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Clinical Rounds

doi: 10.1097/01.NURSE.0000395302.82000.14
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Do long nursing shifts endanger patients?



Patients in hospitals where nurses work long shifts are much more likely to die of pneumonia or myocardial infarction, a new study suggests. Researchers analyzing a 2004 survey of 633 nurses working in 71 acute care facilities found that nurse work schedules were significantly related to patient mortality, even after controlling for staffing levels and hospital characteristics.

  • Pneumonia deaths were significantly more likely in hospitals where nurses worked 12-hour shifts.
  • Acute myocardial infarction was associated significantly with how many hours per week and successive days nurses worked.
  • Lack of time away from work and working while sick were also associated with patient mortality.

Most hospitals now use 12-hour nursing shifts, a trend that began in the 1980s in response to the nursing shortage. "Although many nurses like these schedules because of the compressed nature of the workweek, the long schedule, as well as shift work in general, leads to sleep deprivation," says Alison Trinkoff, ScD, MPH, RN, FAAN, professor at the University of Maryland School of Nursing in Baltimore and a co-author of the study. "The finding that work schedule can impact patient outcomes is important and should lead to further study and examination of nursing work schedules," Trinkoff says.

Source: Trinkoff AM, Johantgen M, Storr CL, et al. Nurses' work schedule characteristics, nurse staffing, and patient mortality. Nurs Res. 2011;60(1):1–8.

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Performance-based pay incentives don't pay off

Linking nurses' pay to the quality of patient care could weaken the nursing workforce and practice environment, according to interviews with staff nurses and hospital leaders in 25 hospitals. Although most of those interviewed expressed favorable views of the effect performance-based incentives have on care quality and patient safety, many felt that incentives increase the burden and blame for nurses without improving staffing levels, work environment, salaries, or turnover.

To achieve the benefits of the pay incentives without jeopardizing the nursing workforce, researchers suggest implementation support, a redesign of incentives to reward teamwork, and involvement of nursing leaders in the creation of future incentive policies.

Funded by the Robert Wood Johnson Foundation, the study is part of a 2-year research project examining the impact of performance measurement, public reporting, and performance-based compensation policies on the nursing workforce.

Source: Kurtzman ET, O'Leary D, Sheingold BH, Devers KJ, Dawson EM, Johnson JE. Performance-based payment incentives increase burden and blame for hospital nurses. Health Aff (Millwood). 2011;30(2):211–218.

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What's behind errors involving analgesics?

The rate of errors involving orders for analgesics was 2.87 for every 1,000 orders in a recent study of 2,044 prevented (near-miss) analgesic prescribing errors. The error rate for pediatric orders was more than twice that for adults (5.9 per 1,000 orders).

Reviewing 714,290 orders for analgesics, researchers found that "commonly prescribed medications were associated with the most errors, but less frequently prescribed agents had higher error rates." Factors contributing to 40% of errors included drug availability for multiple administration routes, modified dosage forms, atypical dosage regimens, sound-alike drug names, and drug use in an ongoing scheduled regimen.

Some causes for errors were failure to modify therapy based on patient-specific information, inadequate drug therapy knowledge, wrong use of a dosage form, mistakes in dose calculations, and improper dose for the route of administration.

Researchers suggest that study results be used to guide patient and caregiver education and to improve medication safety strategies.

Source: Smith HS , Lesar TS. Analgesic prescribing errors and associated medication characteristics. J Pain. 2011;12(1):29–40.

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Kids go for bold prints

To investigate whether nurses' uniforms affect perceptions of professionalism, researchers asked pediatric patients and their adult visitors to view eight photos of the same nurse in different uniforms and give their impressions. Based on responses from pediatric patients ages 7 to 17 and their adult visitors at two midwestern healthcare centers, they found that both children and adults prefer nurses to wear uniform tops with bold prints and either white or blue pants, and that this was much preferred over monochromatic uniforms or those with a small-print top and pants. But they found "no evidence of a clear relationship between uniform color and style and perceptions of nurse professionalism in hospitalized school-age children, children treated in a hospital-based ambulatory care area, or their adult visitors of either group of children."

Source: Wocial L, Albert NM, Fettes S, et al. Impact of pediatric nurses' uniforms on perceptions of nurse professionalism. Pediatr Nurs. 2010;36(6):320–326.

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Value of subcutaneous heparin questioned

Heparin administered subcu-taneously may not provide optimal protection against venous thromboembolism (VTE) in patients who've had major abdominal surgery, according to a study presented at the Society of Critical Care Medicine's 40th Critical Care Congress. The study involved 50 ICU patients recovering from major abdominal surgery; most patients had cancer.

Researchers randomly assigned patients to receive either I.V. or subcutaneous heparin. The I.V. infusion was titrated to a target activated partial thromboplastin time range of 40 to 45 seconds. Patients who received heparin subcutaneously were given 5,000 units three times a day.

Every day for 10 days after surgery, researchers checked patients' blood heparin activity levels and whole blood coagulation parameters. Patients also underwent ultrasound screening of the lower extremities for deep vein thrombosis (DVT).

The generally accepted range for preventing DVT is an anti-Xa range of 0.1 to 0.3 units/mL. Those who received I.V. heparin had statistically significant increases in anti-Xa activity on day 3 (0.04 units/mL) and day 4 (0.05 units/mL). But those who received subcutaneous heparin had no detectable levels of anti-Xa activity 5 days after surgery. What's more, patients who received subcutaneous heparin had a hypercoagulable profile for as many as 5 days after surgery; in comparison, patients who got I.V. heparin had a normal profile.

Ultrasonography didn't find DVT in either group, and no episodes of bleeding or heparin-induced thrombocytopenia occurred. Also, ICU lengths of stay and 28-day mortality were similar among patients in both groups.

Researchers conclude that subcutaneous heparin may not provide optimal protection for patients after major abdominal surgery because absorption appears to be decreased in these patients.

Source: Lowry R. Subcutaneous heparin not adequately absorbed after abdominal surgery. Medscape Medical News. January 19, 2011.

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In April, celebrate

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How dangerous are imaging studies?



Despite the recent interest about the link between radiation from imaging studies and cancer, clinicians have little solid data about the long-term risks of radiation from cardiac imaging. A 2009 report from the National Council on Radiation Protection and Measurements stated that medical procedures exposed Americans to more radiation than radon. One recent study reported that almost one-third of patients undergoing myocardial perfusion imaging receive a cumulative radiation dose from all medical sources of more than 100 mSv, which is a level associated with an increased risk of cancer.

Dr. Andrew Einstein of Columbia University, New York, a leading researcher of radiation exposure from cardiac imaging, says that healthcare providers' knowledge about radiation is limited. In the absence of knowledge, people tend to ignore the issue or overreact to it, he says. Currently, healthcare providers and patients must make decisions with only rough estimates of long-term radiation risk.

Source: Miller R. Fear of radiation from cardiac imaging outpaces knowledge about the risks. The from WebMD, January 25, 2011.

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Get on track with Healthy People 2020



Federal health officials have released a new 10-year agenda to help Americans live healthier lives. Healthy People 2020, the fourth edition of this government-supported health initiative, offers evidence-based interventions and resources to improve public health.

Healthy People 2020 addresses 42 topics, 13 of which are new. Among the new topics are adolescent health, dementias, healthcare-associated infections, disaster preparedness, sleep health, and blood disorders and safety. Read the full initiative at

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© 2011 Lippincott Williams & Wilkins, Inc.