I have been a staff nurse in the emergency room for fourteen years. I have worked a variety of 8, 10, 12, and even 16 hour shifts. I currently am working 8 and 12-hour shifts on nights. Previously, I also worked some 12-hour day shifts. I personally have been struggling with working the 12-hour shifts. My commute to work is 1 hour one way and I have fallen asleep several times driving home from work. The last four hours of my shift I experience great fatigue and even have had trouble staying awake. I have come close to having medication errors and feel that my quality of care is less during the last four hours.
When working 12-hour shifts I average around 5-6 hours of sleep before returning to do another 12-hour shift. During an interview with another colleague also working 12-hour shifts she states she also experiences feeling very tired and less alert. She actually admits to having a medication error that she feels was associated with the long hours and fatigue. With these concerns I ask, “Are nurses work hours a concern for nurses and patient safety”? Introduction As demands for flexible work hours and a balance between home and work life have increased for nurses, twelve hour shifts are more common.
The nursing shortage has also contributed to nurses’ working longer hours to cover shifts. Nurses must remain alert to provide safe care and prevent errors in medications and procedures. Nurse work hours are a concern to me regarding patient safety. I am also concerned with the health risk of nurses working long hours so I decided to do a search on how long hours affect nurses and their patients. I searched evidenced based research articles available from a variety of trustworthy healthcare sites like CINHAL, ANA, and Nursing Journals. I organized this literature review in three categories.
These categories are: Positive and negative effects of long hours, effects of long hours on patient safety, and if there are any health effects on the nurse working 12-hour shifts. Literature Review Positive and Negative Effects of Long Hours There are both advantages and disadvantages of working 12 hour shifts (Ede, Davis, & Sirois, Circadian, 2007). One advantage is working less days during the week, which is desirable of most nurses. It is also easier to have all the shifts covered because you do not have to hire as many nurses (Circadian, 2007).
In a qualitative study by Richardson, Turnock, Harris, Finley, & Carson (2007) the purpose was to examine the impact and implications of 12-hour shifts on critical care staff. Two groups and questionnaires with critical care staff from three critical care units were reviewed. Positive effects were found with planning and prioritizing care, improved relationships with parents/relatives, good quality time off work and ease of travelling to work. Less favorable effects were with caring for patients in isolation and the impact on staff motivation and tiredness.
Acceptable patterns of work were suggested like no more than 2-3 consecutive shifts should be worked and rest periods between shifts. The survey concluded that most of the nurses that responded wanted to continue with 12-hour shifts. Systems and practices need to be developed to improve on the negative effects of working 12-hour shifts. In one of my interviews the nurse agreed that she enjoys 12-hour shifts because she has more days off during the week and feels she has more time with her family, although I personally disagree.
She also states it is easier to provide day care for her children. Disadvantages of longer work hours according to Circadian (2007) included that it is harder to cover
I have no time with my family on the days I work 12 hours. Even though I have more days off I feel I am spending at least one day recovering after working a long shift. I personally would rather have interaction with my family daily especially since the kids are in school. A colleague I interviewed also agreed that when working 12 hour shifts she had limited time with her family. Effects on Long Hours on Patient Safety As a result of nursing shortage hospital staff nurses are working longer hours with few breaks (Chen et al. 2011). In one quantitative study by Scott, Rogers, Hwang, & Zhang (2006) they randomly selected 1148 critical care nurses and sent them a demographical questionnaire to fill and return related to medical errors and the hours they worked. The objective of this article was to describe the work patterns of critical care nurses, determine if there was a relationship between the occurrence of errors and the hours worked by the nurses, and explore whether these work hours had adverse effects on nurses’ vigilance.
The 502 respondents consistently worked longer than scheduled and for extended periods. Longer work duration increased the risk errors and near risk errors and decreased nurses’ vigilance. The findings supported the Institute of Medicine recommendations to minimize the use of 12 hour shifts and to limit nurses’ work hours to no more than 12 consecutive hours during a 24 hour period (IOM, 2006). Although the findings note that 12 hour shifts can have negative effects, most participants wanted to continue working them. Nurses are responsible for the safety of their patients.
