Written by Rochelle Ferguson
New Zealand is one of numerous countries that have introduced twelve-hour hospital shifts for registered nurses in addition to the historical eight-hour shifts. There is much discussion in the literature about the effects twelve-hour shifts have on the registered nurses’ health and wellbeing as well as patient safety.
The purpose of this literature review is to identify whether twelve-hour shifts have greater risks than benefits to patient safety and satisfaction of nursing care. As a third-year nursing student shift-work and hospital based nursing is probable for my future as a registered nurse. I have already been exposed, through my placements, to eight-hour and twelve-hour hospital shifts. The registered nurses I have worked with have had varied opinions to the extent where some nurses only do twelve-hour shifts and others only do eight-hours. I am interested in how working longer hospital shifts as a registered nurse impacts the care of the patient.
The definition of nursing provided by the New Zealand Nurses Organisation states, “nursing’s core focus is people (he tangata)” (Clendon, 2010, p. 3). I think this is an important reminder to all registered nurses that our primary role is to care and advocate for our patients. In order to do this effectively we need to care for our own health and wellbeing.
Traditionally shifts have been divided into three eight-hour shifts to cover every twenty-for hours in which nurses work a variety of morning, evening or night shifts. More recently, twelve-hour hospital shifts have been introduced meaning handover is either at 7am or 7pm. There is much discussion between researchers, clinical managers and registered nurses whether twelve-hour shifts should remain an option for nurses.
‘For registered nurses working full time in a hospital setting, does duration of shifts effect patient outcomes?’
My clinical question is based on the PECOT framework and specifies the purpose of my literature review (Schneider & Whitehead, 2013). Using the CINAHL, Pubmed and Ovid databases I searched several keywords (nurse*, shiftwork, patient safety, hospital shift and patient satisfaction) to find relevant research. Literature specific to New Zealand is scarce however there have been many international studies regarding the possible consequences of twelve-hour shifts.
Evidence, based on patient safety and patient satisfaction, concludes that registered nurses should not be working twelve-hour shifts in a hospital setting (Estryn-Behar & Va der Hejden, 2012; Josten, Ng-A-Tham & Thierry, 2003; Stimpfel, Sloane & Aiken, 2012). Registered nurses working long (twelve-hour) shifts are at more risk of nursing related errors and less critical thinking while working (Kellor, 2009).
One American study, where a sample of registered nurses and patients from four States, concluded that nurses shift length is associated directly with patient satisfaction (Stimpfel et al., 2012). Results showed registered nurses working between twelve and thirteen-hour shifts were less responsive to the patients needs and had decreased communication with patients and other physicians. Patient satisfaction was measured by their care experiences while staying in hospital. Findings also showed that the patient’s pain was not controlled as effectively and that they got inadequate explanation of their medications and treatment (Stimpfel et al., 2012).
There is evidence to support that longer hospital shifts increases the risk of nursing errors or near errors. A sample of 393 hospital staff nurses completed logbooks showing that work duration, over-time and number of hours worked in a week has significant effects on medical errors (Rogers, Hwang, Scott, Aiken & Dinges, 2004). Twice as many errors were recorded when registered nurses worked between eight and a half and twelve-hour shifts. Drug errors were one of the nursing issues raised that increased dramatically if the duration of the shift, some of which may have ended in serious injury or death (Rogers et al., 2004). A narrative explaining an error from one registered nurse said, ‘major med error: Pt received 12 500 bolus of heparin; pt ended up going back to OR’ (Scott, Rogers, Hwang & Zhang, 2006, p. 34). Evidence from another study concludes that working longer hospital shifts significantly increased the risk of needle stick injuries and a 1.9-3.3% increase of making patient care errors (Lockley et al., 2007).
Josten et al., (2003) state that twelve-hour nursing shifts have either neutral or negative effects on employee’s fatigue, health and performance. This study compared nurses working either 8-hour or 9-hour shifts in which their results showed that 9-hour shifts have the same negative effects of twelve-hour shifts (Josten et al., 2003).
According to the Nursing Council of New Zealand there were 45,318 practicing registered nurses in 2011 with over half of those working in a hospital setting (Nursing Council of New Zealand [NCNZ], 2011). The majority of these nurses work a variety of different shifts to cover the 24-hours of every day.
The nurses’ role in the hospital context has changed over time along with our health system. Registered nurses have a greater scope of practice and need to take more responsibility for their patient’s care. The acuity of patients in hospitals has increased and there are faster admissions and discharges (Rogers et al., 2004). As a result registered nurses have increased workloads and are providing care for more acute patients (Josten et al., 2003). It is for these reasons that twelve-hour shifts need to be reviewed in New Zealand.
