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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000414310.10965.f4
AJN Reports

Long Work Hours for Nurses

Nelson, Roxanne

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Abstract

Are 12-hour shifts here to stay, despite evidence against them?

With 12-hour shifts largely replacing the eight-hour day, most nurses would agree that long hours are a way of life in the profession, especially in the hospital setting. Employers like them because they eliminate the need to staff an evening shift, and many nurses enjoy having more days off per week, even if it means a longer workday. And at least one school has created a program that makes use of 12-hour clinical shifts to help students experience a “real world” schedule. (For more on this program, see “Trying On the 12-Hour Shift,” at http://links.lww.com/AJN/A42.)

But is working 12 consecutive hours in a high-stress setting that's physically, mentally, and emotionally demanding a good idea? And should we be helping students to get used to the idea earlier despite the evidence that long hours affect patient safety and nursing judgment?

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WHAT THE EVIDENCE HAS TO SAY

A growing body of research shows that nurses working 12-hour shifts are more fatigued and at greater risk for making errors, according to Geiger-Brown and Trinkoff, who reviewed evidence that challenges the current scheduling standards in the March 2010 issue of the Journal of Nursing Administration. The article also found that nurses’ performance is adversely affected by long hours, and the odds of a needlestick injury are significantly increased.

The link between extended work hours and worker fatigue, reduced productivity, and compromised patient and personal safety is particularly well documented in physicians undergoing their residency. The Accreditation Council for Graduate Medical Education began implementing duty-hour restrictions in July 2003 and currently limits duty hours to 80 hours of work per week, averaged over a four-week period, inclusive of all in-house call activities and all moonlighting. But no state or federal regulations restrict the number of hours a nurse may voluntarily work in a 24-hour or seven-day period, although 16 states do have restrictions on the use of mandatory overtime, according to the American Federation of Teachers (AFT), a union that also represents health care workers (to read a 2010 AFT summary of state rules regarding mandatory overtime, go to http://bit.ly/dFusCH).

Rogers and colleagues studied data on 5,317 work shifts and found that hospital staff nurses generally worked longer than their scheduled shift and more than 40 hours a week. According to the study, published in the July–August 2004 issue of Health Affairs, several nurses reported that either the overtime was mandatory or they were “coerced” into working voluntary overtime. The duration of work, the amount of overtime, and the total number of hours worked significantly affected the incidence of errors, and the likelihood of making an error increased along with the length of the shift. Overall, the likelihood of making an error was three times higher when nurses worked 12.5 hours or longer.

The study is a cautionary tale, according to lead author Ann E. Rogers PhD, RN, FAAN, Edith F. Honeycutt Chair in Nursing and professor and director of graduate studies at Emory University. “Although we agree that the evidence is growing that 12-hour shifts are unsafe,” she told AJN, “if we are going to have them, health care employers and we as a profession have a responsibility to ensure that the practice environment is safe for both patients and nurses. If we cannot put fatigue management strategies in place, then extended work shifts, including mandatory and voluntary overtime, should be eliminated.”

In a study published in the January 2006 issue of the American Journal of Critical Care, Scott and colleagues found that critical care nurses worked longer than they were scheduled to work on 86% of their shifts. Nurses responding to the survey worked on average almost one additional hour, and of 502 respondents, only one didn't put in any overtime during the 28-day study period. Roughly half of the shifts were scheduled for 12 hours or more, and two-thirds of these shifts exceeded 12 consecutive hours. The risk of making an error or a “near error” increased with longer shifts, and longer shifts were also associated with a decrease in vigilance. Specifically, critical care nurses working 12.5 consecutive hours or longer had nearly double the risk of making an error.

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WHAT NURSES PREFER

Despite the fatigue and risks associated with 12-hour shifts, many nurses prefer them. Even as far back as 1998 (April 9), the New York Times reported that when a Brooklyn hospital threatened to replace 12-hour shifts with eight-hour shifts, nurses went on strike. Geiger-Brown and Montgomery, writing in the April 2010 Journal of Nursing Administration, believe that going back to eight-hour shifts could adversely affect nurse satisfaction and recruitment and retention rates and would require a dramatic change in hospital culture.

Stone and colleagues, reporting in Medical Care in December 2006, found that nurses who worked 12-hour shifts were generally more satisfied with their jobs, reported less emotional exhaustion, and were about 10 times more satisfied with their work schedules, compared with those working eight-hour shifts. There were also lower vacancy rates on units that offered 12-hour shifts, and vacant positions were filled more quickly. In addition, there were no differences between the eight- and 12-hour shifts in any of the quality of patient care outcomes. Lead author Pat W. Stone, PhD, FAAN, director of the PhD program and the Center for Health Policy at the Columbia University School of Nursing, notes that she was surprised at the findings. “But the data are the data and speak for themselves. Although our work found that 12-hour shifts had no detrimental effects on the patient, the nurse, or even the hospital (in terms of increased absenteeism hours), we didn't study longer shifts,” said Stone. “We also didn't study mandatory overtime.”

Stone also pointed out that hospital policies come from the managers, usually nurses. “Nurse managers and staff nurses both need to realize that staffing should be flexible, with as much self-selection as possible,” she said, but emphasized that staffing also needs to be safe. It's not just the level of staffing that's important, she said; the tenure and experience of the nursing team on a unit also make a difference.

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CURRENT STRATEGIES AND FUTURE DIRECTIONS

Because many nurses prefer 12-hour shifts, it isn't likely that they will disappear anytime soon. However, specific strategies can be put in place to reduce harm to both nurses and patients; these apply not only to 12-hour shifts, but to long shifts in general. The strategies include making sure that nurses working 12-hour shifts get mandated breaks and leave work on time and that planned napping is available for night shift workers.

Jeanne M. Geiger-Brown, PhD, RN, codirector of the Center for Health Outcomes Research at the University of Maryland in Baltimore and author of several studies on the topic, also believes that leaving on time isn't as difficult as it may seem. “My observation is that this is partly a unit-culture issue,” she said. “I've observed units where nurses leave on time and the next shift picks up the work, and equally busy units where there is an obligation to stay and finish a preset list of ‘stuff.’”

Excessive overtime remains an issue, too, regardless of the designated length of the shift. Nurses working eight-hour shifts often do “doubles,” therefore working a 16-hour day, and many nurses do it for the extra money. But Geiger-Brown questions whether voluntary overtime is really “voluntary” at all. “I think there is coercion, even if unspoken,” she explained. “Nurses also have to take some responsibility to recognize their professional responsibility not to work beyond what is reasonable.” And she thinks that many nurses don't understand the basic relationship between sleep and performance.

If that's the case, then whether it's a good idea for the profession to inculcate the expectation of long shifts within nurse training programs is an important question. Future data from such programs may shed light on the answer.—Roxanne Nelson

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© 2012 Lippincott Williams & Wilkins, Inc.

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