Patient Ratios and Extended Shifts Are Separate Nursing Issues

Added on Apr 5, 2019

By Christina Dempsey, RN, Chief Nursing Officer

nurse burnoutThe ill effects of extended work shifts on nurses and the patients they care for will not be remedied simply by government-mandated nurse-to-patient ratios. Instead, it will take a commitment by registered nurses and employers to work together to ensure a safe and healthy work environment for all nurses and to promote a positive work–life balance.

Advocates of nurse ratio legislation have suggested that unmanageable patient loads force some nurses to work straight through a 12-hour shift without a “time out,” which in turn can degrade the safety and quality of care they provide as well as their own physical and emotional well-being. In fact, the extended shift without a break, independent of patient load, is a major risk consideration on its own, and it is not likely to be “fixed” by mandated ratios.

The literature is clear on this point. Research has consistently shown that, relative to traditional eight- to 10-hour shifts, extended nursing shifts are associated with an increased incidence of burnout and job dissatisfaction,[1] negative health consequences,[2] and poorer performance on safety, quality, and patient experience measures.[3], [4]

In particular, researchers have demonstrated a threefold increased risk of nursing staff making an error when shifts last longer than 12.5 hours.[5] And the reality is that 12-hour shifts routinely turn into 13- or 14-hour shifts because of the unpredictability of patient care needs. When these extended shifts are not punctuated by regular, uninterrupted meal and rest breaks, the nurse work environment suffers, and while staffing is important, work environment is more important.[6]

Without question, safe and appropriate staffing that takes into account patient acuity, patient volume, nurse experience, and nurse education is a best practice and should be a leadership priority. Efforts to legislate staffing, however, should not be held up as a solution to mitigate the dangers associated with extended work shifts. Any way you look at it, enforcing nurse-to-patient ratios without other considerations will not solve for 12-hour shifts with no breaks from patient care. However, monitoring nurse staffing ratios along with limiting shift duration, mandating uninterrupted breaks, eliminating mandatory overtime, and using creative scheduling to reduce consecutive extended shifts will. 


[1] Dall’Ora, C., P. Griffiths, J. Ball, et al. 2015. “Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: Findings from a cross-sectional study of 12 European countries.” BMJ Open 5:e008331.

[2] Stimpfel, A.W., C.S. Brewer, and C.T. Kovner. 2015. “Scheduling and shift work characteristics associated with risk for occupational injury in newly licensed registered nurses: An observational study.” Int J Nurs Stud 52(11): 1686–1693.

[3] Stimpfel, A.W., and L.H. Aiken. “Hospital Staff Nurses’ Shift Length Associated with Safety and Quality of Care.” J Nurs Care Qual 28, no. 2 (April–June 2013): 122–129.

[4] Stimpfel, A.W., D.M. Sloane, and L.H. Aiken. 2012. “The Longer the Shifts for Hospital Nurses, the Higher the Levels of Burnout and Patient Dissatisfaction.” Health Aff 31(11): 2501–2509.

[5] Lorenz, S.G. 2008. “12-hour shifts: An ethical dilemma for the nurse executive.” J Nurs Adm 38(6): 297–301.

[6] “The Influence of Nurse Work Environment on Patient, Payment and Nurse Outcomes in Acute Care Settings.” 2015 Nursing Special Report, Press Ganey Associates, Inc.