Long Work Shifts Impact Nurses and Patients


By Debra Wood, RN, contributor

Nurses who work longer days may appreciate having more days off in between shifts, but they can face some challenges, as well.

Adding to the existing body of knowledge surrounding the risks associated with nurses working long hours and getting fatigued, a new study shows that even though nurses overwhelmingly expressed satisfaction with their schedules, working long hours was associated with more nurse burnout, a greater intention to leave their positions and decreased patient satisfaction.

“Part of it might be that it sounds good to work three days a week, but once you start working it and your shift is longer or you are called in on your day off, the benefits disappear,” said Amy Witkoski Stimpfel, PhD, RN, post-doctoral fellow at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia.

The Penn team, which included Douglas M. Sloane, PhD, and Linda Aiken, PhD, FAAN, FRCN, RN, conducted a secondary analysis of 22,275 registered nurses, from 577 hospitals in four states, using data from the Multi-State Nursing Care and Patient Safety Study. Sixty-five percent of the nurses had most recently worked a 12- or 13-hour shift.

More than 80 percent of the nurses said they were satisfied with scheduling practices. However, as shift length increased so did the percentage of nurses reporting burnout and the intention to leave their current job. They found the odds of burnout and job dissatisfaction were 2.5 times higher for nurses who worked longer shifts when compared with nurses who worked eight or nine hours.

“By the end of 12 hours, [nurses] are spent,” said Jan Conway, PhD, RN, dean of the School of Nursing at Cedarville University in Cedarville, Ohio. “Nurses are rushed. They are getting in, getting out, and I can see where patients may have a sense of dissatisfaction.”

The authors said they found a significant association with patient satisfaction and hours worked. When nurses worked 13 or more hours, patients were less happy with their pain control and less likely to recommend the hospital to others.

Kim Siarkowski Amer, PhD, RN, associate professor at DePaul University School of Nursing in Chicago and author of Quality and Safety for Transformational Nursing: Core Competencies, said she was not surprised by the findings.

“Patients sense the [nurses’] frustration or lack of caring,” Amer said. “Patients are a lot more sophisticated and more consumer-focused and know when they are not getting the care they should be getting.”

Amer indicated that inadequate staffing leads to poor satisfaction and harms nursing care. Fatigue is a safety issue as well as a workplace issue.

“When you have high ratios and working 12 hours with fatigue, that can push nurses over the edge of being burned out,” Amer said.

Ann Rogers, PhD, RN, FAAN, an Emory University Nell Hodgson Woodruff School of Nursing faculty member in Atlanta, called this a good study, saying Witkoski “pulled together patient satisfaction data and nurse satisfaction that prior studies [about length of shift] haven’t addressed.”

Rogers pioneered research on the effect of working long hours with her groundbreaking 2004 investigation, which found longer work hours and errors associated with shifts lasting 12.5 or more hours raised the risk of mistakes three fold.

“Some of our data showed that nurses come home exhausted,” Rogers said. “We need to stop allowing people to work longer than 12 hours. But I am not sure we can get rid of 12-hour shifts, but we should offer an option for eight hours.”

Abandoning 12-hour shifts would be difficult, because nurses like them. Hope Otto, RN, an emergency charge nurse at Texas Health Presbyterian Hospital Dallas, said 12-hour shifts fit her schedule. She works three days a week and has four days to do other things she loves like going to the gym and spending time with her children.

“It’s really about enjoying what you do,” she said. “The key to staying healthy--mentally and physically--is to maintain a good life/work balance.”

But the high intensity of the job and long shifts lead to fatigue and decreased mental functioning, Conway said. Long hours and sleepiness also present risks to nurses who are more likely to have an accident when tired.

Rogers pointed out that her data, the data used by Alison Trinkoff, ScD, MPH, RN, FAAN, professor at the University of Maryland School of Nursing in Baltimore--who also has studied the association of long work hours and nurse reaction time--and that used in this new study are different, yet all indicated similar risks.

“Different groups used different methods over a 10-year period and still we are seeing the same thing,” Rogers said. “We ought to be paying more attention.”

Witkoski suggested nurse managers and staff nurses discuss scheduling, overtime and the potential side effects of working longer hours and consider more flexible workdays, perhaps offering an eight-hour or 10-hour shift option. She also recommended nurse managers monitor the shifts nurses work, respect nurses who say “no” to overtime and allow staff members to leave promptly at the end of their shift.

“There needs to be an acceptance to say ‘no,’” Witkoski said. “I think they get coerced all too often to stay when it’s not the best choice.”

Nurses and hospitals should limit the number of consecutive days a nurse can work 12-hour shifts, Conway added. She thinks hospitals might change their practices as they strive for better outcomes.

“We are one of the few professions that allows our people to work those kinds of hours, and we have people’s lives in our hands,” Conway added.

Amer suggested more hospitals allow nurses to take short naps in a break room while someone else covers that person’s patients.

“If you do that for 15 or 20 minutes, that decreases fatigue, and nurses will be less likely to make mistakes,” Amer said.

State boards of nursing could consider restricting shift length or the use of voluntary overtime, the team wrote. Conway indicated The Joint Commission also is looking at shift length.

“This is a complex issue,” Witkoski said. “It is going to take time and a cultural shift to bring about change. Twelve-hour shifts are not going away…Small steps to create culture change are important.”

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