The influence of working longer shift on nurses` quality of care

During the past three years, a series of studies have demonstrated the risks to patients and providers of long work hours in health care. Compared with nurses working shorter hours, nurses working greater than 12.5–13 consecutive hours report (1): a 1.9- to 3.3- fold increased odds of making an error in patient care1,2; (2) a significantly increased risk of suffering a needlestick injury, exposing them to an increased risk of acquiring hepatitis, HIV, or other bloodborne illnesses3; and (3) significant decrease in vigilance on the job. (9)

A number of healthcare organizations and state boards of nursing have adopted strategies to address concerns related to nurses’ shift lengths and fatigue and the connection with risks to patients and care providers. In 2003 the Accreditation Council for Graduate Medical Education (ACGME) began limiting shift length and duty hours of residents and fellows (ACGME, 2010), and ACGME published additional limitations in 2011 (ACGME, 2011). The Institute of Medicine (IOM) has also published guidelines and recommendations regarding nurses’ roles in the protection of patient safety and improved patient outcomes (IOM, 2004). (7)

Shift work is an inevitable part of many jobs which require 24 hour attendance and comprise working at unusual hours, especially at length shift . Because of potential hazards of length shift work on safety and health, there was an intensive debate on the “best compromise” shift system (Folkard, 1992). Shift length and kind of shift rotation (forward/backward rotation; quick and slow rotation) have been considered at length (Smith, Folkard, Tucker & Macdonald, 1998). Up to now, no unequivocal conclusion can be drawn with respect to shift length. One reason might be that mediating factors play an important role, such as length of recovery intervals between shifts, options for sleep recovery in these intervals, options to cope with fatigue within the shift, or personal and family activities, all of which contribute to cope with work stress (Folkard, 1992; Smith et al., 1998). (32)

Extended work shifts of twelve hours or longer are common and even popular with hospital staff nurses, but little is known about how such extended hours affect the care that patients receive or the wellbeing of nurses. Survey data from nurses in four states showed that more than 80 percent of the nurses were satisfied with scheduling practices at their hospital. However, as the proportion of hospital nurses working shifts of more than thirteen hours increased, patients’ dissatisfaction with care increased. Furthermore, nurses working shifts of ten hours or longer were up to two and a half times more likely than nurses working shorter shifts to experience burnout and job dissatisfaction and to intend to leave the job. Extended shifts undermine nurses’ well-being, may result in expensive job turnover, and can negatively affect patient care.(29)

Background:

Due to social, economical, and technological changes in the past 10 years, the workforce has adapted to different forms of work schedules. Work schedules have changed in some industries to include flexible hours, irregular shifts and at times, elongated shifts (Jansen et al., 2003). Shiftwork may be defined as a job schedule other than the standard hours of 8am to 5pm (Institute for Work & Health, n.d.). Although many sources refer to shiftwork as time worked outside the standard working daytime hours, there are “shifts” that include daytime hours, specifically in healthcare and hospital settings. Shiftwork in these settings usually revolve around 24 hour coverage, and is mostly characterized as 8 to 12 hours for full time employees.(37)

nursing work hours could influence workers’ health in a variety of ways. They frequently contribute to disrupting circadian rhythms and impacting length of recovery time before a nurse returns to work. They also contribute to overall fatigue in the workplace, affecting nurses’ vigilance and critical thinking (Tabone, 2004). (37)

Job satisfaction and burnout in the nursing workforce are global concerns, both due to their potential impact on quality and safety of patient care and because low job satisfaction is a contributing factor associated with nurses leaving their job and the profession).31)

Shift patterns have been identified as an important factor in determining well-being and satisfaction among nurses. Providing in-patient nursing care inevitably involves shift work. Shifts of 12 h or longer have become increasingly common for nurses in hospitals in some countries in Europe. This change is mainly driven by managers’ perceptions of improved efficiency from reducing the number of nurse shifts a day, therefore resulting in fewer handovers between shifts,less interruptions to clinical care provision and increased productivity due to a reduction in the overlap between two shifts.10 From the nurse perspective, longer shifts offer a potential to benefit from a compressed working week, with fewer work days and more days off-work, lower commuting costs and increased flexibility. However, previous studies on shift length in Europe did not provide evidence of nurses working a compressed work week, so it is not clear if working 12 h shifts is associated with fewer days at work. These scheduling practices have not been systematically evaluated and the movement to longer shifts for nurses has not been based on research evidence of improved outcomes for nurses and an absence of harm to patients.(31)

