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    Reconsidering the 12-hour shift for nurses

    Hospitals, nurses enjoy the flexibility of the 12-hour shift, but patient safety remains a concern

    The 12-hour shift has become the standard in most hospitals and while nurses value the flexibility this scheduling offers, new data has revealed that longer work hours are damaging to both patients and healthcare workers.

    “Many hospitals have adopted 12-hour shifts as the norm and it is a similar choice among nurses who want to limit the number of days they work in a week, but research on the 12-hour shift and its relationship to patient safety needs further review,” says Theresa V. Arnold, DPM, manager, clinical analysis for the Pennsylvania Patient Safety Authority (PPSA).

    A new report from the PPSA highlights the risk of healthcare worker fatigue. The study, which collected data submitted through the Pennsylvania Patient Safety Reporting System, revealed that 1,600 incidents or near misses that didn’t end in harm to the patient were reported between June 2004 and August 2013. Overall, 88.5% of the incidents were reported as resulting, at least in part, from healthcare worker fatigue. Thirty-seven of the incidents reported resulted in serious harm, including four that ended in the death of the patient. The top five locations where adverse events were reported were the medical-surgical unit, emergency department, pharmacy, general medical ward, and the laboratory.

     “The most common medication errors made involving healthcare worker fatigue were wrong dose given, dose omission, and extra dose given,” Arnold says. “The most common errors related to a procedure, treatment or test were laboratory errors, and other miscellaneous errors included radiology or imaging problems and surgical invasive procedure problems.”

    Errors involving medications made up 62% of the reported incidents. Medication errors occurred most often in the medical-surgical unit, pharmacy, general medical ward, and emergency department. Procedures, treatments or tests made up another quarter of all incidents reported with worker fatigue listed as a contributing factor, according to PPSA.

    The report includes an anecdote of a case in Wisconsin in 2006 in which an RN was charged with a felony after mistakenly giving a patient epidural medication through an IV line instead of the prescribed antibiotic. The nurse had worked two consecutive eight-hour shifts ending at midnight immediately prior to the incident, and was schedule to work another eight-hour shift beginning the following morning at 7 a.m.

    While nurses admit working longer hours can be difficult, especially overnight hours that inhibit the body’s natural rhythm, data suggests the impact goes beyond simple tiredness. Studies have shown 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%, says PPAS.

    “In studies conducted with nurses, it was shown that working a 12-hour work shift or working overtime is associated with difficulties staying awake while on duty, reduced sleep times, and nearly triple the risk of making an error,” Arnold says. “The most significant error risk observed was when nurses worked 12.5 hours or longer.”

    A study published in Health Affairs in November 2012 by researchers from the University of Pennsylvania School of Nursing also found that as the proportion of nurses who worked more than 13 hours increased, patient satisfaction decreased.

    But reducing shift lengths won’t be an easy feat to accomplish. Hospital executives value longer shifts for the ease of scheduling they offer, and they believe offering 12-hour shifts help recruit and retain nurses who value a short work week.

    The Health Affairs study found that 80% of nurses surveyed were happy with the scheduling practices at their hospital. Yet while scheduling less shifts with longer hours might seem appealing, in the long run the study found that nurses two worked shifts of 10 hours or more were more likely to experience burnout, job dissatisfaction and leave nursing compared to nurses who worked shorter shifts.

    “Nurses underestimate the impact of working long shifts because the idea of working three days a week instead of five seems appealing,” the report notes, explaining that while nurses like the idea of longer shifts, the impact catches up to them over long stretches of time.

    But a simple reduction in shift length may not solve the problems of worker fatigue, either.

    “Recent literature shows that one of the first efforts made to reduce events related to fatigue was targeted to limiting the hours worked,” Arnold says. “However, further study suggests a more comprehensive approach is needed, as simply reducing hours does not address fatigue that is caused by disruption in sleep and extended work hours.”

