abouhmoud final thesis study

Final Thesis Draft November 8, 2015 1

The 12 hour Registered Nurse work shift and its Downfalls.

Amer Abouhmoud

Dr. Su

HSC 484

11/8/2015

Cleveland State University


ABSTRACT

The path to becoming a registered nurse is a long and difficult road to travel and not

many do. For the ones who push on and make it out on the other side to become a successful

registered nurse, a life of strenuous responsibility awaits them. What I have chosen to do in this

research thesis is go out into the field of work and observe these registered nurses in action and

see how their daily shifts go. For this particular research, I wanted to look at 12 hour shift

registered nurses who work within a hospital. For comparison purposes, I have chooses to

observe and do research on three separate groups consisting of 20 registered nurses respectively.

Group A which will be 12 hour day shift registered nurses (7am-7pm) , Group B night shift

registered nurses (7pm-7am) as well as Group C registered nurses who work outside of a hospital

in a traditional Monday through Friday 8 hour work week. The hypothesis here will state that 12

hour registered nurses will begin to hit a proverbial wall around their tenth hour of work, and

will be even worse for the nurses who work the overnight shifts. However for the nurses who

work outside of the hospital in a more traditional work schedule in Group C, they will have a

smaller turnover ratio, and the error in care will be significantly less.

KEYWORDS

-Registered Nurses

-Circadian Rhythm

-Shift Work Disorder

-Hospital

-Hours of Sleep

-Diet

-Errors


-Melatonin

-Heart Rate

-Organ enzymes

Table of Acronym Definitions

RN – Registered Nurse

CR – Circadian Rhythm

RMR – Resting Metabolic Rate

HOS – Hours of Sleep

BP – Blood Pressure

SWD – Shift Work Disorder

Group A – 12 Hour Hospital Day Shift Registered Nurses

Group B – 12 Hour Hospital Night Shift Registered Nurses

Group C – Non Hospital Registered Nurses Who Work 12 Hour Shifts

Introduction

The topic will be to the benefit of numerous lives that that can be potentially affected by

this research proposal. As stated before, being an RN comes with a heavy responsibility and

requires dedicated passion to others as one you are sworn into a group of people who dedicate

their lives, their passion, sweat and time to ensuring that others’ lives around them and under

their care and supervision is better than when they first met. To my own amazement our society

does not hold being a nurse to the same prestigious levels of those that are doctors let us say.


People still look down upon RNs due to the over shadowing of the all mighty doctor titles in this

world. This is no more evident than when Miss American runner up Kelley Johnson came out on

stage at the Miss America Pageant in her nursing scrubs to prove a point about nursing because

she had just graduated with her nursing degree and was becoming a RN in the process of doing

Miss America. However when a day time talk show called The View talked about what Kelley

Johnson did, they made fun of her and one co-host was stated saying “why does she have a

doctor’s stethoscope on?” The issue was that the talk show hosts did not take her seriously for

only being just a nurse, and made the assumptions that only doctors can carry the all might

stethoscopes (HENSLEY, 2015). This proposal will truly show how hard being a registered

nurse is, which leads me to my thesis of why RNs should not be working 12 hour shifts,

especially overnight 12 hour shifts.

For RNs who work 12 hour shifts, it can be very beneficial to their at home lives. This is

due to the fact that they will then get days off during the week to be at home and do whatever

they need to do in their lives and be around their families more if they have any. However the

problems lie in the patient not caring about the RNs outside life, as they are in pretty rough shape

being stuck in a hospital, if not in deathly shape, as well in those who are signing off on these

schedules allowing these nurses to work at times 3 if not more days in a row where they can

become less effective to patient care. This means that the nursing staff better be on their A game

when on the clock because this is not like any other line of work due to the high level of stress,

that being a human life in your hands, and if you mess up you can really be dealing with a life or

death situation. These nurses who work within a hospital are working at all odd hours, seven

days a week, 365 days a year including all holidays. A problem with this is that the RNs are over

working themselves which in turn is putting the patients who are already vulnerable, in worse


shape because now the room for human error has grown because of the RNs body and brain

becoming fatigued. Working a 12 hour shift is bad enough due to the long hours and doing a 12

hours shift as a nurse overnight has to be even worse, especially for new RNs who have never

done it before coming right out of nursing school and have to be able to think clearly at all odd

hours of the night. This proposal will take a look at how working these kind of hours affect

patient care, the RNs themselves and what we can do to fix these issues that arise.

