12 hour shifts, the debate continues, 2015

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18 Kai Tiaki Nursing New Zealand * vol 21 no 5 * June 2015

12-hour shifts:the debate continuesSome nurses elect to work 12-hour shifts; others have no option.However, evidence is mounting that working longer shifts has a

negative impact on nurses health and patients well-being.

research

Nurses and patients are at greater risk of accident and injury when nurses work 12 hours or more on a single shift.

By NZNO principal researcher

Lonie Walker and nursing policyadviser/researcher Jill Clendon

Arecently published systematic review of

the literature provides further evidence

that shifts of 12 hours or more may be

associated with increasing error rates among

nurses.1In light of continued debate in New

Zealand and elsewhere as to the operation of12-hour shifts, this article aims to summarise

the pros and cons, the impacts on nurses

health, and to outline some internationally

recognised strategies to try and mitigate these

ill effects when 12-hour shifts are deemed

unavoidable.

BackgroundFrom the latest NZNO employment survey,

around 10 per cent of registered nurses cur-

rently work 12-hour shifts.2However, this

number is not distributed evenly, with district

health boards (DHBs) in Auckland and Wel-

lington using 12-hour shifts more frequently

than most others intensive or coronary care/

high dependency unit, child health (includ-

ing neonatology), emergency and trauma, and

obstetrics being the most frequently cited

settings.

The negative impacts of night shift work

on nurses health (including heart disease,

obesity, diabetes, mood disorder and breast

cancer) have long been acknowledged.3Nightshifts are an inevitable requirement of a

system required to care for patients round the

clock. However, there is mounting evidence

that longer shifts, in addition to many other

factors, may lead to increased risk of error

and harm to patients, and harm to nurses.

Many nursing organisations advocate for the

withdrawal of 12-hour shifts, and for strate-

gies and practices to minimise harm when this

is not possible.

NZNO has taken the position in the NZNO/

DHB multi-employer collective agreement

that 10- and 12-hour shifts are not recom-

mended as a standard rostering pattern and

should only occur where clear clinical/service

rationale supports this practice. NZNO also

advocates for healthy rostering practices andother provisions to mitigate the negative

impact on members health.

Benefits of 12-hour shiftsTwelve-hour shift rosters are more popular

with some nurses, who find they enjoy more

days and weekends off, and have more com-

pressed work weeks. Employers cite increased

ease of scheduling two shifts compared to

three, and reduced staffing costs, due to fewer

wage hours (36 hours for 3x12-hour shifts

per week, compared to 40 hours for 5x8-hour

shifts per week), lower handover hours

and less paid break time,

as benefits of the

two-shift system.4There are conflicting results

on the impact of shift length on nurses job

satisfaction or intention to stay in nursing.5

Negative health impactsFor many years, increased fatigue has been

recognised as a consequence of extended

shifts.7Associated with this fatigue are

increased accidents, such as needle stick and

musculoskeletal injuries, and vehicle accidents

post-shift. However, due to the difficulties of

statistically untangling the effects of differ-

ent shift patterns, different recovery periods,

workloads and environmental factors (to name

but a few confounding issues) and their im-pact on fatigue, little consensus has emerged

about the need to protect nurses from the

negative health impacts of longer shifts.

Fatigue in nurses (especially on night shifts)

increases with age; an important factor, given

the age demographics of the New Zealand

workforce. Some research found that older

nurses significantly favoured shorter shifts.8

Twelve-hour shifts could increase older nurses

job dissatisfaction, exacerbating a projected

workforce shortfall.

Now a new study RN4Cast, involving more

than 31,000 nurses across 15 European coun-

tries has robustly confirmed that increasedfatigue, loss of alertness, impaired decision-

making and increased accidents are associated

with longer shift length itself, irrespective of

other confounders.9

The latest review of nursing error rates and

shift length found that of 13 relevant, high

quality studies, six reported higher rates of

error for nurses working 12 hours or more

on a single shift, four reported higher rates

of error on shifts of up to eight hours, and

three reported no difference.1The six stud-


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19Kai Tiaki Nursing New Zealand * vol 21 no 5 * June 2015

research

References1) Clendon, J. & Gibbons, V. (2015) 12 hour shifts and rates of error among nurses: A systematic review.International Journal of Nursing Stud-ies. http://dx.doi.org/10.1016/j.ijnurstu.2015.03.011. Retrieved 05/05/15.2) Walker, L. (2015) NZNO Employment Survey.Wellington: NZNO.

3) Schernhammer, E.S., Laden, F., Speizer, F.E. et al. (2001) Rotating night shifts and risk of breast cancer in women participating in thenurses health study.J National Cancer Institute;93: 20, pp1563-8.4) Georgia Nurses Association. (2012) Conference report; 12 hour shifts and fatigue.www.georgianurses.org/?page=12HourShifts. Retrieved15/03/15.5) Todd, C., Robinson, G. & Reid, N. (1993) 12-hour shifts: job satisfaction of nurses.J Nursing Management;1:5, pp215-20.6) Boivin, D.B., Trembley, G.M. & James, F.O. (2007) Working on atypical schedules. Sleep Medicine; 8: 6, pp578-89.7) Bae, S. & Fabry, D. (2014) Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematicliterature review. Nursing Outlook;62: 2, pp138-156.8) Hoffman, A.J. & Scott, L.D. (2003) Role stress and career satisfaction among registered nurses by work shift patterns.J Nursing Administra-tion;33:6, pp337-42.9) Aiken, L.H., Sermeus,W., Van den Heede, K. et al. (2012) Patient safety, satisfaction, and quality of hospital care: cross sectional surveys ofnurses and patients in 12 countries in Europe and the United States; BMJ.doi: http://dx.doi.org/10.1136/bmj.e1717.Retrieved 20/03/15.10) Nursing Standard. (2013) News: Research fails to show value of 12-hour shifts. Nursing Standard;27: 29, p9. http://dx.doi.org/10.7748/ns2013.03.27.29.9.p10791. Retrieved 15/03/15.11) Witkosi Stimpfel, A., Sloane, D.M. & Aiken, L. (2012) The longer the shifts for hospital nurses, the higher the levels of burnout and patientdissatisfaction. Health Affairs; 31: 11, pp25012509.12) Geiger-Brown, J. & Trinkoff, A.M. (2010) Is it time to pull the plug on 12-hour shifts? Part 1. The evidence.J Nursing Administration;40:33, pp100-102.