    Initial efforts in addressing fatigue have been through implementation of hours-of-service standards, such as those implemented for residents in training. These alone have not been successful, as they do not address the two major causes of fatigue, which are disruption of circadian rhythm sleep and sleep deprivation. Hours-of-service programs address how much work is performed but may not take into account what time of day the work is done and for how many consecutive days.

    The Health Affairs report notes that there are already voluntary recommendations that nurses limit their work hours to no more than 60-hour weeks or 16 hours in a 24-hour period. In 2004, the Institute of Medicine recommended that state regulators prohibit nurses from working more than 12 hours in a 24-hour period, and over 60 hours in a seven-day period. These recommendations apply to any combination of scheduled shifts and mandatory or voluntary overtime. Some states are also prohibiting mandatory overtime, but even voluntary overtime can cause problems. PPAS’ report reveals that fatigued workers may not make the best judgment on his or her ability to work safely.

    Moving away from 12-hour shifts would result in a huge culture change for hospitals, Arnold adds, and would require evidence-based data to support such a change.

    The American Nurses Association (ANA) recommends that nurses who work 12-hour shift be allowed to leave on time at the end of their shifts instead of staying over for staff meetings or educational requirements. ANA also urges hospitals to offer support to nurses in a position to experience fatigue by offering breaks away from patients during their shifts. Creating a culture that doesn’t discriminate against nurses who refuse overtime is also important, ANA notes, adding that part-time nurses can help units meet staffing goals without burdening full-time nurses at risk for burnout.

    Rachael Zimlich, RN
    Ms Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and ...

