Patient Safety Tip of the Week
July 29, 2014
The 12-Hour Nursing Shift:
Debate Continues
Our all-time most popular Patient Safety Tip of the Week was our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety”. In that column we discussed some of the pros and cons of these longer shifts as they related to both healthcare and other industries. We concluded that the literature to date really did not answer the question as to whether those shifts had a detrimental impact on patient safety or patient outcomes.
Then in our February 2011 What’s New in the Patient Safety
World column “Update
on 12-hour Nursing Shifts” and our November 13, 2012 Patient Safety Tip of
the Week “The
12-Hour Nursing Shift: More Downsides” we discussed some evidence
suggesting a detrimental impact of such hours on patient care and satisfaction
as well as a longer term negative impact on nurses’ satisfaction (Stimpfel
2012).
There hasn’t been a
whole lot on the 12-hour shift in the literature since that last column. But it
did come up again in a couple articles within the past few months. The first
was a Pennsylvania Patient Safety Authority review of data on incidents
reported in which healthcare worker fatigue was noted to be a contributing
factor (Dubeck
2014). Between 2004 and 2013 they found over 1600 such incidents
involving fatigue on a variety of healthcare workers. Medication errors
accounted for 62.1%, and errors related to a procedure, treatment, or test
26.4%. Dubeck discusses the 12-hour nursing work
shift in addition to other factors which promote fatigue.
Another new study (Chen 2014),
based on survey data, found that nurses on 12-hour shifts experienced a
moderate to high level of acute fatigue and moderate levels of chronic fatigue
and inter-shift recovery. Lack of regular exercise and older age were
associated with higher acute fatigue. They concluded there is a need to
establish fatigue intervention programs for nurses working 12-hour shifts.
There is ample
evidence in the literature that fatigue has detrimental influences on attention
and concentration, reaction time, cognition, communication and judgment among
other things. Dubeck notes the widely quoted
statistic that 17 hours of sustained wakefulness is equivalent to a blood
alcohol level of 0.05% and that after 24 hours, it is equivalent to 0.10%. And
we’ve done multiple columns on the impact of fatigue on healthcare workers, not
only nurses but physicians, pharmacists and others (see the list at the end of
today’s column). One study (Arnedt 2005) demonstrated that resident performance
impairment post-call after 4 weeks of heavy call is equivalent to or worse than
the impairment observed at 0.04 to 0.05 g% blood alcohol concentration on tests
of sustained attention, vigilance, and simulated driving. Moreover, residents’
self-assessment of heavy call performance was limited and task-dependent. And
there are numerous examples of the negative impact of fatigue on the health of
nurses’ themselves (eg. higher risks of needle
sticks, car accidents, etc.) that we’ve noted in previous columns listed below.
But the fundamental
question we are asking here is “Is there evidence that the 12-hour nursing
shift results in more patient harm or worse patient outcomes than the more
traditional 8-hour shift?” And, because no studies have been done allowing
direct comparison of care rendered via the two scheduling patterns and
eliminating potential confounding factors, we still cannot confidently answer
that question. Because the 12-hour shift has become so popular, both with nurses
and hospitals, it will likely take compelling evidence to cause reversion to
shorter shifts. In fact, we previously noted the most common shift length in a
survey was 12-13 hours, worked by 65% of nurses responding (Stimpfel
2013). Another recent paper puts that number at 75% (Townsend
2013). The majority of nurses we know like the 12-hour shift because of its
flexibility and that it allows them to spend more time with their families and
other activities outside the hospital.
There are some things we like about 12-hour shifts. The major one is the reduction in handoffs. In fact, in most industries that reduction in handoffs is touted as the most important benefit of 12-hour shift. Instead of the three handoffs seen with 8-hour shifts, you only have two handoffs with 12-hour shifts. And, just as importantly, you are typically handing off to the same individuals that you received a handoff from at the start of your shift (adding an element of “I want my handoff to be as good as the one I expect to get”). Since handoffs are very vulnerable to errors, anything that reduces the number of handoffs or improves their efficiency and efficacy is likely to improve patient care.
Another unknown variable is what we refer to as the “consecutive day phenomenon”. A study on shift workers in fields other than healthcare (Folkard 2003) showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). Extrapolating, one might suspect that we might see fewer errors if you only have to work 3 straight days rather than 4 or 5. The Folkard study demonstrated that risks are not uniform throughout the day but are greater at certain times, especially at night, and even vary based upon temporal relationship to breaks. Those authors stress that all these factors (number of successive night shifts, length of night shifts, and provision of breaks) must all be considered in combination. They note it is conceivable that a 12-hour night shift with frequent rest breaks might well prove safer than an 8-hour shift with only one mid-shift break.
Another factor in
the 12-hour vs. 8-hour debate is the hours actually worked. In the old “8-hour
shift world” it was very common for nurses to work back-to-back shifts
(“doubles”) to fill in when scheduled nurses were unable to work. So those
nurses were working at least 16 straight hours. So reversion to 8-hour shifts
won’t be successful if many nurses now end up doing 16 consecutive hours.