SPECIFC AIMS OF THIS STUDY

1- To see if 12 hour shifts are beneficial to registered nurses, or if they are causing too

much distress and error in the field of being a registered nurse working within a

hospital.

HYPOTHESIS

My hypothesis for this proposal is that if RNs were to work no more than 10 hours shifts,

error in care would occur less, and the RN turnover rate would come down substantially. This

would also mean that the health issue diagnosed as Work Shift Disorder (WSD) would start to

diminish and appear less in RNs who work odd hours such as 7pm to 7am. This will now let RNs

go home when they start to become dangerous to patient health caring, and allows them to still

maintain their days off during the week if they so choose by working up to the ten hour mark if

they can. Although the schedule of three days on and four days off is appealing, that should not

be the deciding factor of someone wanting to go into nursing because the degree of difficulty due

to this profession of taking care of human lives.


BACKGROUND AND SIGNIFICANCE

The whole point to this proposal is effectively to make more people healthier and safer

inside the work sector of a hospital setting, patients and RNs alike. In the big picture, the thing

that will make patient care even better and safer will effectively be making a RNs job more

convenient and less stressful. To do this we have to dive into the lives of an RN and seek

information into their lives outside of the hospital as well. For instance, it is important to obtain

the number of hours of sleep an RN gets before coming into work for a day shift, versus the

number of hours of sleep for an RN coming onto do the night shift. Then to compare the two, we

will add in the number of hours of sleep for nurses we have working a traditional 8 hour day

outside of a hospital. Within that information, we will be able to tell is WSD is occurring due to

lack of sleep in these nurses. According to Horng et al, they conducted research into a group of

all female nurses who worked all sorts of shifts in nursing. Their research was not environment

oriented in a hospital like mine as they were truly trying to observe a nurses home life. They

were more interested in surveying these nurses and finding out who had a more productive life

outside of work and how happy they were outside of work as well. They came to the conclusion

that nurses who worked an 8 hour day had a more productive life style outside of work and

nurses who worked an overnight shift had a more robust activity rhythm (Kang, Miao, Trevor, &

Min, 2015, pp. 348-355).


(Saleh & Awadalla, 2014)

A key factor into the 12 hour work shift becoming a very serious problem for nurses is

when it comes to error in their work, specifically in this case medication errors which have led to

death in some cases. When you go to the hospital, or have a loved in in the hospital, you are

putting your whole trust fund into the hands of another human being in hopes that they will take

care of you or your loved one. Your expectation is to get better and move on. However according

to this graph done above by Saleh et al. it shows us that the number of hours of sleep an RN gets

can greatly increase the chances of error when it comes to passing medications to their patients.

This graph shows us how when a an RN gets 6 hours of sleep or less, there is a much greater risk

of medication error occurring to the patient. 9 dots, which in this case 1 dot represents 1 nurse,

were plotted at the 6 hours of sleep mark, opposed to only 4 dots on the side of an RN obtaining

more than 6 hours of sleep. That is over a 50% increase in error to happen when an RN does not

obtain enough sleep. Whether you are working the day shift or night shift, getting the right

number of hours of sleep is very important when it comes to taking care of your patients, as well


as yourself. From the same group of researchers, they have added another graph to prove how

important it is for the RN to take care of themselves as well.

(Saleh & Awadalla, 2014)

This study also helped show how depression in nurses effects their work as well.