Patient safety can be compromised due to nurses working long (twelve-hour) hospital shifts however there are other factors that implicate the issue. There is conflicting evidence between the negative and positive effects longer shifts have on registered nurses own health and wellbeing.
New Zealand took part in a study that compared registered nurses with five other countries which results showed high rates of burnout and job dissatisfaction. “New Zealand nurses reported highest levels of job related stress, high levels of job dissatisfaction and more that half report receiving inadequate organizational support” (Finlayson, Aiken, & Nakarada-Kordic, 2007, p. 17). Both negative and positive effects of the registered nurse need to be considered when discussing the issue of twelve-hour shifts. It is relevant to nursing practice because it is threatening the delivery of health services to patients and is increasing the risk of problems.
Longer shifts impact negatively on the nurses’ physiological health and wellbeing. Fatigue and burnout are two of the most common symptoms according to researchers (Chen, Davis, Davis, Pan & Daraiseh, 2011; Josten, et al., 2003; Rogers et al., 2004).
“Nurses have been identified as a high-risk group for burnout because of the highly demanding nature of caring for others, organizational expectations, and the high emotional expectations of patients,” (Allen & Mellor, 2002, p. 905). Compared to five other countries (Canada, U.S, Japan, Germany and the U.K), Finlayson et al. found New Zealand registered nurses had the highest levels of job related stress and high levels of burnout (Finlayson et al., 2007).
According to Stimpfel et al., (2012) study the percentage of nurses reporting burnout increased by two and a half times more as shift length increased. Lockley et al., (2007) described work schedules of nurses as a ‘permanent state of jet-lag’ (p. 8). The combination of having twelve-hour shifts and night shifts in a work schedule leads to sleep deprivation and increased fatigue. It is also suggested that registered nurses have an increased risk of cardiovascular disease, insulin resistance and diabetes due to shift work (Lockley et al., 2007).
Nursing management needs to take responsibility for their registered nurses and their health and wellbeing by establishing and enforcing safe limits. Registered nurses who took part in these studies expressed their frustration when shifts change at short notice or when they are ‘required’ to work extra hours if needed (Rogers et al., 2004).
Despite evidence against twelve-hour shifts they are still popular among many registered nurses. The majority of registered nurses who work twelve-hour shifts are satisfied with the schedules at their hospital (Stimpfel et al., 2012). Nurses have more days off and find it easier to balance work and family commitments (Ganong, Ganong & Harrison, 1976; O’Connor, 1992;). By working twelve-hour shifts nurses typically work three twelve-hour shifts a week and then have four days off meaning they have more days away from work (Stimpfel et al., 2012). Other appealing factors nurses have identified are less travelling to and from work and more time for leisure activities (Kellor, 2009).
Another advantage from an organizational perspective is that longer shift duration means a decrease in payroll expense and lower staffing requirements (Estryn-Behar & Van der Heijden, 2012; Ganong et al., 1976). This 1976 study found there were more advantages than disadvantages regarding twelve-hour shifts. Results showed that nurses in two different hospitals had better communication and continuity of care with both physicians and patients while working twelve-hour shifts (Ganong et al., 1976).
Nurses and managers have often given these two reasons about the effectiveness and convenience of twelve-hour shifts. It is perhaps the only reasons why twelve-hour shifts are still present in our health system today.
Based on these findings nurse managers need to be aware of the potential risks of twelve-hour shifts (Estryn-Behar & Van der Heijden, 2012’ Lockley et al., 2007; Stimpfel et al., 2012). Evidence from one study suggests that nurse managers, colleagues and registered nurses need to cooperatively establish strategies that protect both patients and nurses from the negative effects of long shifts (Epp, 2012). Extra consideration needs to be made regarding rosters and sensible schedules for registered nurses including flexibility. Working longer shifts has been suggested to lead to high turn over rates due to nurses’ dissatisfaction with work with the intent to leave (Chen et al., 2011; Finlayson et al., 2007). According to Finlayson et al., (2007), ‘resolving organisational issues is essential to stabilizing hospital workforces, as well as providing consistent high-quality patient care and safety’ (p. 18).
Nurses in general are not good at looking after their own health and knowing personal triggers of stress and burnout (Epp, 2012). Work/life balance of nurses is important and can improve safety while working in the hospital (Achieving work/life balance creates safer workplaces, 2004). I think twelve-hour shifts should be reviewed in New Zealand based on the safety issues that have been identified.
