The Impact of Longer Shifts on Nurses and Patients

Abstract

Long nursing shifts of 12 hours or more have shown to be detrimental to patient care and have resulted in increased levels of both patient and nurse dissatisfaction. Studies have found that long shifts can result in fatigue and increased stress levels, and research has suggested that the demands of long shifts can result in increased medication errors and compromised patient care. There is currently minimal oversight regarding regulating nurse shift hours in medical industry. In many cases nurses must work more than 12 hours and more than three days per week due to overtime requirements. With higher job dissatisfaction and error rates for nurses who work longer hours, there may be many benefits for hospitals and other medical employers to revise their workplace protocols to limit fatigue and manage shifts more efficiently. Revised protocols that taken into account the dangers of overworking nurses may reduce workplace stress levels, fatigue, errors, and improve patient and nurse satisfaction rates.

The Impact of Longer Shifts on Nurses and Patients

In modern times nurses rarely work traditional 8 hour shifts with 12 hour or longer shifts being common at many nurse employers due to a higher demand. One of the purposes of instituting 12-hour shifts was to give nurses a more flexible schedule, but in many cases it has resulted in longer hours and workweeks due to increased work demands and overtime requirements when there is a higher volume of patients. Various studies on registered nurse work patterns have found that longer hours create poor work outcomes and result more injuries to patients and accidents. The implication of many of these studies is that the reduction of overtime shifts and allowing nurses the ability to have more control over their schedules may improve patient safety and care quality.

There is a growing body of research that has shown increased reports of poor-quality care when nurses work longer shifts of 10 or more hours (Stimpfel and Aiken, 2012, p. 7). Recent studies have concluded that nurses may benefit from the ability to exercise more control over their schedules and that longer hours may be affecting patient safety. Most of the studies on extended shifts have concluded that employers and supervisors need to exercise more oversight regarding extended shifts and pay more attention to the effect of fatigue in the workplace to reduce injuries and errors.

Literature Review

In Stimpfel and Aiken’s 2012 study on nurse shift length and the association with patient safety and quality of care it was found that extended shifts were correlated with a poor quality of care and safety, and that employers should consider reducing extended shifts (Stimpfel & Aiken, 2012, p. 1). Higher work hours can result in increased needlestick injuries and musculoskeletal injuries for nurses and an increased rate of clinical errors and infections for patients (Stimpfel & Aiken, 2012, p. 1). The nurses in the study worked between 1 to 24 hours in their last shift and only direct care nurses were included. Surveys were used to assess the number of work breaks, hours worked, and the quality of care delivered to patients in the nurses’ units.

The study found that the most common shift length was between 12 to 13 hours with 65% of respondents working this shift length, while 26% of the nurses in the study worked 8 to 9-hour shifts, and 5% worked more than 13 hours. Nurses who reported shift lengths of 10 or more hours had a greater chance of reporting a poor unit safety grade compared to the nurses who worked an 8- or 9-hour shift (Stimpfel & Aiken, 2012, p. 5). Also, the odds of reporting a poor quality of care were twice as high for nurses who worked the longest shifts (Stimpfel & Aiken, 2012, p. 6).

Stimpfel, Sloane and Aiken published another study in 2012 that detailed patient dissatisfaction rates in correlation with longer nurse shifts. This study found that patients were less satisfied with the quality of care they received when there were a larger percentage of nurses in their unit who had worked over 13 hours, and they were more satisfied when there were more nurses who had worked 11 or fewer hours (Stimpfel, et al., 2012, p. 2506). Shifts of more than 13 hours were also found to be correlated with a higher chance of burnout, a desire to leave the job, and dissatisfaction (Stimpfel, et al., 2012, p. 2506). The study suggested that nurses underestimate the impact of working longer shifts due to the idea that three-day workweeks are more appealing and that 12-hour shifts are also attractive to nurses who desired to work a second job (Stimpfel, et al., 2012, pp. 2506-2507).

In Smith, Folkard, Tucker and Macdonald’s 1998 study it was found that 12-hour shifts result in increased fatigue levels for workers and increased safety concerns for nurses. Smith et al.’s study compiled various studies on the effect of 12-hour shifts compared to 8 hours shifts and summarized the results of those studies. A study that they summarized by Johnston et al. found that nurses who worked 12-hour shifts had an increased rate of errors and worked faster, resulting in a speed accuracy tradeoff (Smith et al., 1998, p. 219). Another study that they summarized by Smiley and Moray found that rest days, rotations, work scheduling, and overtime practices all play a role in alertness and fatigue levels during shifts (Smith et al., 1998, p. 219).