Looking into the graph, the regression line is trending upwards, which means the more someone

is depressed, with respect to levels of depression, that the RN is more prone to making errors in

their care of medication use to patients. This is proof that nurses with a higher rate of depression

are obviously more prone to being side tracked at work and cause error in patient care as well.

Another issue for nurses is the 12 hour night shift, and is especially hard for the nurses who are

beginning to work on that shift that have never done work, or even been awake typically during

those off-set hours (Summa & Turek, 2015). Being an RN is hard enough, being one from the

hours of 7p to 7a is a whole different challenge. This is proved when Summa and Turek studied

how ones circadian rhythm is thrown off when you begin to work during hours your body is not

used to. They came to a conclusion that every human has a master clock embedded within our


brains that regulates mass functions occurring within our bodies. Thus, humans typically find

themselves becoming sleepy when it is night time and dark outside, and we begin to function

when the sun arises and have more energy. They also looked into the idea that there are also

other clocks in the human body, referred to as peripheral clocks, which micromanage the organ

they are in. Something interesting they found was how someone’s weight and diet could play

into making the transition into being up during your bodies not normal hours can affect your

function (Summa & Turek, 2015, pp. 5063-6755)

Based off the work they did, it would be ideal that we could figure out when each

person’s circadian rhythm is at peak performance, which would in turn allow us to place nurses

on a more efficient work schedule for their life and health, and also help treat people with WSD

and other medical conditions. This would allow a breakthrough in the medical treatment world

and pharmaceutical world as well, as it would allow us to understand certain conditions more,

and avoid them as well, making RNs more efficient at work and allowing them to work when

their bodies are at full functional capacity.

Another reason to find out the true importance of the humans circadian rhythm is to find

out how it effects our moods. According to a study done by Zhang, Zeng and Huang, the CR is

what also affects our relationships at home, along with our social lives in general. This research

was important because their theory is that people are more social between the hours of 8pm and

midnight, making them less inclined to be sociable at 8am. This does no good for the RNs who

are at work during these hours. If these are the true peak hours of being social, then their social

lives at home are taking a major hit which will turn into some sort of depression or anger down

the road (Zhang, Zeng, & Wang, 2015, pp. 1-8)


-MORE BACKGROUND TO BE WRITTEN-

METHOD

There will be three (3) groups with 20 RNs in each group.

1- Day Shift RNs (7am-7pm)

2- Night Shift RNs (7pm-7am)

3- RNs who work outside of a hospital on an 8 hour schedule

A mix of male and female RNs will be requested, with no specific target or male RN to female

RN ratio. Consent will be mandatory from the research participants by a hand written signature

from each nurse. We will never request and not adhere to hearing any patient information, or any

information regarding to any patient in particular, and we will adhere to the HIPA laws in

accordance to the law.

This will also include observations of the nurses inside their working environments on site, and

interviews on site as well as questioners on a daily basis to each member.

RESEARCH DESIGN

A quantitative experiment that will be supplemented by onsite interviews and questionnaires to

be answered by the RNs as well.

Procedures- Mood will be measured every time an RN comes into work by asking the

RN how they feel right before they clock in, how their day went, and if anything happened to

make them frustrated during their day before work to gage how emotionally stable they are going

into their shift ahead.


- I will also be asking how many hours of sleep the RN had and compare it to the

national average of HOS set forth by the World Health Organization (eight hours).

- My data and analysis plan will be quantitative.

RESOURCES AND ENVIRONMENT

For resources, I will be using not much more than the following

- Voice recorder for interviews to compare tone of voice on a daily basis.

- Pencils

- Notepad paper

- Blood pressure and heart rate monitors

- Thermometers

- A Hospital with both Medical Surgical Unis in it, as well as an emergency room.

- We will also be in need of a doctor’s office or nursing facility which is not a hospital,

which has a nursing staff who works on 8 hour rotations.