Nurses must remain alert to provide safe care, recognize discrete changes in patient conditions, and intercept potentially dangerous errors in medication and procedural orders (Keller, 2009). Nurses’ work hours are a concern given the expectation of their sustained vigilance to maintain the well-being of patients. The 12 hour shifts worked by many nurses are associated with reduced sleep times, difficulties staying awake, frequent overtime, and significant risk for error (Rogers, Hwang, Scott, Aiken & Dings, 2004)( Scott, Rogers, Hwang, & Zhang, 2006).
Even though 12 hour shifts may be preferred by many nurses, studies indicate that extended shifts worked by hospital staff nurses are associated with higher risk of errors. Long hours coupled with insufficient sleep and fatigue is even risker (Scott et al, 2010). More than two-thirds of 895 hospital staff nurses reported “struggling to stay awake on duty” at least once during a 28-day data gathering period (Rogers, Hwang, Scott, & Dinges, 2003). Nurses reported fighting sleep about once every five shifts (2,258 out of 11,218 shifts).
Drowsiness was not confined to the night shift; more than half of these episodes occurred between 6 A. M. and midnight. Nurses who reported shorter sleep durations were more likely to struggle to stay awake, fall asleep, and make errors while on duty (Scott et al, 2010). Effects on Nurses Working Long Hours Studies examing the health and safety consequences of nurses themselves are beginning to shed some doubt about the wisdom of continuing to use the twelve hour work schedule.
According to one study, adverse health and safety outcomes of extended work hours include increased rates of musculoskeletal disorders, needlestick injuries, motor vehicle accidents, and inadequate sleep (Greiger-Brown, & Trinkoff, 2010). All of these can be attributed to reduced vigilant attention, fatigue, and decreased neuromuscular fine motor control associated with sleep deficiency. In an interview with one colleague she states that her body, “hurts all over”, when working a twelve our shift. I have fallen asleep driving before which could of resulted in injury of myself or someone else.
Lengthening of the shift duration from 8 to 12 hours significantly restricts the opportunity for sleep and produces sleep deficiency (Smith et al. , 1998). Working without adequate sleep between shifts can lead to negative chronic health effects including Cardiovascular Disease, metabolic syndrome, diabetes, obesity, decreased immune function, and increased cancer risk (IOM, 2006). In a quantitative study by Chen, Davis, Pan, & Daraiseh (2011) a total 145 nurses wore monitors for one 12-hour day shift to record heart rate (HR) and work pace(WP), which were used to calculate energy expenditure(EE).
The purpose of this study was to determine whether hospital nurses are experiencing physiological strain at work by examining their physiological and behavioral response patterns over 12-hour shifts. The EE and HR data presented in the study revealed a moderate physiological strain experienced by 12-hour shift nurses, regardless of their slowed paces during the last four hours. The study noted that although work pace slowed during the last 4 hours, the nurses’ heart rate continued to be elevated, which could lead to cardiovascular disorder.
Moreover, inadequate work break and sleep, family care-giving responsibility and aging presented challenges that may have prohibited nurses from full recovery and potentially exacerbated the negative impacts of the 12 –hour shifts. Overall their results relates to EE and HR suggest that nursing workload of 12-hour has a negative physiological impact on nurses. Policy Implications Although there are negative effects noted in working twelve hour shifts, I don’t think it is going anywhere due to the fact that nurses love them, and the increase in nursing shortage.
Keeping this in mind instead of focusing on stopping twelve hour shifts, there needs to be interventions on how to improve the 12 hour shifts to provide safer patient care and prevent health problems in nurses. The preliminary policy implications I have discovered is the possibility of limiting how many twelve hour shifts a nurse should work in a row, mandating breaks while working twelve hour shifts, allowing the night shift to nap, regulate how many hours a nurse can volunteer to work, and allow the older nurses to have an option between 8 and 12-hour shifts.
In my institution there is no limit on how many hours a nurse can voluntarily sign up for as long as it is approved if it puts the nurse in overtime. Our breaks are not mandated, if we get one great, and if not we can get paid for not getting a break. Most of the time, our breaks are interrupted. Regarding naps, physicians on the night shift are allowed to sleep if there are no patients, but there is no policy stating the nurse can sleep. Some nurses actually work 24 hour shifts, but are allowed to sleep at night if they are not busy.