When 12-hour shifts were scheduled on five to seven consecutive days, there were decreased in productivity and when 12-hour shifts were scheduled consecutively over a period of 4 weeks with only one to two-day breaks, the highest levels of reduced productivity were shown (Smith et al., 1998, p. 219). Smith et al. suggested that scheduling 12 hour shifts in a compressed schedule should be limited to no more than four consecutive days to avoid performance issues (Smith et al., 1998, p. 219).

In Rogers’ study on the effects of fatigue and sweatiness on nurse performance it was found that nurses who prefer working 12 hour shifts and overtime had difficulties staying awake while working, had a three times greater chance of making a bath, and had reduced sleep levels (Rogers, 2008, p. 512). Rogers referenced the numerous potentially negative and hazardous effects of reduced sleep levels including a greater risk of vehicle accidents, a greater chance of depression, and irritability (Rogers, 2008, p. 510). Several hundred studies on the effects of 12 hour shifts were referenced in Rogers’ paper, and nearly all of them demonstrated no positive effects resulting from sleep restriction and that it affected the moo of people of all ages and professions including nurses (Rogers, 2008, p. 510).

Rogers (2008) also pointed out the dangers of driving while fatigued and referenced the Staff Nurse Fatigue and Patient Safety Study which found that over half of nurses who participated in the study reported difficulties staying awake after driving home from work, and that critical care nurses who over 12.5 hours reported difficulties staying awake once every three shifts increasing the chance for automobile accidents (Rogers, 2008, pp. 511-512). Rogers (2008) suggested that measures to improve alertness should continue to be researched and that more detailed studies needed to be performed on the effect of fatigue on nurse performance and patient safety because of the current evidence that suggests nurses are putting patients at risk when working while fatigued (p. 521).

In a detailed paper published by Ellis on the quality of care by nurses and fatigue found that the current nurse shortage puts unique pressure on nurses to work longer shifts, and is one of the primary reasons for longer shifts that can extend up to 24 hours (Ellis, 2008, p. 1). Ellis (2008) referenced a study by Dorian et al. published in 2006 that found nurses report a higher level of stress, exhaustion and fatigue while working night shifts (p. 2). Ellis (2008) expressed concern that the aging of the nursing workforce combined with high work demands and long shifts may result in more personal health problems and chronic illnesses for older workers (p. 1).

Ellis (2008) made several recommendations for nurses to take action to reduce the impact of extended hours on the safety of the profession including documenting unsafe staffing conditions, calling for collective action by nurses and professional associations to protect the rights of nurses to refuse a work assignment without fear or repercussions, confronting colleagues who seem too tired to work, making improvements to identify fatigue in the workplace (p. 2). Ellis (2008) also called on employers to identify situations that can contribute to fatigue in their workplace and correct them, employ an adequate number of nurses and schedule them properly so that sufficient breaks and rest periods are allowed, research creative options to manage staffing shortages, and limit nurses from working over 12.5 hours in any circumstance (p. 2).

Discussion

The findings of these studies suggest that there needs to be more oversight and stricter workplace oversight at nurse employers regarding extended work shifts. More research needs to be performed on the effects of extended shifts on patients and the injuries that may result from fatigue related errors. Many of the suggestions that Ellis made for changing work protocols may be effective ideas for reducing the negative effects of extended shifts at nurse employers. Nurses also likely need a more detailed education of the potential dangers of working while fatigued and be more conscious of the signs of fatigue in themselves and their peers.

Protocol Recommendations

Nurse employers should evaluate current work protocols and determine if their work scheduling requirements and demands may be contributing to workplace fatigue and stress levels. There are several protocol adjustments that can help to reduce workplace fatigue for nurses while ensuring that hospitals are fully staffed and that a high level of patient care is maintained. Legislation may need to be passed to enforce safe work limits in the United States and protect patient and nurse safety, particularly if more studies continue to demonstrate a substantial risk to patients as a result of nurse fatigue and stress.

Checklists are one method of reducing the impact of longer shifts by limiting errors, and employers may need to adopt checklists in their workplaces while educating their executives and nurse managers and leaders on the dangers of workplace fatigue and implementing practices to regulate shifts. Checklists have shown to be successful in critical care units and operating rooms and have been an effective method to reduce errors in the aviation industry (Ellis, 2008, p. 15). Hospital executives should be educated on nurse scheduling best practices and safety considerations, and there should be a greater emphasis placed on balancing efficiency with safety. It’s also important that every hospital and health care organization participates in implementing best practices for nurse scheduling and oversight that can reduce stress and fatigue levels.