LIST OF ALL MATERIALS

-A hospital, specifically Cleveland Clinic Fairview Hospital with permission from the

Nursing directors who I share an office with here at Fairview Hospital.

- Other nursing facility

- Nurses Station with office available for interviewing

- Blood pressure cuffs

- Heart rate monitors

- EKG machines

- Psychiatrist

- Dieticians

- Physicians

- Questionnaires

- Snacks such as chocolates and vegetables


TIME LINE

The time line for this research shall be done and completed within 6 months. Each month I will

compare my data to the previous month and see how the 12 hour work shift is effecting the

nurse’s work. I will recruit nurse by telling them how this study will help me depict to others

why some do and do not like the 12 hour work shift for being a nurse. I will get this done in 6

months by being on site every day, calculation my research to fit within that time span as well as

basing a half way point at the 3 month mark to compare and see if regression happens at the end

of 6 months.

CONCLUSION

This study was done to make numerous lives in the world of health care much safer and

much happier. This is also going to make a RNs job a lot less stressful as they will be able to get

home quicker, then having to stay at work and stew over something bad that has happened to

them over the course of their day. This will hopefully make the patients stay at the hospital much

more efficient and enjoyable. This will show an increase in a RNs attitude, and thus make the

turnover rate for RNs much smaller. This will also drive dow (Paschos, 2015)n the numerous

cases of WSD. Getting all RNs to work on an 8 hour schedule will reduce anxiety of being away

from home for upwards of 12 to 14 hours, including commute time and pass off report time, it

will stave off depression, and make attitudes and moods in general go up for the better for each

RN. Night shifts will never go away in the area of work that is in a hospital, however there is a

way to make those hours of work more efficient and safer for everyone involved, not just the

patients.


PERSONAL BIOGROPHIES

This will include all research members who accept to give us information about

themselves. If they decline, they will not be featured under this section in respect to their wishes.

BUDGET

The budget for this research will hopefully remain small, as the most costly items will be

the snacks and paper we have to go through. Our hope is that we can get these RNs and maybe

doctors to join in on this research as it pertains to their livelihood, their field of work which we

would hope that they are passionate about and are interested in being a part of research about, as

well as we hope that the RNs will be enticed by our offer of food as compensation instead of

being financially compensated. We will ask to borrow and use all medical related items from the

hospital floors while we are there. This does not look to break the bank by any stretch of the

imagination, and should be more then fine to get done without having to stress about finances.

(Saini, 2015)

ReferencesHENSLEY, N. (2015, September 16). Nurses upset with ‘The View’ hosts Joy Behar and Michelle Collins for

making fun of Miss Colorado’s stethoscope . Retrieved from NEW YORK DAILY NEWS: http://www.nydailynews.com/news/national/nurses-upset-view-making-fun-colorado-article-1.2363266

Kang, J. H., Miao, N. F., Trevor, S., & Min, C. H. (2015). Research Into Work Shifts. Biological Research for Nursing, 17(3), 348-355. doi:10.1177/1099800414549454

Saleh, A. M., & Awadalla, N. J. (2014, January 1). Impacts of nurses’ circadian rhythm sleep disorders, fatigue, and depression on medication administration errors. Egyptian Journal of Chest Diseases and Tuberculosis, 63(1), 145-153. Retrieved November 5, 2015, from http://www.sciencedirect.com/science/article/pii/S0422763813002380

Summa, K., & Turek, F. (2015). THE CLOCKS WITHIN US. Scientific American, 312(2), 5063-6755.

Zhang, P. C., Zeng, C., & Wang, X. X. (2015). Circadian Rhythms in Socializing Propensity. Plos ONE, 10(9), 1-8.


Questionnaire:

1.) Do you enjoy the work that you do?

2.) Are you happy with your life?

3.) Are you happy at work?

4.) If no to the previous answer, would a change of work place make it different?

5.) Do you like the hours you work, if not, what hours do you wish you could work?

6.) Are you single, domestic partner, married or other?