    11 Comments

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    • MarshaMoore
      I have been a night shift nurse, actually a night person, for many years. I have been a traveler for 12+ years. I do well with 12 hour shifts, and I usually have to have my shifts 3 in a row as I often drive 2 1/2 hours to get to my job, then stay in a motel a couple of days to complete my week. The biggest problems I see with fatigue and burnout are related to staffing and politics. If the staff is overwhelmingly negative about the facility and their policies, it creates a bad work environment and people are less likely to work together--toxic in an ICU. Hospitals have taken away ancillary staff at night. It's common to take out your own trash and linens. We put in orders because doctors who are supposed to be putting in their own now still do not. We draw our own labs. We have no techs any more to assist with baths, vitals, and blood sugars. It is increasingly common to have 3 critical patients in ICU, setting us up to work in great jeopardy every time we work. When our neighbor goes on break, we're covering their 3 as well as our own 3. The acuity is so much higher, there is more technical equipment than ever. Many ICUs are allowing family to come and go at any hour so we are forced to police them as well. Then there is administration that thinks nothing of calling you at 11 AM to tell you to come do something (the equivalent of the middle of your night). It has always been a given most places that you're given the worst assignments "because you make so much more than we do". I have found that the best way to deal with all this is to go do something else periodically so that I can continue to love what I do and do it cheerfully. Ths best advice I can give to other nurses, especially newer ones, is to get another skill that you enjoy that pays well as a backup. The modern landscape for nursing isn't likely to get any better with more government involvement in healthcare. They have NEVER run anything efficiently.
    • JonathonBlair
      Studies show that 'night' nurses are not as impacted with the 12 hour shift as 'day' nurses. This being due to the increased workload and lack of breaks daytime nurses face. The problem is most nurses, day or night shift, want to work 12 hours so the have more time off. But studies also show that the recovery for nurses working 12 hours is more than twice as long for nurses working 8 hours. So even on days off nurses feel fatigued which is less common with 8 hour shift nurses. Geiger-Brown, J., & Trinkoff, A. (2010a). Is it time to pull the plug on 12-hour shifts? Part 1. The evidence. Journal of Nursing Administration, 40(3), 100-102. Josten, E., Ng-A-Tham, J., & Thierry, H. (2003). The effects of extended workdays on fatigue, health, performance and satisfaction in nursing. Journal of Advanced Nursing, 44(6), 643-652.
    • ZachStanford
      I have been an ICU and ER/Trauma nurse for the past 17 years. The bulk of that time have been working 12 night shift. The article seems to be focused on one factor of fatigue but doesn't seem to address other contributing factors. Factors such as short staffing or reducing the amount of ancillary staff available. During my night shift in level 2 trauma/emergency department we loose lab, transport, and half of our EMTs and our registration staff is cut in half. The reduction in available recourse and support for me plays a much bigger role in my fatigue. Other factors not apparent in the article is the common practice (at least in the California Bay Area) of working multiple jobs. I work with many nurses who do this or they are an only parent and are trying to be the provider (working nights) and be the caregiver during the days. With these nurses they either have less than 8 hours rest in between shifts, or they have no days off - either way is exhausting. I am in favor of 12 hour shifts. I currently have the flexibility to work my commitment in a row. Doing this not only gives me the benefit of having several days in a row off but allows me to completely switch my sleep patterns. I have found that working my schedule like this I am more alert and have more energy for when that code 3 medical or trauma pt comes in at the tail end of my shift. Unfortunately the ICU manager has taken articles like this as gospel truth and has severely limited the scheduling abilities of his staff. Doing this has driven staff away (have spoken to staff before they've resigned) and left posted openings unfilled (current posting has been up for over 6 months). It also appears to have increased sick calls for that unit (during my shifts there has always been 1 or 2 sick calls that restrict how many pts we can admit to ICU forcing ER to hold pts) All too often it feels like when a problem is identified a "solution" is applied to EVERYONE instead of addressing the problem specifically. Fatigue is a real problem but it shouldn't be solved by taking away nurses freedom to have a schedule that works well for their lifestyle. However attention should first be looked at expectations placed on nurses and how realistic they are. For us in the ER EVERYTHING is time stamped and resources that are available during the day is NOT available at night with our skeleton crew and yet we are held to the same standard with a very similar pt load/acuity.
    • KarenAyers