Breaks have shown to be an effective way to manage fatigue and reduce errors. Allowing breaks during the workday is important for managing fatigue levels and reducing errors (Stimpfel and Aiken, 2012, p. 7). Their study found that most nurses do not receive adequate breaks. Legislation was passed in California that protected nurse’s rights to a work break of 30 minutes after working 6 or more hours, as well as a 10-minute break every 4 hours (Stimpfel and Aiken, 2012, p. 6). Similar legislation may need to be passed in other states as a way to enforce nurses’ rights to a break, but employers also need to recognize the importance of allowing their nurses the right to adequate breaks as way to reduce errors and improve performance. Stimpfel and Aiken (2012) found that nurses who took longer breaks had a 10% less chance of making an error (p. 7).

Various fatigue countermeasures need to be adopted both by nurses and employers so that adequate sleep levels are maintained throughout the workweek. Sleep hygiene should be emphasized and more strongly supported by employers, and there should be several methods available at the workplace to reduce fatigue. Nurses need to exercise control over their work schedules and ensure that they accept work obligations that allow them adequate resting periods between shifts.

Controlled rest is often discouraged in the health care industry when it has proven to be effective in many other industries (Ellis, 2008, p. 13), and this culture may need to be reevaluated in the nursing industry because controlled rest in the form of brief naps is a highly effective fatigue countermeasure and may dramatically reduce errors in the clinical care setting if healthcare workplace culture in the United States adjusted to allow for it.

Challenges of Implementing Protocol Recommendations

Government regulations of work shifts for medical workers have been strongly opposed by various groups due to a concern that regulations will not take into account patient needs (Ellis, 2008, p. 13). Even though some states like California have implemented mandatory staff ratios to reduce the need for overtime, there is a concern that employers will run into staffing shortages with mandatory ratios (Ellis, 2008, p. 13).

As mentioned previously, controlled rest is not widely accepted in the U.S. medical industry, and there may be resilience to implementing controlled rest recommendations at many employers. As a result, the changes that need to occur in reducing fatigue in the nursing industry and changing workplace culture will likely have to happen on the individual level first.

Due to the relative lack of research on the dangers of nurse fatigue and the resulting incidence of patient errors, there continues to be a relative lack of attention on the matter. More detailed studies on the negative effects of longer shifts are necessary to raise awareness of the issue. Also, the current nursing shortage cannot be overlooked as being one of the main obstacles to regulating nurse work hours and recruiting campaigns to attract more people to the profession can help alleviate shortages.

Because of the large number and diversity of medical employers in the United States, it is difficult to implement wide regulatory changes. Accrediting bodies and professional nursing organizations are the most appropriate groups to encourage and implement national changes in workplace policies because of their specific understanding of the profession (Ellis, 2008, p. 18). In general, the more measures that are taken to limit workplace fatigue in the medical industry, the more likely that patient satisfaction rates will improve, nurse stress levels will be reduced, and dangerous errors will be limited.

References

Ellis, J. R. (2008). Quality of Care, Nurses' Work Schedules, and Fatigue. Washington State Nurses Association , 1, 1-19. Retrieved March 28, 2014, from http://www.wsna.org/Topics/Fatigue/documents/Fatigue-White-Paper.pdf

Rogers, A. E. (2008). The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety. Patient Safety and Quality: An Evidence-Based Handbook for Nurses, 8(43), 509-533. Retrieved March 28, 2014, from the National Center for Biotechnology Information database.

Smith, L., Folkard, S., Tucker, P., & Macdonald, I. (1998). Work shift duration: a review comparing eight hour and 12-hour shift systems. Occup Environ Med, 55, 217-229. Retrieved March 28, 2014, from the BMJ database.

Stimpfel, A. W., Sloane, D. M., & Aiken, L. H. (2012). The Longer The Shifts For Hospital Nurses, The Higher The Levels Of Burnout And Patient Dissatisfaction. Health Affairs, 31(11), 2501-2509. Retrieved March 28, 2014, from http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/Longer-Shifts-For-Hospital-Nurses-Higher-Levels-Of-Burnout-And-Patient-Dissatisfaction.pdf

Stimpfel, A. W., & Aiken, L. H. (2012). Hospital Staff Nurses’ Shift Length Associated With Safety and Quality of Care. Journal of Nursing Care Quality, 28(2), 1-7. Retrieved March 28, 2014, from http://www.nursing.upenn.edu/chopr/Documents/witkoskiHospitalStaff.pdf