Patient Safety Tip of the Week
July 11, 2017 The
12-Hour Shift Takes More Hits
We’ve discussed the
pros and cons of the 12-hour nursing shift in many columns. On the “pro” side
the only real theoretical advantage is fewer handoffs. However, also on the
“pro” side is that many nurses do like the flexibility of work hours and having
more time to spend with family or other activities. And many nurse
administrators like the flexibility of scheduling.
But on the “con”
side there are many more arguments. The most salient ones are the impact of
fatigue on patient care and the personal health of nurses.
Now a new study
comes out of the RN4CAST study, which has
provided many good lessons learned in the past. Ball and colleagues (Ball
2017a) used survey data from the RN4CAST
study to correlate measures of nurse-reported quality with shift duration. They
found the odds of poor quality care were 1.64 times higher for nurses working
≥12 hours. And rate of “care left undone” (our Patient Safety Tips
of the Week for November 26, 2013 “Missed
Care: New Opportunities?” and May 9, 2017 “Missed
Nursing Care and Mortality Risk”) was 1.13 times higher for nurses working ≥12 hours. In
addition, job dissatisfaction was higher the longer the shift length, with
nurses more than 50% more likely to report job dissatisfaction when working
12-hour shifts compared to 8-hour shifts.
The care left undone
finding is particularly bothersome. In our May 9, 2017 Patient Safety Tip of
the Week “Missed
Nursing Care and Mortality Risk” we noted a striking finding in a previous study by Ball (Ball
2017b) that a 10% increase in the amount of care left undone by nurses was
associated with a 16% increase in mortality. While that study focused more on
overall nurse staffing levels and care left undone, the current Ball study
suggests that care left undone is a significant problem with 12-hour shifts and
one might assume that same effect on mortality rates might apply.
A systematic review of the relationship between shift length
and nurse errors (Clendon
2015) found that the risk of making an error appears higher among
nurses working 12 hour or longer on a single shift in acute care
hospitals. Though some of the smaller studies included in that systematic
review did not show such an association, 6 studies that made up 89% of the
total sample size showed a strong relationship between errors and 12 hour or
longer shifts.
In our October 2014 What’s
New in the Patient Safety World column “Another
Rap on the 12-Hour Nursing Shift” we discussed another study from the RN4CAST
Consortium (Griffiths
2014) which showed nurses working shifts of 12 hours or more were more
likely to perceive poor or failing patient safety, poor or fair quality of
care, and more care activities being left undone. Working overtime, regardless
of shift length, was also associated with nurses’ perception of poor or failing
patient safety, poor or fair quality of care, and more care activities being
left undone.
Multiple studies,
discussed in our prior columns, have described the negative effects of 12-hour
shifts on nurse health, well-being, and job satisfaction. In our September 29,
2015 Patient Safety Tip of the Week “More
on the 12-Hour Nursing Shift” we noted another RN4CAST study that provides
insight into the impact of 12-hour shifts on nurse well-being (Dall’Ora
2015). Those researchers found that, while all shift lengths greater
than 8 hours were associated with more nurse adverse outcomes, nurses working
shifts ≥12 h were more
likely to experience burnout, have emotional exhaustion, depersonalization, and
low personal accomplishment. Moreover, they were more likely to have job
dissatisfaction, dissatisfaction with work schedule flexibility, and report
intention to leave their job due to dissatisfaction. Nurses working shifts of
12 hours or more were 40% more likely to report job dissatisfaction and 29%
more likely to report their intention to leave their job due to
dissatisfaction.
Another yet unpublished study from the RN4Cast study apparently
shows that nurses are more likely to call in sick and miss work after a 12-hour
shift (Merrifield
2017).
One of the problems with studies on shift duration and any
sort of outcome is that there may be a difference between scheduled 12-hour
shifts and unscheduled (i.e. overtime) ones or between circumstances where
nurses choose to work 12-hour shifts vs. those where the extra hours are
mandated. Note that the term “mandated” overtime is used loosely. Even when
overtime cannot be truly “mandated”, most nurses feel obligated to work overtime
when unexpected absences lead to nurse shortages on an upcoming shift.
Ball and colleagues note that a key issue of 12-hour shifts
is that “it depends on how it’s done”. They acknowledge that future research
should focus on how 12-hour shifts might be optimized to minimize the potential
risks.
