude to emphasis the open investigating mode. Next, the students were trained in upholding this phenomenological attitude during the interview; They were taught how to be focused on eliciting descriptions from informants about their lived experience of working through the night time by asking open questions to let the informant’s perspective appear while holding their own knowledge back. This was facilitated by their thorough personal insight into the phenomenon studied, being aware of issues that had to be raised for a full exploration. In addition, they trained to ask open questions and elicit descriptions of lived experiences like: “Please tell me about your experiences when working through the night time. More details were elicited by asking: “Can you provide an example?” This implied listening to the experiences, soliciting detailed descriptions and asking new open questions when expected parts were left out. All interviewers had participated in the same training, which contributed to giving the interviews a similar overall format, even though some provided richer descriptions than others did. After the course, the interviews were assessed and evaluated. The interviewers had all managed to obtain sufficiently detailed descriptions of the experiences of working through the night time. In total, the data provided many and varied descriptions of the phenomenon. We therefore concluded that the data collected had the quality needed to conduct this study.

Data analysis

During the course, the master students also trained analysing data. To ensure a thorough analysis of all data, the teacher and a colleague also dedicated considerable efforts to the analysis across all interviews. In this process, we were open to how the phenomenon showed in the data and aware of our natural attitude to working at night as a nurse and our adoption of a phenomenological attitude [22]. In the analysis, we familiarised ourselves with the nurses’ description of their experiences and worked back and forth between their descriptions and a possible essence of working through the night time. To support our openness towards the data material, we conducted the analysis using the phenomenological method [22]; We systematically read and re-read the transcribed interview to obtain a global sense of the material. Then, we both worked through the text addressing meaning units. After having gathered these meaning units into clusters, we used a reflective approach to build a proper description of the phenomenon identified. In this process of clarifying the essence and its constituents, we worked out how the clusters were interrelated. To determine which were needed and if any constituent was missing to describe the phenomenon, we tried out each constituent individually and then all constituents as a whole, also named the method of free imaginative variation [20].

The essential structure was thereby unfolded by the constituents.

Ethical considerations

The study was conducted in accordance with Danish legislation and with the Declaration of Helsinki [23]. Informants received written and oral information about the study and their participation. They were assured complete anonymity and told that they could withdraw their participation at any time without stating a reason. Furthermore, informed consent was provided by each of the master students, allowing the authors to use their interviews (sound file and transcription) for research purposes. The study was registered at Aarhus University, cf. the General Data Protection Regulation (Aarhus University’s reference number 2016-051000001, serial number 1448). 

Findings

The essence in nurses’ experiences of living and working through the night time

For the nurse, the work at night is a balance between facilitating the patients’ rest and sleep, longing for sleep themselves and being alert to any unforeseen acute situations. This implies relieving pain, reducing physical and psychological discomfort, promoting patients’ sleep and rescuing lives. During quiet periods at night, unsolved tasks from the day and evening shifts are concluded to prepare for the next day shift. If an emergency or an acute situation occurs, this may require all the nurse’s skills and full concentration despite her tiredness. Being fewer employees at work triggers a feeling of vulnerability and dependency, particularly in acute situations. Uncertainty can be reduced by building a good relationship with another nurse on the shift. This may also boost the nurse’s confidence in her ability to handle whatever might occur during the night. Building such confidence is important because night can rapidly shift from being comprehensible and controllable to being chaotic and uncontrollable. 

