By Shawn Kennedy, AJN editor-in-chief
A new study in Health Affairs provides yet more support that reliance on 12-hour nursing shifts (or longer—we all know that shifts often extend a bit longer than scheduled) should be reconsidered. The study supports previous findings of increased burnout among nurses who work shifts longer than eight hours, but finds as well that longer shifts (13 hours or more) are associated with increased levels of patient dissatisfaction.
Despite these negatives for both nurses and patients, 80% of nurses surveyed across four states said they were happy with their hospitals’ scheduling practices.
I imagine that, with all the recent emphasis on patient satisfaction scores, this study will make nurse executives and hospital administrators take notice—especially as consumers become more aware of the research through coverage like this story at the U.S News & World Report site.
We’ve had evidence for a while that the 12-hour shift is not a best practice. For example, in 2004, Anne Rogers and colleagues also published research in Health Affairs. In their national survey of over 1,000 nurses, they found that most nurses generally worked longer than their actual shifts; nearly 40% of shifts were longer than 12 hours, and 14% of respondents had worked “16 or more consecutive hours at least once during the four-week period.” More importantly, they found that “the likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting 12.5 hours or more.”
In 2006, Alison Trinkoff and colleagues published their research on the lengths of nursing shifts in AJN. Their conclusion: “The proportion of nurses who reported working schedules that exceed the recommendations of the Institute of Medicine should raise industry-wide concerns about fatigue and health risks to nurses as well as the safety of patients in their care.”
And just this May in AJN Reports, we examined the controversies surrounding 12-hour shifts, discussing the research and the issues involved.
In Nursing Outlook last January, American Academy of Nursing president Joanne Disch asked, “Are we evidence-based when we like the evidence?” It would seem so.
So the question remains: should nurses’ convenience trump patient safety and satisfaction, and our own health? Is it time to abandon the 12-hour shift?
From the patients point of view, 12 hour shifts are horrible. Everyone is exhausted all the time. Nurses and doctors and nurses aids need to be relaxed and cheerful, not stressed and cranky. Other jobs do not demand this level of long hours, on your feet for hours at a time and being mentally alert. Think about the office worker enjoying their lunch at a cafe or in a quiet park. No, we ask way to much and therefore get too little of drs and nurses. Sweat shops of the last centuries come to mind. 8 hours a day and FOUR days a week should be plenty for everyone.
I have just implemented a 12 hour shift im my hospital due to nursing staff shortage and patient care declination. i am encouraged by those who supported the 12 hour shift as my evaluation for 5 rosters reveals that nurses have mood changes and fatigues but it is also the same with 8 hours shift. however I find that there is more staff on 12 hours giving a hand than on 8 hours. my hospital nurses work 3-4 shifts and have 3-4 days off.
It is not the 12 hour shifts that is the problem. It is not having the time to take breaks or lunches. Doing the 12 hours is better for the patients and the nurses. It allows handoff between two instead of three plus with two you can notice a change in patients condition quicker than if there was 3. What the individual does on their days off and time off may be a contributing factor and should be looked at before discussions of abandon 12 hour shifts.
How would like a nurse on her 11th hour at work taking care of you with a heart attack?
12 hour shifts are dangerous for the patients and bad on the health of the nurses. For those nurses that like it for the extra time off, they are thinking of themselves and not their patients. Nurses are not very bright as a group. I have heard it stated that we need 12 hour shifts because of a nursing shortage. Not very bright huh? Why not demand safe 8 hour shifts and get overtime for everything over 8 hours? 12 hour shifts are for loosers in every way.
12 hours allows for better continuity of care if combined with adequate staffing. Unfortunately if a hospital is using 12 hours as a cost saving device, then they may also be understaffing as a cost saving device. The two together are a disaster. In-Patient acuity is much higher than in years past. Time to revisit the issue of hours and staffing.