7.) Do you have children?

8.) Are you currently enrolled in classes?

9.) Do you plan to farther your education or advance in the work place?

10.) Where do you see yourself in 5 years?


Institutional Review Board

Human Subjects in Research

Instructions and Checklist for Applicants

The Institutional Review Board (IRB) of Cleveland State University (CSU) is responsible for ensuring the

protection and ethical treatment of human participants in research conducted under the auspices of the

University. Accordingly, the IRB must evaluate all such research projects, in compliance with Federal

Regulations. Your application to the IRB for permission to test human subjects should follow the guidelines

provided below. Proposed Departures from the guidelines should be justified thoroughly.

Some protocols may be approved through one of the expedited or exempt categories in the Federal Regulations,

and some require full Committee consideration. These determinations are made by the IRB, not by the

researcher. If your protocol requires full Committee consideration, the University Office of Sponsored Programs

and Research must receive it no later than two (2) full weeks prior to the IRB meeting; this meeting normally

occurs during the first week of the month. Protocols should be submitted to the IRB, Office of Sponsored

Programs and Research, 2258 Euclid Avenue, Hannifin Hall, Cleveland, OH 44115-2440 ATTN: IRB Coordinator.

Issues of Particular Concern to the IRB

Privacy: In most research, subjects’ willingness to participate will depend on the researcher’s explanation of

the project and its purpose, the subject’s understanding of risks and benefits, and the assurance that the


specifics of their participation will not become known to other individuals. A mismatch between your

assurance to the subjects and the procedures you explain in your Project Description will lead the IRB to

request revisions before approval can be granted. Issues of anonymity and confidentiality are of special

concern when subjects might divulge sensitive information, including situations in which their responses

might place them in jeopardy (e.g., public embarrassment, threats to job security, self-incrimination). The

care with which you address these issues in your procedures is very important to the IRB approval process

Risk: In much research, subjects’ participation involves little or no risk. If this is genuinely the case, say so;

e.g., “minimal risk,” “no foreseeable risk,” “no risks beyond those of daily living.” If there is some risk,

where physical, psychological, social, legal, or otherwise, the IRB will be particularly interested in the

safeguards you implement to deal with these risks. The overall importance and soundness of the research

project will be especially important if subjects are placed at some degree of risk by participating.

Special Populations: Testing minors, pregnant women, prisoners, mentally retarded or disabled persons, or

other special populations raises serious issues regarding risk and informed consent, which your protocol

must address. On the other hand, recent federal guidelines mandate the inclusion of women and minorities

in research. The nature of your subject population must be clear in your proposal, and you must provide

your rationale for including/excluding identifiable subgroups based on gender and minority status.

IRB Procedures: CSU’s IRB receives approximately 300 applications a year, each of which must be evaluated

for adequate protection of the subjects against research risks. You will enhance the acceptability of your

proposal, and the speed with which the IRB can evaluate it, if your protocol is concise, deals specifically with

the issues discussed in these instructions, and shows your sensitivity to the overriding concerns of ethical

treatment of human subjects. Please feel free to suggest any modifications or elaboration to these

instructions that would be helpful to you as you write or revise your applications.


II. Participant Information

Total number of participants:

Age range (lower limit – upper limit):

Gender: Select one

Ethnic Minority: Select one

Inclusionary criteria:

Exclusionary criteria:

Source of participants:

Is the data going to be extracted from records that already exist on these participants (e.g. school records,

grade transcripts, medical records, etc.)?

Yes No

If yes, will the data be recorded in a way that prevents subjects from being identified?

Yes No

Length of participation (x time/session, y sessions, over z months):

Participants in Special Consideration Categories: (Check all that apply.)