The essence is described under the following constituents:

• Establishing a good link between the evening and the day shift
• Facilitating rest and sleep
• Being fundamentally tired and remaining ready for the unexpected
• Relieving pain, frustration and sombre thoughts
• Needing a colleague to avoid feeling alone and vulnerable Coping with unforeseen acute situations

Establishing a good link between the evening and the day shift

The primary task in the night shift is to build an overview of the workload and the patients’ clinical condition. When this has been accomplished, patients are divided between the nursing staff according to the level of disease severity or the complexity of care. As soon as possible, provided no urgent matters arise, a closer look at the patient’s medical history is taken to memorize important and practical information. A memory list with a strong focus on any severe and complex patient needs may help the nurse in this situation. When the shift is quiet, the items on the worklist with practical tasks are checked and any unsolved tasks from the previous day or evening shift are done. A nurse from a paediatric ward explained:

 We have such a note where all practical things are listed; we try to prioritize quickly; you have get around to the patients; and when there are no issues needing attention, you get started on the practical stuff. However, if there are issues that must be dealt with, the patients are prioritized (Informant 1).

To prepare for the day shift, shelves, drawers and cabinets are re-stocked with equipment; rooms are disinfected and cleaned (outer rooms; offices, kitchen); documentation is updated; a summary is made of various treatments; and new forms and schemes are prepared (fluid and nutrition schemes). The nurse from the paediatric ward noted:

It’s a great help for the day shift that it’s done and very unfortunate if it’s not done. So, if we cannot finish these tasks, we work overtime (Informant 1).

Another routine task of the night shift is to dispense the medicine for the next day. If the night shift is hectic and does not allow the nurse to complete the practical tasks, this must be done during overtime to ensure a good beginning of the day for the day shift.

Facilitating rest and sleep

Facilitating patients’ sleep, the nurse accommodates their needs, relieves pain and reduces any physical and mental discomfort, makes observations and provides the patients’ prescribed medication. When special medication is needed due to an unforeseen development, the nurse walks silently into the room, avoids making noise, dims the light and speaks in a muted voice not to wake up other patients. The nurse regularly checks on patients during the night, even though they are sleeping, to reassure herself that everything is going well. Occasionally, a patient needs bedside monitoring throughout the night regardless of any other activities in the ward. However, a night shift is good when patients are sleeping and everything is quiet. A nurse from a neurological ward described this as follows:

A night shift that works and where everything goes well is when you walk around and check on patients and everyone is sleeping and doing well and nothing is happening, and we quickly get the practical tasks done; I would call that a good night shift (Informant 12).

Being fundamentally tired and remaining ready for the unexpected

The silence and peace in the ward are an opportunity to have a quiet moment with time to be alone, catch up on patients and information, tidy up, do some cleaning and maybe some personal activities like needlework, reading or studying. Still, being basically tired affects the nurse’s ability to remember, concentrate and respond, which creates an awareness of the risk and maybe even a fear of making a mistake or doing a poor job. This pressure associated with being tired was explained by a nurse working at a medical endocrinology ward:

There are often high demands, and sometimes it is challenging when you are completely tapped for energy, and I really just want to sleep (Informant 8).

For this reason, the nurse arrives at the night shift as rested as possible, prepared for the worst possible events that could happen during the night. Working at a surgery ward, a nurse found:

To have slept before night shift so that you are well and refreshed, … that means a lot, … it’s important in the small hours because you know that often errors can happen… I am always mentally tuned to face a hard night shift. It’s better to be pleasantly surprised (Informant 14).

The night shift may instantly turn from being calm to being hectic. Several patients may call for assistance at the same time and they must then be prioritized; who needs help first and who can wait until there is more time. In addition, being alone or being the most experienced nurse exacerbates fear of making mistakes; this, in turn, leads to actions to enhance safety, like thinking everything through and having an eye for everything. Although this situation demands a display of enhanced skills and competences, it also offers an opportunity to be challenged and thereby develop further skills and build self-confidence. Even so, these conditions may seem unsafe and frightening when the nurse is at a loss about what to do or when something goes wrong. High demands concerning personal professionalism imply pushing oneself physically and mentally to provide safe patient care despite being tired. Standing firm against tiredness makes the pressure feel almost unmanageable. A nurse from the ward of medical endocrinology explained:

I notice my patience at the last night shift; it is getting worse and worse, and I hear myself be a bit negative and the patience is even more limited because I need sleep and it worries me a bit that it may challenge my professionalism (Informant 8).

