Patient Safety Tip of the Week

September 4, 2018

The 12-Hour Nursing Shift: Another Nail in the Coffin



For several years we’ve struggled with the conundrum of the 12-hour nursing shift. On the “pro” side there are fewer handoffs, many nurses like the flexibility of work hours and longer periods of off-time, and nurse administrators often like the flexibility it offers in scheduling.


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.


In our July 11, 2017 Patient Safety Tip of the Week  The 12-Hour Shift Takes More Hits” we discussed a study by Ball and colleagues (Ball 2017a), using survey data from the RN4CAST study, which showed the odds of poor quality care were 1.64 times higher for nurses working ≥12 hours. And rate of “care left undone” 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.


Many of the previous studies relating shift length to nurses’ health have relied upon survey responses or other subjective data. Recently, however, researchers were able to analyze objective data relating sickness absence and shift duration for registered nurses and health care assistants (Dall’Ora  2018). Results were striking: when more than 75% of shifts worked in the previous 7 days were 12 hours in length, the odds of both a short‐term and long‐term sickness episode were increased compared with working none (respective adjusted odds ratios 1.28 and 1.22). Occasional shifts of 12 hours or more (<25%) in the past 7 days were not significantly associated with more sickness absence. But when staff worked a higher proportion of shifts of 12 hours or more, sickness rates increased, with the highest odds for those working more than three quarters of their shifts as 12 hours or more shifts. The authors conclude that routine implementation of long shifts should be avoided.


The scales have been progressively tipping against the use of the 12-hour nursing shift. The downsides on both patient care and the personal health of our valued staff now appear to negate any perceived value of more flexibility.


The current Dall’Ora study certainly dampens some of the enthusiasm generated by earlier studies. A study done in New York City hospitals (Stone 2006) showed that nurses working 12-hour shifts were more satisfied with their jobs, had less emotional exhaustion, and less absenteeism than nurses working 8-hour shifts, all without impacting patient outcomes. One key element to worker satisfaction with 12-hour shifts seems to be how the change was developed and implemented. Where workers had a voice in developing the system, rather than having it imposed on them, satisfaction levels are much higher. But most subsequent studies have tended to show less satisfaction, more burnout, and more absenteeism with the longer shifts.


In our July 11, 2017 Patient Safety Tip of the Week  The 12-Hour Shift Takes More Hits” we even questioned the value of the other “pro” argument for 12-hour shifts: fewer handoffs. Quite frankly, we don’t know if handoffs are 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.


Unfortunately, nursing shortages are one of the drivers of use of longer shifts. We’ve speculated that longer shifts due to “mandatory” overtime may be even more detrimental to patient care and nurses’ personal health. And we’ve made strong arguments that factors other than shift length are extremely important. While nurse:patient staffing ratios are important, we made the argument in our May 29, 2018 Patient Safety Tip of the Week “More on Nursing Workload and Patient Safety” that nursing workload may not be adequately reflected in those ratios and that nursing workload is probably a much more important factor influencing both patient care and nurses’ personal health.


We doubt the debate will end here. But the new study by Dall’Ora and colleagues (Dall’Ora  2018) should make healthcare organizations take an even more critical look at their approaches to scheduling nursing shifts.




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

July 11, 2017              The 12-Hour Shift Takes More Hits

May 29, 2018              More on Nursing Workload and Patient Safety







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



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



Ball JE. Nurse Staffing Levels, Care Left Undone, & Patient Mortality in Acute Hospitals. Karolinska Institutet; Stockholm 2017



Dall’Ora C, Ball J, Redfern O, et al. Are long nursing shifts on hospital wards associated with sickness absence? A longitudinal retrospective observational study. J Nursing Management 2018; 5 July 2018



Stone PW. Du Y, Cowell R, et al. Comparison of Nurse, System and Quality Patient Care Outcomes in 8-Hour and 12-Hour Shifts. Medical Care 2006; 44(12): 1099-1106,_System_and_Quality_Patient.7.aspx





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