Evidence and Positions on Nurse Fatigue and Shift Length Geiger-Brown, J., & Trinkoff, A. M. (2010). Is it time to pull the plug on 12-hour shifts?: Part 1. The evidence. Journal of Nursing Administration, 40(3), 100-102. Montgomery, K. L., & Geiger-Brown, J. (2010). Is it time to pull the plug on 12-hour shifts?: Part 2. Barriers to change and executive leadership strategies. Journal of Nursing Administration, 40(4), 147-149. Geiger-Brown, J., & Trinkoff, A. M. (2010). Is it time to pull the plug on 12-hour shifts?: Part 3. Harm reduction strategies if keeping 12-hour shifts. Journal of Nursing Administration, 40(9), 357-359. This three-part series featured in the Journal of Nursing Administration is thorough and well researched, carrying a very impressive reference list. After reviewing the evidence of harm associated with 12-hour shifts in part 1, the authors question the ethics of continuing 12-hours shifts and state in part 2: We believe that there is a visible mandate to move away from 12-hour shifts for nurses, and in this article, we examine the barriers to eliminating 12-hour shifts and recommend leadership strategies based on AONE s nurse executive competencies. Part 1 of the series analyzed a large body of evidence related to nursing care delivery and shift length. The authors conclude: Nurses working extended length shifts are at an increased risk of making errors. It is also evident that nurses working longer shifts experience more needle sticks, musculoskeletal injuries, drowsy driving, sleep deprivation, and fatigue compared to nurses working 8-hour shifts.
Part 2, as mentioned earlier, addresses the ethical obligation nurse administrators have in moving nurse shift length away from 12-hour shifts. The authors note that the challenge for administrators is to persuade nurses to move away from 12-hour shifts. It is peculiar that SHMC administration is forcing nurses to 12-hour shifts while the majority of staff nurses impacted are opposed to this move, a situation not even considered in this seminal piece of literature. The narrative of part 2 discusses obstacles and provides advice for administrators to move nursing care delivery models away from 12 s. They specifically mention the struggle of nurse administrators accountability for an immense and diverse dashboard of performance metrics. One of the most important metrics on the dashboard is nurse satisfaction, retention, and recruitment. They present this metric as a barrier to moving nurses away from 12 s in most institutions, while SHMC administrators are choosing to do create this barrier to move toward 12 s. Of the three parts to this series, it is vital that part 2 is read by the nursing administrators of SHMC, and that they reflect on the ethical responsibilities inherent in their positions. The current proposal is antithetical to the responsibilities outlined in this piece of literature. As the authors say at the end of part 2: The evidence is compelling, and the mandate is clear. Part 3 of the series aims to addresses methods to mitigate the many harmful consequences of 12- hour shifts. One method is to create policies preventing the clustering of shifts to maximize time off, as the evidence indicates fatigue is cumulative and working multiple shifts greater than 8-hours should be avoided. SHMC administrators have not outlined, or even mentioned, techniques they will use to minimize the risks associated with 12 s. Trinkoff, A. M., Le, R., Geiger-Brown, J., & Lipscomb, J. (2007). Work schedule, needle
use, and needlestick injuries among registered nurses. Infection Control & Hospital Epidemiology, 28(2), 156-164. Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses' work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), 1-8. The first article is a longitudinal study conducted in three waves that examined nurse work schedules and incidence of needle stick injuries in a sample of over 2,500 nurses from two states. The study found a statistically significant increase in needle stick injuries for nurses working 12 or more hour shifts. The risk increased for those working night shifts. They also found increased risks for needle stick injuries in relation to working consecutive extended length shifts. The authors identified that risk is compounded for those nurses working 12 hour night shifts. The second article used the same sample to investigate what impacts nurse schedules have on patient mortality. The authors found that pneumonia deaths were significantly more likely when nurses worked long hours and lack time away from work. The also found increased mortality in ascending aortic aneurysms (AAA) and acute myocardial infarctions (AMI) when nurses lacked time away from work and had an increased weekly burden (defined as days worked in a row and hours per week), respectively. Extended shifts are more likely to increase the weekly burden of SHMC nurses impacted by the proposal. Nurses working 8-hour shifts are often working 32 or less hours per week, when they pick up an extra shift it increases the weekly burden to the standard 40-hour week, or less. If a nurse working three 12 s picks up an extra shift they
increase the weekly burden to 48hrs. The American Nurses Association (ANA) position is that nurses should not work more than 40 hours per week. Griffiths, P., Dall Ora, C., Simon, M., Ball, J., Lindqvist, R., Rafferty, A. M.,... & Aiken, L. H. (2014). Nurses shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety. Medical care, 52(11), 975. A cross-sectional survey of 31,627 RNs in 488 hospitals in 12 European countries found nurses working shifts 12 or more hours report lower quality and safety and more care left undone compared to nurses working 8 hours. The authors argue that policies adopting 12-hour shift patterns should be met with caution. Estabrooks, C. A., Cummings, G. G., Olivo, S. A., Squires, J. E., Giblin, C., & Simpson, N. (2009). Effects of shift length on quality of patient care and health provider outcomes: systematic review. BMJ Quality & Safety, 18(3), 181-188. A similar study as above but within the United States. It surveyed 22,275 RNS in 577 hospitals in four states and reported nurses who worked the length of shifts proposed by SHMC administration reported poor quality care compared to those nurses working 8-9 hour shifts. Caruso, C. C. (2014). Negative impacts of shiftwork and long work hours. Rehabilitation Nursing, 39(1), 16-25.