There are times though that they are busy the whole 24 hours. In one interview a nurse stated that if she lays her head down and naps for about 20 minutes she feels much more alert. I have also tried taking a nap at work when there were no patients in the ER, and I did feel so much more alert, especially driving home. It is therefore wise to consider limiting shift length and hours worked per week per IOM recommendations. After reviewing the literature it is clear that the main problem is nurses not getting enough sleep between shifts which causes fatigue.
In a study of nurses’ sleep habits, Geiger-Brown (2010) found that 58 percent averaged only 5. 5 hours of sleep. When they work three or four 12-plus hours a day, they are also unable to easily reestablish a “consistent sleep schedule”. In one research article it noted that allowing the nurses to nap, especially the night nurses showed improvement in alertness and feeling less fatigued and ultimately showed a reduction in errors or near errors (Fallis, McMillan, Edwards, 2011). It also noted that anagement needs consider to mandating that the 12 hour plus nurses are taking full uninterrupted breaks which also improves alertness. Most nurses are not taking full breaks and stay longer than the scheduled 12 hours which reduces their sleep and recovery time between shifts (Greiger-Brown, & Trinkoff, 2010). In a recent review of studies between 1970 and 1998, 12 hour shifts nurses were fatigued in 5 of 7 studies, and of 10 studies measuring performance, 4 were negative, and 6 were neutral; none showed positive effects.
In this review, laboratory studies showed deteriorated performance; but field studies found no difference between 8 and 12 hours. Recent studies with stronger designs and methods have increased the evidence that questions the safety of 12-hour shifts. More recent studies as mentioned earlier demonstrate an increase in patient care errors when nurses work 12 hour shifts compared to 8 hours. The research question that has been uncovered related to nurses’ long work hours is if the long hours affect the health of the nurse and patient safety?
In my institution other colleagues have stated that they feel that when working 12 hours or longer more than two days in a row really decreases their quality of care because they are tired. I feel more studies need to be done on the impact of working hours and the nurses’ health along with more evidence regarding patient safety. One ethical implication researching effects of 12-hour shifts is that the managers do not want to take away 12-hour shifts due to nursing shortage because they do not have to hire as many nurses to cover shifts.
Another issue is that most nurses enjoy the twelve hour shifts even though they know they become really tired because they enjoy having more days off during the week. Managers may fear that nurses will leave to find jobs that offer 12-hour shifts. I feel this is ethically a problem with colleagues and coalitions because they are not looking at the negative effects on the nurses and the patients. With research it has become obvious that working longer hours can effect both the health of the nurse and safety of the patients yet our facility along with many others have not come up with adequate resolutions to the problem.
Conclusion Twelve hour shifts contribute to flexible patterns of work, but the effects of delivery of direct care and staff fatigue are important topics for deeper examination. More recent studies as mentioned earlier demonstrate an increase in patient care errors when nurses work 12 hour shifts compared to 8 hours. Although 12 hour shifts are popular, evidence shows us that extended working hours, and working while fatigued and sleep deprived reduce vigilance and impair physical/behavioral functioning. The result has damaging effects on patient safety, quality of care provided and the health of the nurse.
I believe it is the responsibility of the nurse to recognize the risks of working longer hours to keep the patient safe and to also maintain their own health. I used the Patterns of Knowing (White, 1995) to view my topic and to gather information on this literature review. These patterns of knowing in nursing include empirics, esthetics, ethics, and personal knowing (White, 1995). I used empirics by gathering factual information regarding my topic. I discussed issues in regards to ethics on my topic that was mentioned in chapter 3.
I included my personal knowledge and experience with working longer shift hours, and also looked at the esthetic form by putting it all together and acknowledging what the problem is. Doing this literature review I realize that working the longer hours does put a strain on my overall health, and also has potential to put my patients at risk. I will focus more on getting better sleep, and I have asked my manager about working only 8 hour shifts. I also really want to pursue gathering more information about night nurses being able to nap.