Relieving pain, frustration and sombre thoughts

In the deep of the night, patients’ sombre thoughts often intensify, and experiences occurring during the day may have built up frustrations, and it may seem impossible to rest if problems remain unresolved. With the time and serenity of the night, the patients’ emotional needs are met with care. Patients may relate a desire to talk about and share their thoughts (concerns, anxiety and sadness), and this calls for the nurse to help them manage their concerns. Some patients may be afraid to die. Sitting beside the patients’ bed, holding their hand and meeting their need for deep dialogues, understanding, consolation, and care, listening may support the patient in his or her attempt to find peace and rest. A hospice nurse noted:

I think that talking of feelings with patients at night is more intense than during the day shift (Informant 11).

The night, in particular, provides room for establishing a deep connection with the patients, and an emotional bond may be established when connecting in vulnerable situations. This may also be the case for relatives. This type of stress relief and getting some rest are important in building energy for the next day. It is also a rewarding feeling to serve the patient’s and relatives’ best interest in this manner.

Needing a colleague to avoid feeling alone and vulnerable

Being just a few (often two) employees enhances nurses’ collaboration as they work towards the same goal of achieving a good night shift. A good night shift presupposes that things should be under control, that the patients sleep and that the nurses are ready to manage any situation that may arise. The unforeseen tasks occurring on night shifts are often of an acute and serious nature. Safety is based on having a competent and available physician on call. To decide when it is time to call the physician, nurses confer, discuss and confirm with each other that the situation is sufficiently severe for assistance to be needed. A nurse from the medical respiratory ward explained:

On the night shift, you do not call a doctor when the patient gets worse as you do on the day shift; first, you consult and discuss with a colleague to agree about what action can be taken. (Informant 2).

However, drawing on mutual skills and doing the best to manage the situation before requesting assistance from the physician increase nurses’ dependency on each other. The awareness that nurses were on their own with their colleague, motivated them to help and support each other, worrying about leaving their colleague alone. The very fact that the other nurse provided significant support and served as a shield made the nurse do her utmost to demonstrate skill and capacity to manage the situation. The experienced nurse may have competencies and confidence in her own ability to manage acute situations, whereas others may need to rely on a colleague to have the necessary knowledge. The importance of this fact made the nurse check beforehand whom she would be working with; and if it was someone she did not know or an inexperienced nurse, she worried. A nurse from the gynaecology ward had the following experience:

It was a situation we had not seen before, and both of us were new nurses and I was the one with more experience; and I did not feel I had the experience to get an overview of what we should do in the situation… so there were many things that we needed to evaluate afterward (Informant 6).

Getting to know each other is important because of the mutual dependency on the night shift; and having only few colleagues to draw on creates a space for intimacy and motivates nurses to spend time together, also when relaxing. Time to enjoy a cup of coffee or a meal together makes it possible to get to know each other better. This time is the most positive aspect of night shifts. A nurse from the neurological ward noted:

On the night shift, there are only two of us. I think it’s good for the relationship between us, because sometimes you talk about things that you don’t want to talk about during a day shift; you get to know each other at a deeper personal level and you’ll talk through episodes and situations for which you have no time on the day shift, so I think it’s sometimes nice to be on the night shift (Informant 4).

Coping with unforeseen acute situations

The reduced staffing at night shifts has a strong bearing on the nurse’s experience of safety. When only few nurses are at work, an unpredictable workload easily becomes more than they can handle, even with a competent and available physician on call. Then the shift turns into a “bad” night due to chaos. This risk can mean that nurses construct their own safety network, even by agreeing on calling an off-duty colleague in case there is a problem. Patients’ symptoms may go from worse to very serious from one minute to the next, and patients admitted during the night are often in a severe condition. A nurse from the medical respiratory ward noted:

We have very sick patients who can quickly get acute exacerbations, particularly in their respiratory system, from one minute to the next. They may feel very well during the evening and at night, but suddenly they become seriously and acutely ill; we have to be two persons to take care of the patient …. and it means that the last colleague must then take care of the other 31 patients (Informant 2).