Andrew Wireman from OHVI 5 sent this extensive literature review by Dr. Caruso. The conclusion is consistent with the majority of literature on extended length shifts and shift work: the fatigue from long hours significantly increases the risks on the health of nurses and the patients they care for. Dr. Caruso points out Healthy People 2020 launched a new chapter for sleep health, with one objective being to increase the amount of adults getting seven of more hours of sleep per day. Geiger-Brown and Trinkoff note that nurses who work 12-hour shifts get an average of five-hours of sleep between shifts. The proposal of SHMC nursing administration is in direct opposition to Health People 2020 and subsequently in opposition to the nursing professions obligation to support healthy communites. Dempsey, C. (2016). The question of 12-hour shifts. Industry Edge. www.pressganey.com/ blog/the-question-of-12-hour-shifts This is a blog post from the Chief Nursing officer of Press Ganey, Christina Dempsey. She notes that hospital administrators believe 12's make it easier to staff units due to fewer shift changes and scheduling variables. She goes on to point out that this perception is deeply flawed as research shows, relative to 8-9-hour shifts, 12-hour shifts are associated with increased burnout and job dissatisfaction, negative health consequences for nurses, and poorer performance on safety and quality metrics. She references the above noted study group that included 22,275 nurses. She notes the study found 12-hour shifts frequently extend to 13-hour shifts and many nurses work on their days off to supplement income, exceeding the ANA position that nurses should not work over 40-hours in seven days.
The CNO of Press Ganey points out that HCAHPS scores are impacted by nurse shift length. Patient experiences scores are lower in hospitals with a higher proportion of nurses working 12 or more hours. She highlights that 12-hour shifts are much longer when considering commute times, call duty, meetings, trainings, and charting catch-up. Again, she notes that the challenge to moving away from 12's is shifting the culture of nurses who perceive a benefit; SHMC is forcing nurses who do not want 12's into a problem nurse leaders elsewhere are trying to get away from. Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. (2015). NIOSH training for nurses on shift work and long work hours. (NIOSH) Publication No. 2015-115). Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Training modules for nurses from the National Institutes of Occupational Safety and Health (NIOSH), a division of the CDC. High level evidence shows shift work and long hours are associated with: 1. Declines in functioning of brain; 2. Reduced job performance (increase in errors, accidents); 3. Increases in poor health (obesity, smoking, substance abuse, DM, etc.); 4. Increased short-
term and long-term health risks (diabetes, HTN); and 5. A 40% increased risk for CAD for long hours, which is even worse compounded with shift work. Shine, K. I. (2002). Health care quality and how to achieve it. Academic Medicine, 77(1), 91-99. Kenneth Shine, former president of the Institutes of Medicine (IOM), stated, We have nurses working 12-hour sessions back to back... We would never do that if we were designing a good system in terms of quality of care. American Nurses Association. (2014). Position Statement on Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of Registered Nurses and Employers to Reduce Risks. American Nurses Association, Washington, DC. The ANA position on nurse work hours is that nurses should not exceed 40 hrs of professional nursing work, including meetings, training, on-call hours, and volunteering. The proposal by SHMC will inevitably lead to more nurses working beyond 40 hrs in a 7 day period, as units are dependent on nurses working extra shifts. Current units that are on 12's depend on nurses working extra to fill holes or adjust for acuity; therefore, there is no evidence that the proposal to force nurses to 12's will decrease the need for nurses to pick up extra shifts. The ANA position statement recommends employers of nurses "Examine work demands with respect to shift length. Shifts longer than 8 hours may be unsafe when work is physically and cognitively demanding." They recommend frequent breaks, every 2 hours, and longer breaks for meals. SHMC has a poor record of ensuring nurses get rest and meal breaks. They recommend
establishing 10 consecutive hours per day of protected time off duty so that nurses may obtain the recommended 7-9 hours of sleep. The evidence states nurses working 12's achieve, on average, 5 hours of sleep between shifts. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: AmericanNurses Association. "The Code of Ethics (the Code) for Nurses makes explicit the primary goals, values, and obligations of the profession. ANA believes that the Code is nonnegotiable and that each nurse has an obligation to adhere to its ethical precepts." The actions by SHMC that are intended to force staff nurses to 12-hour shifts runs contrary to several provisions in the Code. It would do nursing administration well to reflect on provisions 2-4 when considering whether to continue with the proposal. Provision 6 is especially pertinent: "The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective actions." The proposal to force nurses to 12-hour shifts directly conflicts with the nonnegotiable ethical obligations of nurses. The ANA, Healthy People 2020, and a very large, compelling body of literature identifies the risks inherent in long shifts. Nurses have an obligation to implement the best evidence in their practice as well as advance community health goals such as the Healthy
People 2020 sleep health goal. The proposal put forth by SHMC nursing administration is neither founded on evidence nor supportive of advancing community health goals. The proposal to force nurses to 12-hour shifts directly contradicts provision 6 of the Code as the evidence shows the proposal will make the quality of the health care environment and conditions of employment decline. It is difficult to understand how nurse administrators of SHMC feel compelled to move forward with a plan that is in opposition to the most compelling evidence on shift length; will actually work against objectives of Healthy People 2020; and violates the Code of Ethics that guides all nurses. The proposal of SHMC to force nurses to 12-hour shifts is incompatible with what it means to be a nurse: it lacks evidence and compassion.