The evidence on nurse fatigue has been there all along.
During Women’s History Month, which is about to end, I’ve been posting (here and here) on nursing history (and in the process exploring its close confluence with women’s history). For this last post, I’m highlighting an article published in the March 1919 issue of AJN—exactly 100 years ago. The evidence on fatigue from long working hours has been there all along.
“The Movement For Shorter Hours in Nurses’ Training Schools” (free until April 15; click on the pdf version in the upper right), was written by Isabel Stewart, who was professor and then director of the nursing program at Teachers College, Columbia University, and coauthor of the National League for Nursing Education (the forerunner of today’s National League for Nursing) Standard Curriculum for Schools of Nursing.
A call for 8-hour work days for nurses.
In this article, which is in some ways disturbingly relevant today, Isabel Stewart notes that major nursing organizations recently met and were seeking “to enlist the support of a great many influential organizations and the general public in establishing an eight-hour day and a fifty-two hour week for pupil nurses.” (As a reminder, hospital nursing staff at that time were mostly nursing students.)
Fatigue undercuts nurse health and leads to dangerous mistakes.
Stewart cites several key reasons for shortening work hours and cites research from several publications to support her points. Some of her statements ring true today:
- ” . . . the results of fatigue are cumulative . . . [It] encroaches upon the worker’s total strength and endurance and soon permanently lowers the capacity for work and the general level of health.”
- “It has been abundantly proven in other fields of work . . . that with shorter hours there is much less time lost for sickness and the morality rate is lower.”
- “The relation of fatigue to accidents and mistakes has been well-established. The attention flags, there is difficulty in concentrating thoughts, reaction time is diminished . . . We know that in nursing where concentrated attention and alertness are so necessary, the patient’s life is often endangered by the mistakes or oversight of an over-tired nurse.”
What the Joint Commission says about nurse fatigue.
Like Stewart, we know that errors are more likely to happen at the end of long shifts, especially when there are no opportunities for meal breaks. Some hospitals have adopted evidence-based practices, like allowing napping.
A report by the Joint Commission summarizes many of the issues and offers recommendations to reduce fatigue; it notes that “the “Institute of Medicine has recommended that all nursing shifts greater than 12 hours be eliminated. Studies of evidence-based intervention schedules have demonstrated the feasibility of implementing shorter tours of duty; however, adoption of evidence-based scheduling has lagged in the United States.”
Ignoring the evidence.
We’ve reported on research on work hours and on the effects of sleep loss on nurses’ health, and there have been multiple studies on these issues. But the issue and the evidence continue to be ignored. As Isabel Stewart wrote 100 years ago:
“An institution which claims the support of the public as a scientific and humanitarian institution . . . cannot any longer refuse to apply the scientific discoveries regarding the nature and effects of fatigue which are now almost universally known and accepted by even the man in the street.”
Twelve hour shifts means a nurse will have a three day work week. For those studying nursing, this attracts them to keep pursuing their career. Although nurses are experiencing fatigue, due to long work hours, try asking a nurse to change to 8-hour work days. A nurse will look at you as if you were crazy; as if working three days is not enough.
In a survey by Stimpfel, Sloane, and Aiken, 2012, over 80% of nurses working over 10 hours in a work day reported they were satisfied with the scheduling practices in their hospitals. Then why is there such a high turn over rate in these hospitals we work in, if so many nurses are “satisfied” with their work schedule.
I don’t know the answer to that question, but I as a registered nurse, would reconsider my work schedule. The floor I work on is so burdensome, I work an average of 14 hours each shift. I clock in at 6:30 AM and clock out 8:30-9:00 PM every time. I would not mind an 8 hour shift, as the author states. Sure, I would work 6:00 AM- 2:30 PM, five days out of the week, but I feel I would not be as burnt out as I feel now.
Stimpfel, A.W., Sloane, D.M., & Aiken L.H. (2012). The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. US National Library of Medicine National Institutes of Health, 31(11), 2501-2509. DOI https://dx.doi.org/10.1377%2Fhlthaff.2011.1377
Twelve hour shifts definitely affect nurse health and patient safety due to fatigue which
can lead to adverse events. According to the American Journal of Nursing, there have been nursing
organizations that support eight hour work shifts; however there has been no implementation of shortening
shifts even with evidence-based research in support of this change. Although twelve-hour shifts are more
convenient since you get 4 days off for the week, nurses are still burnt out and do not get enough sleep
depending on the unit they work in as well as dealing with demands outside of work.
Furthermore, shortening work hours may decrease accidents and mistakes; however nurses will have
to work more days/week which will not improve the amount of time they have off to recuperate from work.
I do agree that hospitals should allow naps or a mandatory adequate break. The hospital I used to work at
would give a 30 minute lunch break which was sometimes cut short due to the demands of the unit and short
staffing since we did not have any nursing aids on our unit. Unfortunately, sometimes depending on the patient
assignment, you may not even get to take a break, which is against the law and dangerous for patients. In order
to minimize fatigue-related errors and nurse sickness/mortality, there needs to be additional strategies to
protect nurse health and patient safety aside from eight hour-work days. A shorter shift can definitely be an
option but more research needs to be done on additional interventions in regards to this global health issue.
The only reason for 12 hour shifts is the convenience of scheduling. There is no evidence that bringing in the staff from 7 to 7 aids patient care in any way. It ignores that reality that patient care needs vary through the day depending on the type of unit. All units have slow times and heavy times. An 8-hour schedule helps staff closer to those needs. The 12-hour shift should never be followed by another 12-hour shift. The evidence on the decline of care is bad enough without adding to the fatigue of the nurse by coming back so soon. As we get older we have less ability to recover from a long day of work. Other issues that can impair the ability to get adequate sleep are commuting times and family responsibilities.
When I began my career a 12-hour shift was limited to special programs to staff weekends. No nursing research ever said that long shifts would be better for patients or nurses. It’s time to investigate this issue and see if there is any justification for 12-hour shifts beyond the Administrative suite.