Patient Safety Tip of the Week
September 29, 2015
More on the 12-Hour Nursing Shift
We’ve done multiple
columns on the 12-hour nursing shift. While such shifts remain popular in the
US and several European countries, there are downsides as well and we’ve
discussed those in our prior columns. Also, research on the relationship
between shift length and patient outcomes has been limited by issues such as
whether the longer shifts are voluntary or mandated.
Not only is there
limited data on the impact of 12-hour shifts on patient outcomes, there is also
limited data on their association with nurses’ physical and mental well-being.
Now a new study, using data from 12 European countries from the large RN4CAST
study, 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.
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.
Like most previous
studies, the current Dall ‘Ora study was unable to differentiate whether longer
shifts were due to mandatory or voluntary overtimes as opposed to formal
12-hour shifts. Their study confirmed previous studies that there is a
relationship between any overtime and adverse effects on nurses. However, they
were able to demonstrate that both shift length and overtime had independent
effects on the variables studied.
The authors address the seeming paradox that previous studies showed nurses preferred 12-hour shifts and their finding of higher burnout rates and job dissatisfaction.
Their findings are most relevant in that they suggest current strategies of using 12-hour shifts to help retain nursing staff may, in fact, be counterproductive in the long run and lead to more nurse absenteeism and job turnover.
But there are
questions left unanswered by this and all previous studies. The Dall ‘Ora study,
like the Griffiths study before it, 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.
A recent UK review
of 12-hour shifts (Ball
2015) first looked at the published literature on 12-hour shifts and found
many studies were plagued by small sample sizes, limited outcome measures, poor
response rates, self-reporting bias, etc. Importantly, they found no randomized
controlled trials. They conclude that, in
general, most of the studies appear to show some degree of negativity, either
for nurses, patients, or both towards 12-hour shifts and that many of the
adverse outcomes studies relate to fatigue which can also jeopardize patient
safety.
They also found from
survey data that 66% of nurses in the UK working in care homes worked 12-hour
shifts compared to 50% of NHS hospital nurses and 39% of independent hospital
nurses. They also found that those working 12-hour shifts report that they are
equally or more satisfied with their working hours than nurses working shorter
shifts. They then included data from the RNCAST consortium. The odds of
self-reported poor quality care was 1.64 times higher for nurses working a
12-hour or longer shift compared to those working eight hours or less and a
similar pattern of findings was apparent for safety ratings, though the latter
did not reach statistical significance. The risk of care left undone was 1.13
times higher for nurses working a 12-hour or longer shift compared to those
working eight hours or less and was statistically significant. And, when taking
the other predictor variables into account, the odds of being dissatisfied with
their jobs were 1.51 times higher for nurses working on shifts of 12 hours or
longer compared to those work eight hours or less. Somewhat paradoxically,
there was no clear pattern of variation in work schedule dissatisfaction with
length of shift:
Most interesting in an article about a conference that noted some negative union views about 12-hour shifts in the UK (Merrifield 2015) were the comments posted on the website that really reflect the polarized views of nurses toward these shifts. Many love them, many hate them!
If the 12-hour shift
is actually worsening job satisfaction and leading to increased nursing
turnover as the Dall‘Ora study would suggest, we may be exacerbating the
shortage of nurses many countries already face. Because the 12-hour shift has
become so popular in the US and other countries, 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. The
many problems encountered in trying to do such a study were recently noted in a
pilot study intended to do such a comparison of 8-hour vs. 12-hour shifts (Martin 2015).
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 and measures of nurse
well-being. 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 as well as for considerations about nurses’ well-being and the future of the nursing workforce. 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.
And speaking about 12-hour shifts, if you haven’t yet done so read the book “The Shift” by Theresa Brown (Brown 2015). It’s a real-life story about a nurse’s 12-hour shift on an oncology unit. We’ll probably formally review it at some point but it’s great reading and lets you visualize so many of the issues we talk about in our columns.
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”
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”
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”
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”
January 2015 “More
Data on Effect of Resident Workhour Restrictions”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
References:
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
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
Ball J, Maben J, Murrells T, Day T, Griffiths P. 12‐hour shifts: Prevalence, views and impact. National Nursing Research Unit, King’s College London. June 2015
http://www.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/06/12-hour-shifts-report.pdf
Merrifield N. Conference told that repeated 12-hour shifts are same as 'slave labour'. NursingTimes.net 2015; 16 April, 2015
Martin DM. Nurse Fatigue and Shift Length: A Pilot Study. Nurs Econ 2015; 33(2): 81-87
http://www.medscape.com/viewarticle/843884
Brown T. The Shift: One Nurse, Twelve Hours, Four Patients' Lives. Algonquin Books 2015
http://www.theresabrownrn.com/books/
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