The Question of 12-Hour Shifts

Added on May 19, 2016

The Question of 12-Hour Shifts
By Christina Dempsey, RN, Press Ganey Chief Nursing Officer
From Industry Edge May 2016

Should hospitals and health systems continue to embrace 12-hour nursing shifts, or should they eliminate them? This is one of the most polarizing questions in health care today—and one that has taken on new significance with the emergence of data linking extended nursing shifts to safety, quality, experience and cost outcomes.

In most hospitals, 12-hour nursing shifts are the norm. The flexibility of a three-days-on, four-days-off work week appeals to nurses, and hospital leaders believe that offering extended shifts is essential for nurse retention. They also believe that 12-hour shifts improve scheduling efficiency because there are fewer shift changes and fewer scheduling variables. This, they perceive, eases the administrative challenges of keeping units staffed, particularly as the demand for registered nurses outpaces the supply.

On paper, however, the “value” of 12-hour shifts is hard to argue. 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 consequences2 and poorer performance on safety and quality measures.3 Among some of the most disturbing safety findings is a threefold increase in the risk of nursing staff making an error when shifts last longer than 12.5 hours4 and the determination that more than half of nurses’ fatigue-related errors involve medication administration.5

A direct relationship between shift length and patient experience has also been observed. In the November 2012 issue of Health Affairs, a research team led by Dr. Linda Aiken at the Center for Health Outcomes and Policy Research reported the findings of a study that looked at the length of a nurse’s shift, level of nurse burnout, nurse satisfaction and patient experience scores.6

The study included 22,275 nurses working in 577 hospitals in four states. Of the sample, 65% worked 12- to 13-hour shifts, 26% worked eight- to nine-hour shifts and the remaining nurses worked either 10- to 11-hour shifts or more than 13 hours. The authors pointed out that, although many nurses were typically scheduled for 12-hour shifts, these actual shifts frequently extended to 13 or more hours because of the unpredictability in patient care needs, and many nurses worked on their days off to supplement their income.

The major findings of the study included the following.

  • Increases in shift length beyond nine hours were significantly associated with increased burnout, job dissatisfaction and intent to leave.
  • When nurses’ shift length was compared to HCAHPS scores, hospitals with higher proportions of nurses working shifts longer than 12 hours resulted in lower patient experience scores.
  • When nurses worked beyond 13 hours, job satisfaction and patient satisfaction declined significantly and intent to leave rose significantly.

These multiple associations are not surprising, particularly given the growing body of data pointing to the interdependency of health care safety, quality, patient experience and caregiver engagement outcomes. They do, however, suggest a reason for the health care industry, individual health systems and nurses themselves to step back and evaluate whether the perceived benefits of extended shifts are, in fact, benefits at all; whether they are worth the risks; and how the risks might be eliminated.

For example, if 12-hour shifts lead to nurse burnout, which in turn is implicated in nurse turnover, the need to hire and train new nurses more frequently, together with the need to use float or on-call nurses, seems to negate some of the staffing advantages of a “more efficient” scheduling process. Similarly, if stressed and tired nurses are making mistakes or providing care that doesn’t meet patient needs and expectations, hospitals and health systems will take a financial hit, as performance on these outcomes is increasingly linked to payment incentives and penalties.

Finally, and most importantly, if extended shifts compromise nurses’ ability to consistently provide compassionate, connected care, then everyone loses: Patients suffer unnecessarily, nurses fall short of the caring mission to which they’ve dedicated themselves and hospitals risk sacrificing the loyalty of the patients and communities they serve.

Of course, the negative outcomes that have been associated with extended nursing shifts are not really a function of shift duration per se. Rather, they are a consequence of the inadequate sleep, fatigue and stress that go hand in hand with extended shifts, which can compromise memory, coordination, judgment, attention to detail and reaction time. And, practically speaking, 12-hour shifts often exceed 12 hours when commute time, call duty, last-minute documentation catch-up, overtime and pre/post-shift meetings are factored into the equation, all of which exacerbate fatigue and potentially accelerate burnout.

Short of eliminating 12-hour shifts altogether, which would require a fundamental culture change that many hospitals and nurses are not yet prepared to make, health system leadership must focus their attention on improving the nurse work environment to mediate some of the negative consequences. In fact, integrated analyses of data across multiple performance domains reported in a recent Press Ganey white paper indicate that the quality of the work environment exerts a strong influence on many of the same safety, quality, experience and engagement measures as shift length.

With respect to burnout and fatigue in particular, some of the evidence-based strategies for improving the nurse work environment and minimizing negative consequences of extended shifts include the following:

  • Educating nurses and nurse managers about the signs, prevalence and impact of sleep deprivation and fatigue on nurse performance and patient outcomes
  • Educating nurses about fatigue self-assessment
  • Monitoring nurses’ hours worked—including those worked in other organizations
  • Limiting the number of 12-hour shifts that can be worked consecutively
  • Scheduling sufficient recovery time between 12-hour shifts
  • Mandating uninterrupted breaks
  • Providing opportunities for rest, exercise and meals during long work shifts
  • Providing sufficient coverage so that nurses are able to leave work at the end of their 12-hour shift
  • Minimizing mandatory overtime
  • Implementing 12-hour-shift nursing policies based on guidelines from the American Nurses Association
  • Ensuring that nurses’ days off are kept sacred by not scheduling extra work days or training classes
  • Using bedside medication verification systems to reduce medication errors (required by the Joint Commission)
  • Implementing a fatigue risk management system for continuous monitoring and management of safety risks associated with fatigue-related errors
  • Utilizing scheduling software to identify and avoid potentially risky, fatigue-producing schedules

Balancing the staffing needs of hospitals, the lifestyle needs of nurses and the safety, quality and experience needs of patients is a dynamic, continuous process. It requires ongoing monitoring of performance across quality domains, evaluation of outcomes to identify areas in need of improvement and adjustments based on scientific evidence to optimize nursing work environments and outcomes.

Education and collaboration among hospital administrators, human resources managers, nurse leaders and front-line nurses are critical early steps toward achieving this goal, as is additional research looking at the range of work-pattern variables (choice, shift sequence, breaks, etc.) that may influence the spectrum of quality outcomes.

In particular, disrupting the nurse-staffing status quo will require a groundswell of support by the people who take care of patients. In this regard, the onus is on nurse leaders to communicate with their staff about the influence of fatigue, sleep deprivation and burnout on patient and caregiver outcomes in general and the serious safety, quality and experience issues surrounding extended shifts in particular. This must become a policy issue that nurses embrace so that the question around 12-hour shifts becomes, simply, “What do we need to do to ensure that the care we deliver best meets the needs of patients and the nurses caring for them?”

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

5 Dubeck, D. “Healthcare Worker Fatigue: Current Strategies for Prevention.” Pa. Pat. Saf. Advis. 11, no. 2 (June 2014): 5–60.

6 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.