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”
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
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
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
https://onlinelibrary.wiley.com/doi/abs/10.1111/jonm.12643
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
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