Some nights, the situation is so severe and threatening that the nurses have difficulties getting the patient situation under control and avoid getting hurt themselves. The risk that nights may be like that causes nurses to be prepared for an emergency and to be able to change their focus quickly to make a professional judgment, assessment and prioritization and to take action.

They attempt handling emergency situations within the framework stated by the physician in the patient’s medical record. Acute situations often require two nurses, which creates a very vulnerable situation for the other patients in the unit. In an accident and emergency ward, this was expressed as follows:

We are always two when there is a cardiac arrest or if there is a trauma coming in; so, we always have two people in the room and then the rest of the ward is quite vulnerable, and we are stuck. There is not much help to get if something serious happens (Informant 3).

Knowing this stresses the nurse, especially if urgent patient care means that she is the only nurse available. The acute situations are difficult for the inexperienced nurse, and this may also be the case for the experienced nurse when she depends on an inexperienced colleague.

Discussion

Despite the risk of encountering stressful situations, nurses appreciated nights when a calmer environment and more time available allowed them to work calmly with fewer interruptions. These periods also allowed them to achieve a higher level of selfintimacy, build closer relationship with patients and facilitated a higher level of care. This was also reported by Zannini et al. [15] who conducted an

interpretative phenomenological study of 35 nurses working in Italian medical, surgical, and intensive care units. Moreover, working nights also allows time for formation of closer personal and professional relationship with colleagues as shown in the literature [8,15]. Thus, the positive effects of being only a few staff members in the night shift were related to building a good relationship with one’s colleagues [3] and with the possibility for professional growth [3,5,15]. However, whereas Powell [2] found that these benefits outweighed the negative consequences when working at night permanently, the nurses in our study working varying shifts felt that strain far outweighed any benefits.

 Looking at the work at night isolated from how it affects life in general, we found that a struggle between tiredness and prolonged alertness affected nurses’ bodies and well-being. We were struck by the demands the nurses were facing during nigh. Even in good nights that were quiet because patients were sleeping, the nurses were often stressed by having to keep themselves awake and being alert to whatever might happen. To be prepared for unpredictable tasks seemed to be inherent in the night shift, and the nurses had to maintain this alertness while feeling drowsy and tired, maybe even fatigued. Being in a nearly continuous state of alertness has similarities to being in a stress situation. Also, Phiri et al. [6] found that nurses experienced a stressful working environment at night. Being in a situation of stress or fear may trigger more than 1,400 physical and chemical stress reactions involving more than 30 different hormones and neurotransmitters [24]. This may explain why health issues arise and highlights the need for easing nurses’ work conditions, for example by reducing the amount of task, providing space for rest and ensuring that needed help is available.

Working night shifts included preparing for the next day to ensure a good beginning for the day shift, not leaving any undone work. This was a shared expectation among staff, and nurses in the night shift felt highly obliged to prepare for the day shift. Therefore, everyone expected the night shift nurse to work overtime if necessary to complete these tasks. These findings can be explained by reference to Steege & Rainbow’s study [17]. They showed that this perceived obligation was rooted in a feeling of guilt whenever the nurse on night shift needed to leave extra work for colleagues, and a fear of being judged as being less capable. A change of this culture may be required to ease the pressure on nurses working the night shifts.

The nurses in our study experienced that tiredness during the night shift was caused by sleep deprivation, which has also been found in prior research [4,6-8,13]. Knowing that sleep is essential to health [25] it is positive that findings made by GeigerBrown et al. [26] showed that napping on the night shift could reduce nurses’ fatigue. Offering nurses naps during night shifts [8,26] could prevent patient-care error, occupational error and drowsy driving on the way home from work [1,4,6-8]. However, health-promoting rest during night shifts was not compatible with the increase in workload experienced due to limited resources following organisational and structural reorganisation [3]. For instance, patients could be admitted

from the waiting list at night to be prepared for various treatments and interventions the next day [3]. This was done partly to occupy the night staff and partly to facilitate the duties of the daytime staff [3]. These additional tasks did not necessarily have to be carried out during the night. However, some tasks could be accomplished if being active worked best for the individual nurse.