      I have worked full time nights for 40 years and planned on going at least another 10. Loved my career choice and had no signs of burnout until 3 years ago when our facility brought in Wellspring management group to save a dollar and we went to 8 hour shifts. We are now laughing at the huge amount of overtime wages being spent because they can't staff the units. I used to work 6 nights on and 8 nights off with a wonderful work/life balance. Having 8 nights off gave me a chance to travel, spend quality time with my family and most importantly, gave me time to DETOX from the emergency night shift toxic environment and get well rested. Since being forced into 8 hour shifts, with only one night off in a row, I am consistently exhausted, totally burned out and will leave this profession as soon as I can. I am much more prone to and probably making more mistakes than ever before. I don't go to near as many conferences or continuing education classes because I can't stand the thought of wasting my precious one night off doing anything that is remotely related to health care. I now am a couple of years behind in journals with no thought to reading them. The BSN I had started will never be finished. My physical health has suffered as all I feel like doing is falling into bed, exhausted and disheartened. We are frequently short staffed since it takes many more RN's to work an 8 hour matrix vs 12 hours. We lost a large majority of our skilled nurses who left for the facilities that still had 12 hour shifts and now are hiring new grads with no experience or nurses with poor skills who were let go from everywhere else. I am working with nurses that now work a shift at another hospital then come over to ours to work the next shift, they are already tired so you know the attitudes they bring with them. I will be the first to admit that 12 hour shifts aren't for everyone but for the night shift, it makes sense, especially for those of us who have done it for our entire careers with great success. I would be willing to bet that a lot of the studies done regarding 12 hour shifts were done by researchers who haven't lived this lifestyle. Our patient satisfaction scores plummeted with the institution of 8 hour shifts along with the good nurses passion, and morale. Bring back the 12's and let healthcare be controlled by health care providers, not bean counters.
    • Anonymous
      I have worked 12 hr shifts since the 80's and will stop working if it goes back to 8's. I do not want to tie up that many days a week. I have always worked in the ED. The errors I see are not from exhaustion but from understaffing or being screamed at to move faster. Faster care does not mean better care. I refuse overtime unless it is an extremely urgent matter for the department and I also refuse to work 3 in a row. I also see to many nurses working too many different jobs. More staffing is the answer- not less hours. And shorter shifts also wouldn't make people go to bed sooner. Some people just aren't smart about their personal care and nothing we instate will make them smart.
    • Mr. DNurse1
      I am probably an outlier here because I like 12 hour shifts but also recognize they impact the rest of my day so I plan accordingly. Over 25 years, I have worked mostly 12 hour nights and I arrange my sleep wake schedule accordingly. Many nurses have both complex family issues and erratic schedules that complicate maintaining a regular sleep wake cycle which, I believe, promotes a safer work shift. It would seem that staff and facilities managers would collaborate to provide schedule options that meet the needs of their staff and clients more appropriately. Ultimately, I believe it remains the individual's responsibility to be appropriately prepared for their work (and their life) so maintaining a reasonable sleep/ wake cycle should be part of that preparation. I do not subscribe to the napping during your shift option as I see it as a means of administration further dividing nursing and, I hope we agree, this is not a good track. I am sure the wealth of knowledge and experience planning their shift and their lives in the nursing community can provide an excellent source of ideas. It may be premature to offer possible solutions without 'studying' the problem, however I believe that both can occur simultaneously and this may provide safer patient and staff environments more rapidly while the study first, try the proposed solution, revise the study, try the revised plan....model is in progress. In my opinion, driving tired/ working tired, driving impaired/ working impaired have a similar effect. Physicians encountered a similar issue many years ago leading to stimulant addiction by many new physicians and now the residents have limits on their work time. There is data among the impaired nurse group that may provide some insight to the sleep/ working impaired issue. Utilizing the experience of other health care professionals, and even other industries like over the road driving, mining, air travel can aid the progress toward the important goal of a safe work environment and a manageable sleep/ wake schedule for nurses
    • Ms. maxarmstrong
      I've worked 8, 10 and 12 hour shifts. I've never left on time working 8s or 10s, and often working at least 30 minutes over 12s. That's just how much work there is to do. Safety measures, like the electronic MAR and Pyxis have eliminated many errors. Perhaps there should by some more safety measures on theses? Also, on busy units, I often work with no breaks for the first 8 hours, breaks should be mandatory and scheduled, not if and when you can. Many travel nurses only work stacked 12s (3 in a row), eliminating them would limit how many nurses willing to work those units.
    • Anonymous