ies reporting significant rises in error rates

among nurses working 12 hours or more on a

single shift comprised 89 per cent of the total

sample size (N=60,780 out of the total sample

size N=67,967).

This led the authors to conclude that(other confounding factors aside), the risk

of making an error is higher among nurses

working 12 hours or longer on a single shift in

acute-care hospitals, than those working less

than 12 hours. They recommended hospitals

and units currently operating 12-hour shift

systems review this scheduling practice, due

to the potential negative impact on patient

outcomes.

Looking at other impacts on patients, find-

ings are mixed. Some studies have reported

higher patient satisfaction with longer shifts,

due to perceptions of better continuity of care,

and more ability of families of patients to

night shifts and extended shifts on patients

and nurses. Safe rostering practices (some

informed by computer algorithms) can be

deployed to ensure appropriate block lengths

and directions of shift change, and adequate

recovery time. Some self-rostering practices,along with changes at short notice to rosters,

and staff shortages requiring people to come

back to work after inadequate rest, risk endan-

gering staff and patients.

Work environments lighting, ventilation,

access to healthy food and exercise, and provi-

sion for short naps have all been shown to

reduce risks. Ending extended shifts on time,

taking commuting distance into account in

rostering and providing safe transport home

for fatigued staff may address the dangers

associated with driving drowsy.12

Providing

staff with high-quality education on sleep

hygiene and self-care, and giving specialconsideration to those less able to tolerate

longer shifts or night shifts (due to their per-

sonal circumstances, age or particular health

conditions) may help address some of the risks

and lead to more vulnerable staff having their

needs better accommodated.

From a workforce planning perspective,

current moves in some settings requiring all

nurses to do rostered and rotating shifts or

12-hour shifts, irrespective of the factors

above, may exacerbate nursing shortages and

deepen skill/experience deficits as the ageing

workforce chooses retirement over less flexible

and unhealthy options.

From a policy perspective, attention should

certainly be focused on improving rostering,

workloads and the environmental factors that

contribute to fatigue and poor health. But

the writers believe the time has now come

to recognise that, though the need for night

shifts will continue, length of shift is one fac-

tor that policy and practice could address to

the benefit of safer patient outcomes, nurses

health and workforce retention.

. . . the risk of making an erroris higher among nurses working12 hours or longer on a singleshift in acute care hospitals,than those working less than 12hours.

Working longer shifts

a nurses story

Report by co-editor Anne Manchester

access the same nurses for updates and com-

munication, though this has been disputed

in others.10

Further studies have reported

lower patient satisfaction, due to perceptions

of less time being available per patient, and

of fatigued nurses.11

Overall, the weight of

evidence is starting to suggest nurses and

patients are at greater risk of accident and

injury when nurses work 12 hours or more on

a single shift, compared to when nurses work

eight hours or less.

There are several evidence-based strate-

gies to reduce the negative impact of both

AFTER WORKING 10-hour, permanent night shifts at

Waikato Hospital for two-and-a-half years in the late

1990s, experienced theatre nurse Simon Auty vowed

he would never work these longer shifts again.

When I began working these shifts, I thought it

was great, because of the extra pay and longer time

off. I would work three days, then have four days

off, followed by five days on and three days off.

That sounded pretty good but I eventually realised

the first day was a write-off because of being so

wiped out. It also took me a whole day to get back

into sync with normal daylight hours.

But the major reason Auty went off working these

longer shifts was safety considerations. Although he

admits some staff like working longer shifts because

of lifestyle considerations, he is concerned notenough research has been done on the impact of

these shifts on patient safety.

I began to realise that, by the end of the shift,

I was getting slow and tired, and would be hanging

out for the next shift to come on. Sometimes emer-

gency cases would arrive near the end of my shift

and I knew my decision-making was becoming poor.

We were dealing with life-and-death situations.

If my replacement did not turn up at 7am to take

over, then you could be stuck in theatre for another

hour or two, and that became really unsafe.

Auty, now working in Wellington as a charge

nurse, has also worked at Wellington Hospital and

witnessed the way 12-hour shifts were introducedinto the intensive care department (ICU). Basically

they were struggling to recruit enough ICU staff,

so moved to 12-hour shifts as a way of keeping the

unit functioning. Again, I had safety concerns as

patients moved from theatre to ICU.

The labour movement at the turn of last century

worked so hard for the eight-hour day and now we

seem to be giving the battle away. Pilots and truck

drivers would not be allowed to work 12-hour shifts,

nor would staff at nuclear power stations, yet nurses

have peoples lives in their hands and are allowed to

work longer shifts. It does not make sense to me.

Auty believes reports of medical errors made by

staff working longer shifts are just the tip of the

iceberg. He is also concerned about the safety of

staff driving home after their shifts. I know there

were times in the Waikato when I would get home

and not remember the drive home, nor what I had

done at work that night. That really scared me.

Under the new health and safety laws, the em-

ployer is liable for what happens to their staff. What

about staff driving home tired? This is unexplored

territory, but a test case is bound to arise.


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12 hour shifts, the debate continues, 2015

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