Our study illustrates that working night time requires that nurse be more independent and have more clinical autonomy in decision-making than nurses working day shifts, which is in line with previous research [5,15]. Being only a few nurses present, requires that nurses must handle more patients who are at high risk of clinical deterioration and adverse events; according to Kyriacos et al. [27] and Lee et al. [28] this may lead to serious complications and unexpected death. Therefore, confidence in each other’s competence was important to be prepared for and able to manage difficult clinical situations. The nurses in our study were not explicit about anxiety related to making mistakes due to tiredness and fatigue in the same way as reported in some previous studies [6,8,13]. But both the inexperienced and the experienced nurses addressed concern related to their colleagues’ competences, as also seen in other studies [3,5,15]. In our study, these issues were mainly seen in acute situations. This emphasises the importance of training. Furthermore, frustrations and fear stemmed from knowing that when they were occupied, several patients in the ward would have nobody to care for them during prolonged periods. Such a so-called “bad night” was associated with a heightened feeling of vulnerability and a feeling of anxiety that they might not be capable of meeting their responsibilities. Though it will command extra resources to ensure that personnel are available on call, such initiatives may serve to reduce anxiety and increase patient safety while improving nurses’ health, with the benefit that they remain in their positions for a longer time.

Methodological considerations

The students recruited acquaintances to feel safe even if the use of acquaintances involved the risk of lack of explicitness and professional distance. To reduce this weakness, the students were trained and aware of their role as phenomenologists in the interview situation. Furthermore, the informants were clearly informed before the interviews that all findings would be treated anonymously. This resulted in data with rich descriptions of the phenomenon of working through the night time. The rigour of the study is supported by our choice of phenomenology as the analytical lens for this topic to achieve deep insight into nurses’ experience of living and working through the night time [16]. Furthermore, we describe the individual steps of the phenomenological approach to enhance analytical transparency and declare our reflexive stance to heighten reliability in the interviewing and the process of analysing the data, which involved being conscious of our everyday perception (natural attitude) and using an established approach (phenomenological attitude). Remembering not to make the infinite finite, generality, based on our knowledge so far, was sought by trying out each constituent individually and then whether all constituents as a whole reflected the essence [21]. 

Conclusion

Insight into living and working through the night time, as experienced by nurses, shows that while working night shifts, nurses strive to establish a good link between the evening and the day shifts by facilitating rest and sleep, relieving pain and frustration and keeping patients’ sombre thoughts at bay. Being basically tired and having to remain ready for the unexpected and cope with any unforeseen acute situations, nurses needed an ally not to feel alone and vulnerable in the night. Nurses working night shifts make a considerable personal sacrifice since they also have to deal with prolonged tiredness after the night shifts are completed, even during free periods. Furthermore, night work is a key part of providing good, safe-care nursing and ensuring that patients feel that they are being cared for properly at night. Working at night influences nurses negatively; however, these effects may be reduced through interventions such as implementation of power napping, upgrading of competences and access to the needed support. 

Acknowledgments

Thank you to the informants for sharing their experiences and to the students Pernille Bluhm, Lene Lassen Christensen, Tine Didriksen, Monica Ejsing-Pedersen, Signe Eriksen, Cecilie Førster, Jannie Graversen, Kira Jensen, Lise Jensen, Mette Jensen, Sofie Jensen, Karoline, Laerke Lorenzen, Camilla Maibom, Ellen Mouritsen, Anette Nelleman, Laura Oustersen, Louise Rudbeck, Tenna Salmonsen, Camilla Thim for their contribution cord injury. Furthermore, we take this opportunity to express our gratitude to Associate Professor Morten Pilegaard for editing and proofreading services.

Tables

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