But probably the
most important point made in the Dubeck paper is that
solutions focusing only on hours worked are not likely to be very successful.
We agree wholeheartedly. We’re all familiar with the the
work hour restrictions on residents and other physicians in training. The
evidence of impact of those restrictions on patient outcomes is mixed and,
overall, not very compelling. Dubeck notes that two
of the major causes of fatigue (disruption of circadian rhythm sleep and sleep
deprivation) are not addressed by pure work hour restriction policies.
Dubeck makes a case for more focus on FRMS’s
(Fatigue Risk Management Systems) and interventions to mitigate errors that
might be caused by fatigued healthcare workers. These might be modeled on
similar programs recommended by the Federal Aviation Administration (FAA) for
pilots and aviation personnel. She describes what an ideal FRMS would look like
and cites one such FRMS being used by Queensland Health in Australia (Queensland
Health 2014). Dubeck also provides a nice table
of interventions and whether they do each of the following:
- Reduce fatigue
- Reduce or capture fatigue-related errors
- Minimize the harm caused by fatigue
For example, a
napping strategy might only reduce fatigue whereas fatigue-proofing task
procedures would impact the latter two categories.
Multiple studies have also demonstrated that people (in any industry, not just healthcare) tend to underestimate their levels of fatigue and impairment compared to their performance on formal testing. Some day we will have the equivalent of the brief “sobriety” test that can rapidly identify healthcare workers who are impaired by fatigue. We’ll leave development and validation of such a test up to our psychology colleagues but we’d envision that at regular intervals beyond 8 hours (maybe even sooner) the healthcare worker will get buzzed on his/her smartphone and have to complete some simple test of reaction times or attention span. If the worker scores outside the established threshold the hospital will need to have resources in place to take over duties of that worker (completely or at least temporarily until fatigue is alleviated by, for example, a nap).
We recommend you read our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” to see some of the excellent prior work that has been done by Geiger-Brown and colleagues (Geiger-Brown 2010) and Fallis and colleagues (Fallis 2011) regarding some of the strategies to mitigate nurse fatigue and also our columns listed below on the impact of fatigue in healthcare and other industries and use of strategies such as power naps.
Update: See
also our October 2014 What’s New in the Patient Safety
World column “Another
Rap 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 2010 “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”
Some of our other columns on housestaff
workhour restrictions:
December 2008 “IOM
Report on Resident Work Hours”
February 26, 2008 “Nightmares:
The Hospital at Night”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 2011 “No
Improvement in Patient Safety: Why Not?”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “Surgeon
Fatigue”
November 2012 “The
Mid-Day Nap”
December 10, 2013 “Better Handoffs, Better Results”
April 22, 2014 “Impact
of Resident Workhour Restrictions”
References:
Stimpfel AW, Sloane DM, Aiken LH. The Longer The Shifts For Hospital Nurses, The Higher The Levels Of
Burnout And Patient Dissatisfaction. Health Affairs 2012; 31(11): 2501-2509,
November 2012
http://content.healthaffairs.org/content/31/11/2501.abstract
Dubeck D. Heathcare
Worker Fatigue: Current Strategies for Prevention. Pa Patient Saf Advis 2014; 11(2): 53-60 June
2014
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2014/Jun;11%282%29/Pages/53.aspx
Chen J, Davis KG, Daraiseh NM, et al. Fatigue and recovery in 12-hour
dayshift hospital nurses. Journal of Nursing Management 2014; 22(5) 593-603
July 2014
http://onlinelibrary.wiley.com/doi/10.1111/jonm.12062/abstract
Arnedt JT, Owens J, Crouch M, et al. Neurobehavioral Performance of Residents After Heavy Night Call vs After Alcohol Ingestion. JAMA 2005; 294(9): 1025-1033
http://jama.jamanetwork.com/article.aspx?articleid=201473
Stimpfel AW, Aiken LH. Hospital Staff Nurses' Shift Length
Associated With Safety and Quality of Care. Journal of Nursing Care Quality
2013; 28(2): 122-129
Townsend T, Anderson
P. Are extended work hours worth the risk? Am Nurs Today 2013; 8(5): 8-11 May 2013
http://www.americannursetoday.com/article.aspx?id=10272&fid=10226
Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101
Queensland Health.
Human Resources Policy. Fatigue Risk Management. Policy # I1 (QH-OL-171). June
2014
http://www.health.qld.gov.au/qhpolicy/docs/pol/qh-pol-171.pdf
Geiger-Brown J, Trinkoff AM. Is It
Time to Pull the Plug on 12-Hour Shifts? Part 3. harm reduction strategies if keeping 12-Hour Shifts. Journal of Nursing Administration 2010; 40(9): 357-9, 2010 Sep
Fallis, WM, McMillan DE, Edwards MP. Napping During Night Shift: Practices, Preferences, and Perceptions of Critical Care and Emergency Department Nurses
Crit Care Nurse March 31, 2011 vol. 31 no. 2 e1-e11
http://ccn.aacnjournals.org/content/31/2/e1.full
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