For the nurses who are working two jobs, is it really the 12 hour shift that is the enemy? If they worked five 8-hour shifts at one hospital and five 8 hour shifts at another…there would still be that instense level of fatigue…maybe even more. Having worked 12 hours shifts for a number of years, I believe they offer more continuity of care to patients IF and only if, the nurses who hand-off to one another are on top of things. It is a nightmare if you are working behind someone who cannot get themselves organized and keep things under control. I am talking about day-to-day routine circumstances, not those times when all things go haywire. As for the shifts extending on to longer hours, perhaps those persons responsible for determining staffing levels should look at acuity and have enough staff so nurses can take care of their patients at a reasonable pace and have time to think about what they are doing. I have been working as a RN for 35 years and have been a staff nurse on all shifts. My experience has been when people are forced to continually work short, the poor care where just the minimum is done (and barely that) becomes the norm. 12 hour shifts should not be scheduled for more than 3 days in a row and really, 2 is more optimal. NO provider should be scheduled for seven 12 hour shifts…totally dangerous.
All health care providers need to be schooled to take care of themselves and get proper rest. My experience was in order to be successful with 12 hours shifts, on the days that I worked, that was all I did…work, eat, sleep. There is really no time for other activities. It is a trade-off, because there is a finite amount of time in any week.
Thank you Patti Connor Ballard for such an eloquent response. I too have worked a variety of shifts in my 21 year nursing career and I can relate and agree with every point you make. You hit the nail on the head!
I now enter my 32 year of being a RN, 27 of them in direct patient care at the patient’s bedside. During this time, I have done 8 hr, 10 hr, and 12 hr shifts (included fixed shifts, rotating forward, rotating backwards, and weekends only) in medical-surgical and critical care settings of both civilian and military hospitals. I admit that 12 hr shifts in an ICU allowed me to continue working full-time while studying for my PhD. However, my career experience has also strengthened my belief that the 12 hr shifts are detrimental to both staff nurses and patients. The complexity and acuity of today’s civilian hospital setting are significantly greater now than at the time that 12 hr shifts were implemented during a nursing shortage. Do nurses prefer working 12 hr shifts for the added free time they provide? Reduced commute? Reduced days of needed childcare? Probably yes to all of the above (myself included). We already have a good idea of what the staff RNs want. Then there are debates on both sides regarding the correlation of staff RN fatigue with 12 hr shifts. Realistically, even on a good day, 12 hr shifts easily stretch to 14-15 hour “door to door” when you add in commute and child care pick-up, and there were few days that I actually exited the unit door at 7:30. I remember too many times the shear exhaustion I felt at the end of the 12 hr shift despite my marathoner level of physical fitness at the time…and how many times I took a nap in my car (or thought about it) before heading home…or when I arrived home and forgot that I stopped to pick up groceries and the newspaper until I saw them on the passenger seat next to me in the car. I worked alongside staff RNs who worked three 12 hr shifts at Hospital A, then another three 12 hr shifts at Hospital B, in the same week without Hospital A nursing leadership being aware of it. We watched them struggle to fight off fatigue and stay alert to the needs of their assigned patients. The fact is that 12 hr shifts have been retained because they are “staff RN focused” in terms of staff RN recruitment and retention. Yes, RN retention is essential in terms of reducing HR and on-boarding costs in the hospital budget. However, we need to remain “patient-focused” and ask ourselves if the 12 hr shifts are truly in the best interest of today’s patient who is the complex consumer of care. This will require further investigation on measurable patient outcomes, beyond perceived patient satisfaction following discharge. We need to study the correlation of 12 hr shifts to the increased or decreased incidence of safety concerns and hospital-aquired complications that could be traced back to nursing care. The goal is productive, engaged, caring, and competent nurses whose care is correlated to the best possible patient outcomes and the lowest level of risk for all involved. We all entered this wonderful nursing profession to take care of patients, and they are counting on us being there 100%.
I, myself like the 12 hour shifts. Continuity with pt. care is a plus and working the 3/12’s in a row is pretty nice, more days off and great rapport with my pts. I feel more organized and less rushed to finish up my day.