While evidence continues to accumulate regarding the
downside of 12-hour shifts, we don’t expect them to disappear entirely any time
soon. In several of our columns we have talked about interventions like the use
of power naps to reduce the likelihood of fatigue.
But other issues remain. For example, we’ve said that a
“pro” for 12-hour shifts is fewer handoffs. But are handoffs well done after
12-hour shifts? Do we allow enough time to do adequate handoffs between those
12-hour shifts? Moreover, there is probably less time available for educational
activities when 12-hour shifts are being used. And we don’t know how 12-hour
shifts impact team building or social support issues.
Meanwhile, an experiment in the opposite direction –
reducing the hours in the workday – met with mixed findings. In Gothenburg,
Sweden, an “old persons home” looked at the impact of
a 6-hour workday (Greenfield
2017, Heath
2017). While the outcomes on nurses’ health and sick leave were largely
positive, the cost was considered to be too high. The study ended after 23
months when funding ran out. So it is not clear how sustainable any savings on
healthcare expenses might be.
Nurses working six hours took 4.7 percent fewer sick days
and fewer work absences than when they worked eight-hour days. Nurses in the
control group (working eight hour days) actually increased the number of sick
days during the trial by 62.5 percent. Nurses working six hours overall were
more active, less sick, less stressed and had less back and neck pain than
nurses working eight-hour shifts.
The home had to hire 17 additional staff to cover the shifts,
increasing the payroll by about 22%. Theoretically, if the savings on sick
leave are sustainable and if job satisfaction translates to reduced turnover,
the increased costs might be offset in the long run. But we’ll probably never
find out, since the study has been terminated.
However, outcomes regarding patient health and patient
safety have not been reported. While (anecdotally) nurses spent more time with
patients, we’ve not seen any data on patient outcomes. Of course, one concern
with the shorter workday is that the number of handoffs is higher, increasing
the chance for communication errors.
So don’t expect a shift to 6-hour workdays any time soon!
We hope that you’ll go back to some of our prior columns on
the 12-hour shift that highlight the important contributions of researchers
like Geiger-Brown, Stimpfel, Trinkoff,
and others.
Our previous columns
on the 12-hour nursing shift:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
February 2011 “Update
on 12-hour Nursing Shifts”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
September 29, 2015 “More
on the 12-Hour Nursing Shift”
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping
Air Traffic Controllers: What About Healthcare?”
February 2011 “Update
on 12-hour Nursing Shifts”
September 2011 “Shiftwork
and Patient Safety
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 2012 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “June
2012 Surgeon Fatigue”
November 2012 “The
Mid-Day Nap”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
September 6, 2016 “Napping
Debate Rekindled”
April 18, 2017 “Alarm
Response and Nurse Shift Duration”
References:
RN4CAST Study.
Ball J, Day T, Murrells T, et al. Cross-sectional
examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures.
BMC Nursing 2017; 16: 26
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-017-0221-7#CR25
Ball JE. Nurse
Staffing Levels, Care Left Undone, & Patient Mortality in Acute Hospitals. Karolinska Institutet; Stockholm
2017
Clendon J, Gibbons V. 12 h shifts
and rates of error among nurses: a systematic review. Int
J Nurs Stud 2015; 52(7): 1231-1242
http://www.sciencedirect.com/science/article/pii/S0020748915000735
Griffiths P, Dall’Ora C, Simon M,
et al. Nurses' Shift Length and Overtime Working in 12 European Countries: The
Association With Perceived Quality of Care and Patient Safety. Medical Care 2014;
published online September 15, 2014
Dall’Ora C, Griffiths P, Ball J,
Simon M, Aiken LH. Association of 12 h shifts and nurses’ job
satisfaction, burnout and intention to leave: findings from a cross-sectional
study of 12 European countries. BMJ Open 2015, 5: doi:10.1136/bmjopen-2015-008331,
published 23 August 2015
http://bmjopen.bmj.com/content/5/9/e008331.full.pdf+html
Merrifield N. Nurses more likely to be absent from work
after 12-hour shifts, study finds. Nursing Times 2017; 11 April, 2017
Greenfield R. How the Six-Hour Workday Actually Saves Money.
A Swedish experiment may have missed the bigger picture of how shorter days can
mean long-term profit. Bloomberg.com 2017; April 17, 2017
https://www.bloomberg.com/news/articles/2017-04-17/how-the-six-hour-workday-actually-saves-money
Heath T. A six-hour workday could make you happier,
healthier and more productive. Washington Post 2017; April 21, 2017
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