Written by Sally Booker
A nurse’s working day is often busy, heavy and demanding yet the 12 hour shift has become a way of life for many nurses. There are increasing numbers of patients dying each year from medical errors. It is becoming evident that the quality of care provided to patients has been jeopardised since nurses started working these longer shifts (Keller, 2009). The purpose of this essay is to identify a clinical practice issue and critically review evidence-based literature to discuss the implications for practice. My medical/surgical placement was in the intensive and coronary care unit where nurses work a 12 ½ hour shift. They rotate on one month of days followed by one month of nights. I was able to experience this rotating roster working the first week of my 120 hour placement on night shift and the rest of the time was on day shift starting at 7am – 7-30pm. Nurses working in a critical care environment require advanced nursing skills in order to provide multiple treatments to patients with compounded medical and social problems often requiring a one to one nurse- patient ratio. Working alongside my registered nurse partner on the 12 hour shift gave me time to spend with patients giving reassurance and developing a therapeutic relationship with them. The extra time was beneficial when observing trends in a patient’s condition that may not have been observed over a shorter period of time. I was also able to take advantage of gaining academic and technical skills. The quality of my documentation and handovers improved as you were often handing back over to the same nurse that had handed over to you at the beginning of your shift. The nurses I worked with said they were reluctant to change to the 12 hour shift when it was first introduced but would now find it very difficult to go back to working an 8 hour shift.
Using Rod Jacksons PECOT tool I have structured the following question to allow me to search and review best evidence related to this clinical practice (Otago Polytechnic, 2013).
“What are the implications of 12 hour shift versus 8 hour shift for nurses working in critical care?”
Within this review I will discuss the various research published to look at the positives and negative aspects of this clinical practice issue and evaluate this evidence and provide rationale to support findings. In the appendices I have included the three most prominent evidence –based papers that I have used to research this question.
The 12 hour shift was brought in to accommodate for nursing shortages back in the late 1960’s (“Time to do away with 12 hour shift,” 2010). Initially it was only critical care and emergency departments that used the 12 hour shift but nurses and management soon realised the advantages to the 12 hour shift. Over time these shifts have proved popular in all areas of hospitals throughout the world (Fields & Loveridge, 1988). New Zealand along with other countries limits the hours and shift rotation that doctors can work over a specified period but to date there is no polices or guidelines for nurses (Whitt, Harvey, McLeod & Child, 2007). Studies still suggest that nurses feel obligated to work extra hours due to the ongoing issue of staff shortages (Witkoski Stimpel, Sloane & Aiken, 2012).
Fountain, Curzio and Hunt, (1996); and Bloodworth, (2001) suggested that staff morale was enhanced with the introduction of the 12-hour shift due to the flexible work pattern giving more days and weekends off as well as less commuting time to work (as cited in Richardson, Dabner & Curtis, 2003). Further findings by Richardson, Dabner and Curtis, (2003) were carried out a short time after the introduction of the 12 hour shift in an intensive therapy unit in the United Kingdom. The aim was to evaluate the degree of staff satisfaction as well as assess the quality of care provided to patients. Both staff and patients believed continuity of patient care was improved with the implementation of the 12 hour shift. Patient’s preferring to have just two staff changes in a 24 hour period (Pridham, 2009). Nurses also indicated there was an improvement in communication and therapeutic relationships with both patient and patient’s family. More time was spent getting to know the patient in order to implement a suitable care plan (Dwyer, Jamieson, Moxham, Austin, & Smith, 2007).
Nurses are continuously monitoring patient focused trends to enable them to interpret any subtle changes to the patient’s condition and apply appropriate nursing interventions. This requires nurses to be at the peak of their performance (Scott, Rodgers, Hwang, & Zhang, 2006) Working with patients and their families that are experiencing very stressful life changes can have an impact on a nurses own personal life. It is therefore important that nurses take responsibility to look after them, adapting good eating habits with an awareness of caffeine intake (Berger & Hobbs, 2006). Nurses are accountable for their performance which also requires monitoring self- stress indicators in order to combat fatigue (Nelson, 2012).
Fatigue has been associated with long work hours which have contributed to the increase in documentation mistakes, medication errors, and on the job personal injuries (“Time to do away with 12 hour shift,” 2010). Scott and colleagues, reporting in American Journal of Critical Care in January 2006 suggested there is twice the chance of an error occurring on a 12 hour or longer shift than any other time. The authors’ research also found that nurses working in critical care work longer than their required hours on 86% of their shifts. They are working on average an extra hour of overtime per shift, with the longest shift being 23 hours 30 minutes. These extra hours are affecting their alertness and their ability to stay awake on the job as well as their sleeping habits on days off.