None Military personnel


Children (age range: ) Wards of the State

Cognitively impaired persons Institutionalized individuals

Prisoners Non-English speaking individuals

Pregnant or lactating women Students

Blind individuals

Other subjects whose life circumstances may interfere with their ability to make free choice in consenting

to take part in research (please specify):

Site(s) of data collection: Cleveland State University

Letters of approval from project site officials: Select one

*You MUST include letters of approval from appropriate administrative officials at the facility where you will

be collecting data.

III. Project Description

a. Give a concise statement of the area of research and briefly describe the purpose and objectives of your

proposed research:


b. Provide a detailed description of how participants will be recruited and used in the project. Please

include a description of the tasks subjects will be performing, the circumstances of testing, and/or the

nature of the subjects’ involvement.

c. Make an explicit statement concerning the possible risks and benefits associated with participating in

the research. Describe the nature and likelihood of possible risks (e.g., physical, psychological, social) as

a result of participation in the research. Risks include even mild discomforts or inconveniences, as well

as potential for disclosure of sensitive information. If a risk exists, how does it compare to those of daily

living? What are your safeguards for avoiding risks, for protecting subjects’ privacy, etc.?

d. Describe measures to be taken to protect subjects from possible risks or discomforts.

e. Describe precautions to ensure the privacy of subjects and confidentiality of information. Be explicit if

data are sensitive. Describe coding procedures for subject identification. Include the method, location

and duration of data retention. (Federal regulations require data to be maintained for at least 3 years)


IV. Informed Consent Form

Yes No N/A

Does the Informed Consent Statement?

1. Introduce you and your research (including names and phone numbers).

2. Provide the subject with a brief, understandable explanation of the research.

3. Explain the risks and benefits.

4. Explain the details of the time commitment for participation.

5. Explain how your protocol either protects confidentiality or is anonymous.*

6. Mention that participation is voluntary, and that the subject may

withdraw at any time without penalty.

7. Include the exact statement about contacting the IRB.**

8. Provide a phone number where the subject may contact you for further

information (students should include a phone number for themselves and

also for their supervising faculty member).

9. Have a signature/date block for the subject to complete.***


* Confidentiality and anonymity are not the same. Confidentiality means that the researcher will know the identity

of specific subjects and their data. Anonymity means individuals’ responses cannot be associated with the data

they generate.

** “I understand that if I have any questions about my rights as a research subject I can contact the CSU

Institutional Review Board at (216) 687-3630,” or if a minor, “I understand that if I have any questions about my

child’s rights as a research subject I can contact the CSU Institutional Review Board at (216) 687-3630.”

*** If you wish to dispense with a signed consent form, for either procedural or substantive reasons, be sure to

include a clear statement of your reasons and your alternate procedure for obtaining consent.


VI. CERTIFICATION/SIGNATURE

I certify that the information contained in this protocol application and all attachments is true and correct. I

certify that I have received approval to conduct this research from all persons named as collaborators and

from officials of the project site(s). If this protocol is approved by the Cleveland State Institutional Review

Board, I agree to conduct the research according to the approved protocol. I agree not to implement any

changes in the protocol until such changes have been approved by The Cleveland State Institutional Review

Board. If, during the course of the research, unanticipated risks or harm to subjects are discovered, I will

cease collecting data and report them to IRB immediately.

______________________________________________ ______________

__________________________________________________

Sign Name Principal Investigator/Faculty Advisor Date Print Name Principal Investigator/Faculty Advisor

______________________________________________ ______________

__________________________________________________

Sign Name Co-Principal or Student Investigator Date Print Name Co-Principal or Student Investigator


______________________________________________ ______________

__________________________________________________


______________________________________________ ______________

__________________________________________________


______________________________________________ ______________

__________________________________________________



______________________________________________ ______________

__________________________________________________


Forward this completed form to:

Cleveland State University

Institutional Review Board

Office of Sponsored Programs and Research

2258 Euclid Avenue

Hannifin Hall

Cleveland, OH 44115-2405

V. Copies of Instruments and Questionnaires

American Health Association/American College of Sports Medicine:


This study’s running history survey:

abouhmoud final thesis study

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