There is evidence to support hospital shifts longer than 8-hours have greater risks associated with them. There are benefits to longer shifts from both an organizational and nursing perspective however the safety risks are far greater.
Medical errors occur more frequently when nurses are working twelve-hour shifts as well as being less responsive to patient needs. In addition to this, longer shifts have been associated with nurses being fatigued, increased rates of burnout and having less vigilance while working. Twelve-hour shifts are popular among some nurses mainly because of the work/family balance that suits their lifestyle. Likewise these longer shifts have improved some staffing issues for managers who are either short staffed or where funding is very tight. Both managers and registered nurses need to take responsibility for their shiftwork to ensure safety of their patients and themselves. When twelve-hour shifts were first introduced they appeared to have many benefits and no risks however this is not the reality in today’s society.
Achieving work/life balance creates safer workplaces. (2004). Kai Tiaki Nursing New Zealand, 10(11), 7.
Retrieved from: http://web.ebscohost.com
Allen, J., & Mellor, D. (2002). Work context, personal control, and burnout amongst nurses. Western
Journal of Nursing Research, 24(8), 905-917. doi: 10.1177/019394502237701
Calkin, S. (2013). CNO to review 12-hour shifts. Nursing Times, 109(15), 2.
Chen, J., Davis, L. S., Davis, K. G., Pan, W., & Daraiseh, N. M. (2011). Physiological and behavioural
response patterns at work among hospital nurses . Journal of Nursing Management, 19, 57-68. doi: 10.1111/j.1365-2834.2010.01210
Clendon, J. (2010). Nursing in Aotearoa New Zealand: A definition. Wellington: New Zealand Nurses
Organisation. Retrieved from: http://www.nzno.org.nz
Epp, K. (2012). Burnout in critical care nurses: a literature review. Dynamics, 23(4), 25-31. Retrieved from:
Estryn-Behar, M., & Van der Heijden, B. I. J. M. (2012). Effects of extended work shifts on employee
fatigue, health, satisfaction, work/family, balance and patient safety. Institute for Management Research, 41, 4283-4290. doi: 10.3233/WOR-2012-0724-4283
Finlayson, M., Aiken, L., & Nakarada-Kordic, I. (2007). New Zealand nurses' reports on hospital care: an
international comparison. Nursing Praxis in New Zealand, 23(1), p17-28.
Ganong, W. L., Ganong, J. M., & Harrison, E. T. (1976). The 12-hour shift: Better quality, lower cost
. Journal of Nursing Administration, 6 (2), 17-29. Retrieved from: http://ovidsp.tx.ovid.com
Josten, E. J. C., Ng-A-Tham, J. E. E., Thierry, H. (2003). Nursing and health care management issues:
The effects of extended workdays on fatigue, health, performance and satisfaction in nursing. Journal of Advanced Nursing, 44(6), 643-652. doi: 10.1046/j.0309-2402.2003.02854.x
Kellor, S. (2009). Effects of extended work shifts and shift work on patient safety, productivity, and
employee health . American Association of Occupational Health nurses, 57(12), 497-502. doi:10.3928/08910162-20091124-05
Lockley, S. W., Barger, L. K., Ayas, N. T., Rothschild, J. M., Czeisler, C. A., & Landrigan, C. P. (2007).
Effects of health care provider work hours and sleep deprivation on safety and performance. The Joint Commission Journal on Quality and Patient Safety, 33(11), 7-18. Retrieved from: http://www.jointcommission.org
Nursing Council of New Zealand. (2011). The New Zealand Nursing Workforce. Wellington, New Zealand:
Nursing Council of New Zealand. Retrieved from: http://www.nursingcouncil.org.nz
O’Connor, T. (1992). 12-hour shifts begin in Dunedin. New Zealand Nursing Journal, 85(10), 20-21.
Rogers, A. E., Hwang, W., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The working hours of
hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212. doi: 10.1377/hlthaff.23.4.202
Schneider, Z., & Whitehead, D. (2013). Nursing and midwifery research: Methods and appraisal for
evidence-based practice. (4th ed). Sydney, NSW, Australia: Mosby.
Scott, L. D., Rogers, A. E., Hwang, W., & Zhang, Y. (2006). Effects of critical care nurses’ work hours on
vigilance and patients’ safety. American Journal of Critical Care, 15 (1), 30-37. Retrieved from: http://www.sonoma.edu
Stimpfel, A. W., Sloane, D. M., & Aiken, L. H. (2012). The longer the shifts for hospital nurses, the higher
the levels of burnout and patient dissatisfaction. Health Affairs, 31(11), 2501-2509. doi: 10.1377/hlthaff.2011.1377