      I am so glad this issue is finally being publicly addressed, although why it takes a lengthy study to prove what should be obvious to everyone seems ridiculous. Of course nurses who work such long hours are beyond fatigued and prone to errors and burnout. Especially with back to back 12 hour shifts, where nurses rarely get off on time, and yet are still expected to stay late or come in early for staff meetings, in-services, etc. Think about it-let's consider a night shift nurse who is supposed to be off by 7:15 am and actually doesn't leave until 8:30 or later. This is typical. She probably has on average a half hour drive home, so this gets her home around 9 am or so, and she is utterly exhausted after a stressful 12 hours of hard work on her feet. After a shower (yes, you NEED one) and wolfing down some sort of meal, it is 10 am or later. Assuming she has nothing she must do before going to bed, which is rarely the case, she might get in bed by then. This allows for NO time to relax and wind down. From what I have heard from most nurses over the years, the average time to get to bed is around 11 am. So our nurse gets to bed at 11 am. If she falls asleep immediately, (also unlikely) she will get 6 hours of sleep before she must get up at 5pm to do it all over again. Does that sound like adequate rest for performing such demanding and stressful work? In my opinion, hospitals should offer both 8 and 12 hour shifts and let nurses mix and match what hours work best for them individually. Gaps can easily be filled by a healthy float pool of relief nurses. Yes, it costs more money, but isn't patient and nurse safety and satisfaction worth it? It also must be pointed out that providing adequate support staff, manageable nurse : patient ratios, and making fair assignments with patient acuity considered is essential for a safe environment. I have been in many a situation where the workload I was expected to handle was simply impossible. And this with only a half hour break in a 12 hour shift, which I rarely actually got, but was always deducted from my pay. This was at a hospital in Georgia. I finally had enough and began travel nursing. My first assignment was at a hospital in Arizona that does work to ensure that nurses are not over stressed. I felt like I was the best nurse I have ever been and for the first time in a long while truly enjoyed my work. This hospital has patient satisfaction scores in the high 90's. No mystery there. Now, is it going to take another 9 year study to prove that unreasonable workload expectations result in errors and burnout, so that in the meantime hospitals can continue to get away with overworking their staff? Probably. We can only hope that eventually these study results will compel hospitals to do the right thing.
    • Mrs. SCusson
      I am so sorry, but 12 hour shifts should not be a matter of convenience, it should be a matter of patient safety. I worked 12 hour night shifts and not only is it not safe to work a 12 hour shift, but on a very busy night it can actually get dangerous for patients. This is the real world we live in and 8 hour shifts are easier on our bodies. I also think nurses get burned out much faster. It is not good for a family life. I know nurses who would only sleep 4 hours and be back for another 12 hours. Is this a safe practice? I think not! Not for the nurse and not for the patient. Evidence based studies prove this. I am all for the return of 8 hour shift. My patient came first not my schedule. I actually worked 24 hours when I needed the time with the family. We cannot have it all, but we took an oath when we became nurses. We have a responsibility to the public and I vote for return of the 8 hour shifts.
    • Anonymous
      I would not want to work as a nurse if I had to do 8hr shifts. I love my 12hrs as it gives me so much MORE family/rest time every week. I have actually worked places that employ both 8 and 12 hr nurses. The 8 hr nurses are usually the ones that work because they have to, not because they love what they do. THEY were the ones making errors. They were not invested in the care they gave. I have seen more errors made due to poor staffing or more emphasis from management on making families happy than giving care to patients. There are days I am VERY fatigued from trying to be a maid, hostess, waitress for families and small children than from caring for patients. Another thing that should be looked at for mistakes is how the shifts are scheduled. Working 3 on 1 off 4 on can wear some down, while others do best with that. Some prefer 6 in a row and a long stretch off (Im one of those) but that might do another nurse in. I hate it when someone has to point a finger at only one thing as cause/effect. There are many things that cause errors including being more worried about getting back to your cell phone texting. At least look at more than a 12hr shift.
    • CandaceDelano
      I agree fully with Anonymous. I have worked 12 hour shifts and really enjoyed them but I am sure to be scheduled 2 in a row and then 1 off then the 3rd. I work in the OR and we only work m-f in most hospitals as I am a traveler. 10 hour shifts are also great. Before I retired to go traveling I worked 22 years on 10 hour shifts. The last 12 years I had wednesdays off. 2 on, 1 off, 2 on. Once I had been scheduled my 12 hour shift as 3 in a row and that was too much. It also depends on patient load. Luckily, in the OR our patient ratio is 1:1. Some cases are long and some are quick. Call is a major problem for fatigue when you work your 12, 10 or 8 hour shift and then are on call from the end of your shift until 0700 the next morning. Even if you don't get called in, your sleep is not restful because you have getting called in on your mind. Call should be limited to 4 hours at a time. Some hospitals have gone to this type of call schedule. Luckily, we don't have to deal with medical errors very often. It requires the scrub nurse and circulating nurse to visualize any drug placed on the sterile field and repeat drug and dose aloud to each other after verifying verbally with the surgeon. I would not want to work on any floor. Been in the OR for 36 years. Five months of med-surg was five months too long for me.