Sleep habits change and the quality of sleep deceases with age, due to a decline in the body’s circadian rhythm (Keller, 2009). With an aging nursing workforce this becomes a concern according to a report put out by Georgia Nurses Association (12-hour shifts and fatigue, 2012). It suggests that older nurses are experiencing difficulties related to shift work and increased hours at work, resulting in fatigue and sleep deprivation. Sleep deprivation has the potential to have an impact on the patient and the nurse’s personal health and safety (Fallis, McMillian & Edwards, 2011).
To overcome sleep deprivation some nurses have a power nap on their rest break when working the night shift. Fallis, et al., (2011) discuss the concerns associated with napping or not napping while working a 12 hour night shift. Taking time out to have a short sleep while on a break is considered to enhance performance, decrease tiredness and boost alertness. For this to happen it is critical that nurses have access to a quiet room as well as being entirely relieved from their patients for the complete period of time they are on their break (12-hour shifts and fatigue, 2012). Barriers to prevent nurses taking their scheduled break can be that patient’s condition can change very quickly in a critical care environment which can often mean nurses forgo rest and meal breaks to provide patient care as there may not be enough experienced staff to cover (Fallis et al., 2011). From the study most nurses emphasized the benefits of napping while on their break, maintaining they were more alert and refreshed to ensure patient safety at all times. A small percentage of the nurses preferred not to nap on their break stating they experienced concerns of being disorientated and increased sluggishness when waking up (Fallis et al., 2011).
According to Feilds and Loveridge (1988) research there is no conclusive evidence that nurses working a 12- hour day shift were any more fatigued than nurses working an 8-hour day shift. Although nurses finishing a 12-hour night shift were considerably more tired than their 8- hour counterpart indicating fatigue was associated more to the shift rotation than the duration of the shift. When preparing staff rosters management need to consider the amount of consecutive 12 hour shifts a nurse is required to work as well as scheduling an appropriate period of time off before commencing back on duty (Richardson, Turnock, Harris, Finley; & Carson, 2007). Staff shortages as well as the cost of living today impact on the reasons nurses work extended or extra shifts. Witkoski Stimpfel, Sloane; and Aiken, (2012) discuss the consequences of working longer hours for both nurses and the patients. They found “patients were less satisfied with their care when there were higher proportions of nurses working shifts of thirteen or more hours” (p. 2506). Furthermore the long term consequences of nurses working these extra hours is burnout and job dissatisfaction as they try to juggle work and personal life. Burnout is a common term used today in the healthcare profession. It is associated to a stressful work environment and lack of support from fellow colleagues resulting in a nurse losing respect for one’s self, and others around them (Harris, Nagy & Vardaxis, 2010).
Evidence highlighted in this literature review includes findings that suggest nurses working a 12 hour shift or longer or who have insufficient sleep are putting not only the patients health but their own health at risk. Despite the increased chances of an error occurring due to fatigue and sleep deprivation nurses working in the critical care environment prefer the 12 hour shift. For everyone’s protection there needs to be policies and guidelines put in place for nurses in the same way that there is for doctors. Literature has discussed the need to limit the amount of hours and shifts a nurse can work consecutively. Issues of fatigue and burnout arise when nurses are expected to work more than 12 hours within a 24 hour spell or more than 60 hours in a 7 day time frame (Witkoski Stimpfel, et al., 2012). Working these extra hours increases the likelihood of an error occurring related to lapses of concentration, less motivation and energy needed to complete the task at hand (time to do away with 12 hour shift, 2010). To ensure optimum care of patients at all times evidence suggests that nurses should work no more than 12 hours in a 24 hour period as well as stating that the greatest number of shifts worked in sequence should be four. Furthermore there must be consideration regarding an appropriate period of time off after completing a succession of shifts.
Nurses themselves need to be proactive when it comes to taking scheduled work breaks which includes handing full responsibility of patient load over to another staff member for the entire break (12-hour shifts and fatigue, 2012). Evidence highlighted the need for education to be routine around the importance of good sleep hygiene including the benefits of a power nap while on night shift in order to reduce the ongoing consequences of fatigue and sleep deprivation (Fallis et al., 2011). Most importantly there must be an emphasis on ensuring all nurses end their shift on time as a higher percentage or errors have been associated with the prolonged working hours (Scott et al., 2006). Further positive outcomes of finishing work promptly would include having extra time to accommodate good sleep habits, physical exercise, family commitments or quality time for self (Keller, 2009).
In conclusion this literature review has shown that continuity of patient care proved to be the most positive aspect of the 12 hour shift for both the patient and the nurse while fatigue, burnout and sleep deprivation were negative aspects of the 12 hour shift for nurses working in critical care. This has contributed to an increased number of errors occurring. Evidence indicated it is not the length of the shift itself but the amount of hours a nurse is working within a 24 hour period as well as the number of 12 hour shifts they work over 7 days. Literature provided strategies that nurses and management can adapt to help reduce the number of errors occurring and improve the health and safety of both the patient and the nurse if the12 hour shift is here to stay.
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