Whats New in the Patient Safety World
October 2014
Another Rap on the 12-Hour Nursing Shift
Since our
original November 9, 2010 Patient Safety Tip of the Week 12-Hour
Nursing Shifts and Patient Safety weve discussed the pros and cons
of the 12-hour work shift as they relate 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. In several subsequent columns (see list at the end of
todays column) 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.
The fundamental
question should be 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.
There are some
features of the 12-hour shift that we like because they could at least
theoretically improve patient safety. These include fewer handoffs and a
reduction in the consecutive day phenomenon (see our July 29, 2014 Patient Safety Tip of the Week
The
12-Hour Nursing Shift: Debate Continues). But these must be balanced
against the negative influence of worker fatigue that may worsen patient
safety.
A previous survey of nurses in the US (Stimpfel 2013) suggested a detrimental impact of such extended work hours on patient care. Now another nursing survey has linked prolonged nursing shifts to problems in quality and patient safety. Griffiths and colleagues for the RN4CAST Consortium (Griffiths 2014) reported the results of a survey of over 30,000 RNs in general med/surg units at 488 European hospitals. 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.
Though this was a survey that relied on nurse self-reported
responses, previous studies have validated that such nurses perceptions
correlate with actual patient safety and quality measures (McHugh
2012).
12-hour shifts are
not yet as common in most European countries compared to the US. In the US the
most common shift length in a survey was 12-13 hours, worked by 65% of nurses
responding (Stimpfel
2013) and another paper put that number at 75% (Townsend
2013). In contrast, only 15% of nurses in the current survey of European
hospitals worked shifts of 12 or more hours. That did, however, vary by
country. Less than 5% of nurses responding in Belgium, Germany, Greece, The
Netherlands, Norway and Sweden worked shifts of 12 hours or more whereas in
Ireland and Poland such shifts were worked 73% of the time and in England such
shifts accounted for about a third of shifts.
But there are
questions left unanswered by this and all previous studies. The Griffiths study
did not distinguish between nurses who chose to work 12-hour shifts vs. those
for whom it was mandated. Given the correlation between overtime and nurses
perceptions of suboptimal quality and patient safety, one might anticipate that
the degree of discomfort nurses have with their shift length may be an
important contributory factor.
Because the 12-hour
shift has become so popular in the US, both with nurses and hospitals, it will
likely take compelling evidence to cause reversion to shorter shifts. 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. But it is this very personal preference that
would make it very difficult for the ultimate study on this issue a
randomized controlled trial (RCT) to be performed. Probably the only way to
do such a quasi-RCT would be to take a sizeable hospital with multiple wards
handling comparable patients and then make half the units 8-hour shift units
and the others 12-hour shift units, letting nurses choose which unit they want
to work on. Objective quality and patient safety outcomes would have to be
measured in addition to nurses impressions of care. Such a study would
probably still be subject to selection bias. Given the hospital nursing
shortages in the US it would be very difficult to adjust results for the
occurrence of overtime.
This is a critically important issue in quality and patient safety. But conclusive answers are not yet available. In the interim see some of our prior columns regarding strategies to mitigate nurse fatigue and also our columns on the impact of fatigue in healthcare and other industries and use of strategies such as power naps.
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
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
July 29, 2014 The
12-Hour Nursing Shift: Debate Continues
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, Aiken LH. Hospital Staff Nurses' Shift
Length Associated With Safety and Quality of Care. Journal of Nursing Care
Quality 2013; 28(2): 122-129
Griffiths P, DallOra 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
McHugh MD, Stimpfel AW. Nurse reported quality of care: A measure of
hospital quality.
Res Nurs Health. 2012; 35(6): 566575; Article
first published online: 21 AUG 2012
http://onlinelibrary.wiley.com/doi/10.1002/nur.21503/abstract
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
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