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12 Nursing Times 04.02.15/ Vol 111 No 6 / www.nursingtimes.net

Nursing PracticeDiscussion

Working hours

AuthorsJane Ball is principal research

fellow; Chiara DallOra is doctoral student;

Peter Griffiths is chair of health services

research, all at National Institute for

Health Research Collaboration for

Leadership in Applied Health Research

and Care Wessex (NIHR CLAHRC

Wessex), University of Southampton.

AbstractBall J et al (2015) The 12-hour

shift: friend or foe? Nursing Times;111: 6,

12-14.

In recent years the number of hours

worked by nurses in hospital per shift

has started to change and it is becoming

more common for organisations to

implement longer, 12-hour shifts, that are

done over fewer days a week. Some

nurses may prefer this way of working as

it improves their worklife balance but

others may prefer to work shorter shifts

more days a week. Along with staff

wellbeing, patient outcomes can also be

affected. This article outlines the benefits

and concerns of working 12-hour shifts and

discusses what can be done to ensure that

nurse wellbeing is maximised withoutcompromising patient safety.

Traditionally, work in hospitalshas involved dividing the24-hour period into three workshifts an early (for example,

7.00-15.00), late (13.00-21.00) and night(21.00-7.00) shift with nurses generallyworking five such shifts a week. However,in common with other industries, therehas been a trend in recent years for somehospitals to adopt longer shifts. Typically,this is two shifts a day, each lasting12-13 hours, with nurses working a fewernumber of shifts each week (generallythree instead of five).

Keywords:Work/Shift/Staff/Patient

safety/Outcomes/Risk

5 keypoints

112-hour shifts

are becomingincreasingly

common: 32% of

nurses on acute

wards in England

work day shifts of

12 hours or longer

2Little researchhas beenundertaken on

the impact of

12-hour shifts

where these

are widely

implemented

3Although

12-hour shifts

are believed to

save money,

little economic

evaluation of

them has been

undertaken

4Nursesworking for12 hours or more

are more likely

to report poor-

quality care, poor

patient safety andmore care left

undone

5Workingovertime isassociated with

adverse patient

outcomes

The changes are driven by perceivedefficiencies for the employer (fewer hand-overs and reduced overlap between shifts),and an improved worklife balance foremployees, with the opportunity to com-press work into fewer days per week. How-ever, the length of nursing shifts in hospi-tals is hotly debated; the contrasting viewsbelow are illustrative of the divergingopinions given in response to our recentlypublished article on the subject (Griffithset al, 2014).

I do 12.5-hour shifts and to be honest Ipreferthem with the intensity of nursingcare and[the] ward environment, I find itless wearing overallthan coming in4-5 days a week.

I worked 14.5-hour shifts at the hospitalI work at. I left as I couldnt standworking such ridiculous hours. Itsludicrous to expect you to be workingat your bestfor this amount of time, andon your feet.

Concerns about 12-hour shiftsLong shifts have become an establishedfeature of working life for many nurses inthe NHS. Our study, based on a representa-tive sample of 31,627 nurses on acute gen-eral hospital wards in the EU, found that14% were working shifts of 12 hours orlonger (Griffiths et al, 2014). In some coun-tries most notably England, Ireland andPoland 12-hour shifts are far morecommon; in England, 32% of day shifts and37% of night shifts are reported to be12 hours or longer (Griffiths et al, 2014).

Despite the growing use of 12-hourshifts, persistent concerns have beenraised about whether it can be safe towork such long hours. Many nurses

In this article...

Why some nurses prefer to work 12-hour shifts

Potential problems caused by nurses working long shifts Issues to consider when introducing 12-hour shifts

Working 12-hour shifts can benefit staff and healthcare organisations but the risksand potential adverse outcomes must be carefully considered and mitigated against

The 12-hour shift:

friend or foe?

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care left undone (p

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Nursing PracticeDiscussion

accept they cannot possibly maintainconcentration and enthusiasm for solong without adequate food, fluids andrestful breaks.

Perhaps, if more research like this accu-mulates, some consideration needs to begiven to restricting opportunities to work12-hour shifts until adequate safety meas-ures are put in place to mitigate the associ-ated negative effects. Many aspects ofworking hours are governed by the EUWorking Time Directive, but these shiftpatterns seem largely outside its scope.The questions that remain are: Should employees who undertake work

in which safety is critical be permittedto work in ways that are known toincrease risk?

Should employers be allowed to askthem to do so?

ConclusionIt is imperative that healthcare organisa-tions are fully aware of the effect that12-hour shifts can have on staff and, conse-quently, also on patients. They mustunderstand the risks and benefits of suchshifts, along with the importance ofundertaking the proper planning to miti-gate the risks and take full advantage of thepotential benefits. Box 1 lists implicationsfor practice. NT

Quotations are drawn from discussions

and comments on nursingtimes.net, made

in response to a report on Griffi ths et al

(2014), available at: bit.ly/NTShiftWarning.

Bold has been added by the authors,

and spelling and punctuation errors have

been corrected.

The authors receive support from the

National Institute for Health Research

Collaboration for Leadership in Applied

Health Research and Care (NIHR CLAHRC)

funding scheme. The views expressed in

this article are those of the authors and

not necessarily those of the NHS, the NIHRor the Department of Health.