I have rotated all shifts on a med surg floor and can tell you from personal experience (both working and having family members hospitalized) that 12 hour shifts are injurious to patients and unsafe nursing practice. Even in my 20’s and not having a spouse or children to come home to, the fatigue and exhaustion paled in comparison to the way I ever felt after a typical 8 (really 9) hour day. I was barely functional and coherent when getting home. Yes, it is convenient and wonderful to get full time benefits for working 3 days, but at what cost? Many of the nurses I know that work 12 hour shifts take second jobs to enjoy the benefits of having a vacation home or are saving for family trips, helping out elderly parents and college for their children.
Sorry about the delay in approving this and other comments that came in over the holidays. We appreciate your weighing in on this topic and giving your personal angle on the question of shift length.
I have worked every combination of 8 hours, 12 hours, both with and without “on call” added to the mix…..I think the worst of all in terms of burnout and fatigue are rotating shifts. I believe there are studies which show this type of shift work has negative effects on REM Sleep, on overall health, mental alertness, and overall effectiveness. I see administrators who have the attitude “well, I had to rotate, why should it be different now?”
I think focusing on the negatives of rotating shifts, and pressure to do away with them would be of more importance than singling out 12 hr shifts.
In addition to the comments above, I wonder if there have been any studies for those nurses who work 8 hour (+) shifts and the fatigue that comes with working every day and then with only 2 days off which gets crammed full of all the other responsibilities that was not able to be done during the work week. I loved working the 12 hour shifts and rarely did I stay past in contrast to a 8 hour work day.
Twelve-hour shift evaluations should include the type of activities being performed…the physical stress of direct patient increases hormonal responses that may attribute more to burn- out than in- direct care. There must be a way to overlap shifts to allow for a two hour decompressing transition to complete patient evaluations, charting, and “tying up loose ends”.
I have worked 12 hr shifts (day shift only) for over five years and find them far less fatiguing than working 8 hour shifts that frequently run overtime. Those working 8’hour shifts on ,y ward frequently work seven days straight with multiple late early shifts and two days off followed by another seven day stretch. It is not uncommon for them to have a night duty or two added on to their last day or two with only two days off followed by more late early shifts. This is increasingly fatiguing. Give me my five 12 hour shifts a fortnight anytime!
I really want to heed the evidence- and I do know I’ve worked my share of extra long shifts. But anecdotally, I have always felt better, more rested and like I can keep some balance in life when I’ve done 12’s. Having started my career doing 5 8-hour shifts (evenings) and now being in a leadership role working 5 days a week again, I feel more tired continually and really feel the need for time off more than when I worked 12-hour nights.
This post is getting a lot of comments right now at our Facebook page as well. http://www.facebook.com/AJNfans
It seems likely that a more nuanced approach to the question, as suggested by the observations in JParadisiRN’s comment above, may be what’s called for, rather than a strict either/or approach to 12-hour shifts.
I prefer 12-hour shifts to 8 hour shifts for many reasons. First, as mentioned in the previous comment, they rarely lasted over 12 hours, but 8 hour shifts almost always run overtime. Secondly, bedside nursing is so intense, the two days a week “off” for a nurse working full time is not enough downtime to debrief, attend in- services, maintain certification requirements or skills labs, and pursue self care and a life outside of nursing. If you attend school to upgrade to a BSN or Masters Degree to meet employer demands as well, the fatigue from these obligations may play a role in nurse burnout and patient care errors too.
When comparing 12 hour shifts to 8 hour shifts, I wonder if variables such as inadequate staffing, hit or miss lunch breaks, and other scheduled shift breaks are considered? Certainly it’s easier to go 8 hours without breaks than 12, or hold it together while short staffed for 8 rather than 12 hours. Is it possible that these factors affect patient safety as much or more than the shift length?
For myself our hospital rarely goes beyond the scheduled 12 hour shift. I work 12’s qaqnd like them, the problems I have seen re when someone works too many 12 hour shifts in a row without a day off. Has there been a study on MD’s? In our hospital they work at least 7-12 hour shifts in a row?