A recent study among European nurses investigated the association between shift length and nurses’ psychological well-being. The findings show that nurses preferred 12 h shifts because more time off helped them balance work and personal commitments,although the nature of these was not examined (e.g.,having a second job, having caring responsibilities at home and other potential confounders on the impact of 12 h shifts on nurse outcomes). Paradoxically, the study also found that nurses who worked12 h shifts were more likely to experience high levels of burnout than nurses working shorter shifts .(31)

Similarly, Stimpfel16 reported that American nurses working extended shifts,particularly longer than 13 h, were more satisfied with their work schedules but were more likely to experience burnout and job dissatisfaction than nurses who worked shifts of 8 or 9 h. However, the US study did not disentangle scheduled shift length from extended shifts due to overtime worked, a common limitation in previous research on nurses’ shift lengths.Differences between work hour regulations between countries may limit the generalizability of US research.The US has regulations governing nurses’ work hours that differ from the European Working Time Directive,in terms of limiting weekly hours, including overtime,and providing extra protection for between-shift rest hours and night work.(31)

the disadvantages (reduced family time, tiredness and stress, increased health risks). While there was some evidence to support the outcomes noted, there was not always a clear link between longer shifts and changes in the outcomes. (36)

at al found insufficient evidence of effects of shift length on nurse job satisfaction and burnout, while a more recent systematic review reported evidence of adverse nurse outcomes associated with shifts of 12 or more hours, including burnout, job dissatisfaction, intention to leave and fatigue from a number of studies, mostly from the US.(31)

From the nurse perspective, longer shifts offer a potential to benefit from a compressed working week, with fewer work days and more days off-work, lower commuting costs and increased flexibility. However, previous studies on shift length in Europe did not provide evidence of nurses working a compressed work week, so it is not clear if working 12 h shifts is associated with fewer days at work. (31)

Around a third of employers did express some concern over the impact of longer working hours on the quality of care although this should be interpreted with caution as the view was split and equally there were employers who did not feel this was the case. When it came to completion of requirements, there was also a mixed picture with some employers seeing the benefits of longer working hours while others were less convinced. The same was true when it came to concerns around safety and working longer hours. While the majority did not feel there were any concerns, a quarter of employers were concerned about the impact of working longer hours on the safety of people using care and support services. (36)

Staff participants tended to reflect different views when thinking about the impact of longer working hours in general terms compared with personal experience. There was a split in responses when it came to general quality of care – almost half agreeing that longer working hours did impact on quality and the other half disagreeing. However, when it came to reporting personal experience, staff did not feel that longer working hours had an impact on their practice. Staff did feel however that productivity did drop with longer working hours in general terms and again personally there was some difference of opinion with approximately the same per cent of staff stating that it made no difference or that it was sometimes/always the case. However staff did feel that longer working shifts do impact on their fatigue levels, their irritability and demotivation,(36)

systematic national data on trends in the number of hours worked per day by nurses are lacking, anecdotal reports suggest that hospital staff nurses areworking longer hourswith few breaks and often little time for recovery between shifts.2 Scheduled shifts may be eight, twelve, or even sixteen hours long and may not follow the traditional pattern of day, evening, and night shifts. Although twelve-hour shifts usually start at 7 p.m. and end at 7 a.m., some start at 3 a.m. and end at 3 p.m. Nurses working on specialized units such as surgery, dialysis, and intensive care are often required to be available to work extra hours (on call), in addition to working their regularly scheduled shifts. Twenty four- hour shifts are becoming more common, particularly in emergency rooms and on units where nurses self-schedule.

No state or federal regulations restrict the number of hours a nurse may voluntarily work in twenty-four hours or in a seven-day period.3 Even though state legislatures in approximately nineteen states have considered bans on mandatory overtime for nurses and other health care professionals, bills prohibiting mandatory overtime for nurses have passed only in California, Maine, New Jersey, and Oregon. No measure, either proposed or enacted, addresses how long nurses may work voluntarily.4 The recent Institute of Medicine (IOM) report, Keeping Patients Safe, explicitly recommends that voluntary overtime also be limited.