ReferencesBae SH (2013) Presence of nurse mandatoryovertime regulations and nurse and patientoutcomes.Nursing Economic$; 31: 2, 59-68, 89;quiz 69.

Chen J et al (2011) Physiological and behaviouralresponse patterns at work among hospital nurses.Journal of Nursing Management;19: 1, 57-68.Day G(2004) Is There a Relationshipbetween 12-hour Shifts and Job Satisfactionin Nurses.Montgomery, AL: Alabama StateNurses Association.Estryn-Bhar M et al(2012) Effects of extendedwork shifts on employee fatigue, health,satisfaction, work/family balance, and patientsafety. Work;41: 4283-4290.Geiger-Brown J et al(2012) Sleep, sleepiness,fatigue, and performance of 12-hour-shift nurses.Chronobiology International; 29: 2, 211-219.Geiger-Brown J, Trinkoff AM(2010) Is it time topull the plug on 12-hour shifts? Part 1. Theevidence. The Journal of Nursing Administration;40: 3, 100-102.Griffi ths P et al(2014) Nurses shift length andovertime working in 12 European countries: the

association with perceived quality of care andpatient safety. Medical Care; 52: 11, 975-981.Harris R et al (2014) Impact of 12-hour shiftpatterns in nursing: a scoping review. International

Journal of Nursing Studies; doi.org/10.1016/j.ijnurstu.2014.10.014Keller SM(2009) Effects of extended work shiftsand shift work on patient safety, productivity, andemployee health.AAOHN Journal: Offi cial Journalof the American Association of OccupationalHealth;57: 12, 497-502.Olds DM, Clarke SP (2010) The effect of workhours on adverse events and errors in health care.

Journal of Safety Research;41: 2, 153-162.Potera C(2011) Long hours for nurses affectpatient mortality.American Journal of Nursing;111: 4, 14-15.Rogers AE et al(2004) The working hours ofhospital staff nurses and patient safety. Health

Affairs; 23: 4, 202-212.Stimpfel AW, Aiken LH(2013) Hospital staffnurses shift length associated with safety andquality of care.Journal of Nursing Care Quality; 28:2, 122-129.Surani S et al (2007) Sleepy nurses: are we willingto accept the challenge today?Nursing

Administration Quarterly; 31: 2, 146-151.Trinkoff AM et al (2011) Nurses work schedulecharacteristics, nurse staffi ng, and patientmortality.Nursing Research; 60: 1, 1-8.Trinkoff AM et al (2006) Longitudinal relationshipof work hours, mandatory overtime, and on-call tomusculoskeletal problems in nurses.American

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Youll never be perfect, soalways be kind to yourselfRebecca Sherrington p24

After successive shifts (Geiger-Brownand Trinkoff, 2010).

Shorter shifts may be, however, less fea-sible at night.A key issue, and a challenge in trying to

review the evidence on 12-hour shifts, isthat it depends on how its done that is,how 12-hour shifts are implemented andthe wider working pattern context. Clearly,levels of fatigue and associated impairedfunctioning will be affected by many otherfactors beyond the length of shift somerelated to other aspects of shiftworking(sequence, choice, time of day/night) andsome to other dimensions of work, such asworkload, and physical demands.

These contextual factors are rarely

accounted for in the research, with littleinformation about the practical ways inwhich a shift system is operated, such ashow many long shifts are worked in a row,number and length of breaks, and varia-tion in the pattern of shifts worked.

In our study we controlled for one keyfactor known to have associations withpatient safety and quality staffing levelsof registered nurses. However, as we didnot have access to data on other aspects ofworking patterns and deployment (such asbreaks and sequencing), we have littleinsight into their possible effect and howthis may contribute to or mitigate theobserved effect that 12-hour shifts have onspecified outcomes.

Mitigating the risksThis issue of it depends how may be key tounderstanding the mixed views and reac-tion given in response to the use of 12-hourshifts. The question we have sought toaddress has been Are negative effects ofworking 12-hour shifts observed when con-trolling for other factors?. Perhaps futurework needs to start from a different view-point not Are 12-hour shifts good orbad? but In what conditions can a 12-hour

shift system be operated without risk topatient safety or nurse wellbeing? As oneperson said in response to our article:

Yes staff need breaks, preferably withdecent facilities. But dont throw the babyaway with the bathwater;many staff preferlong shifts.

Research such as ours points to theimportance of considering some of the sta-ples of research on shift work over the years.If working long shifts, it is increasinglyimportant to ensure nurses have adequatetime for rest between shifts and must notwork too many in a row. Returning to thecomments ofNursing Timesreaders:

Nursing staff like long shifts but most

For more on this topic go online...

A qualitative study on effects ofworking unsocial hours

Bit.ly/NTUnsocialHours

BOX 1. IMPLICATIONS FOR PRACTICE

A policy of moving to longer shifts may have unintended consequences: nurses

may perform less effi ciently and less safely

Where 12-hour shifts are already in operation, managers should try to plan the

schedule to reduce fatigue

Fatigue countermeasures, such as taking completely relieved breaks, are needed to

improve productivity and relieve stress

Respect for days off is essential; lack of suffi cient time away from work between

shifts can be detrimental

Source: Adapted from Geiger-Brown and Trinkoff (2010)