The Effect of Shift Length on Patient Safety: A Literature ...



The Effect of Shift Length on Patient Safety:A Literature ReviewHeather M. Reeve, Bree Rebman, Sean McLean, Carli Prisbrey, Suzanne Taylor, and Mindi ChristensenDixie State UniversityThe Effect of Shift Length on Patient Safety:A Literature ReviewPatient safety is paramount in the healthcare field. Healthcare workers are influenced by many variables as they act to alleviate suffering, promote healing, and foster health and wellness. The traditional schedule a nurse works in a hospital is 12 hours, while the average non-medical shift is eight hours. The purpose of this review is to determine if there is evidenced based information available that establishes best practice in scheduling nursing shifts.Practice QuestionCould patients’ safety be improved by moving to a standard eight hour work-day in healthcare? Is the patient safer when their nurse works several shorter shifts or fewer longer shifts? Our group clinical causation question: In an acute, in-patient setting, does shift length affect patient safety? Search StrategyAs a group we searched for peer reviewed, journals and articles, relevant to our question. Our search strategy was guided by a PICO approach. For our population we chose all patients in an acute care, inpatient setting. Our intervention of interest was the number of hours in a single nursing shift, in comparison to patient’s safety. With an outcome to determine, with evidence based process, the optimal nursing shift length to promote patient safety. We reviewed the following studies.Summary of EvidenceStudy One In a study done on the effects of the nurses’ work hours and patient safety (Scott, Rogers, Hwang and Zhang, 2006) questioned the association between the occurrence of errors and the number of hours worked by the nurses. 502 critical care nurses kept logbooks recording the number of hours and the time of day they worked; and the nurses self report of errors that they made during their shifts. Scott et al. (2006) explained from the results, “almost two thirds of the participants struggled to stay awake at least once during the study period, and 20% fell asleep at least once during their work shift” (p. 33). Many of the nurses also stated that only a small percentage left work at the end of their shift. Approximately 2/3 of the participants worked overtime. The study found that longer work duration increased the likelihood for errors among nurses. Scott et al. (2006) explains, “Remaining awake for 24 hours slows reaction times to a level approximating the times in a person with a blood alcohol level that exceeds the legal standard for operating a motor vehicle” (p. 35). Longer work duration increased the risk of errors and near errors and decreased nurses’ vigilance. Scott et al (2006) recommended to minimize use of 12-hour shifts and to limit nurses’ work hours to no more than 12 consecutive hours during a 24-hour period. They state, “The risk for making an error almost doubled when nurses worked 12.5 or more consecutive hours” (p. 34). Study TwoAdmi, Tzischinsky, Epstein, Herer, and Lavie (2008) explored whether patient safety was effected by a nurse doing “shift work” (defined as rotating day, evening and night schedules). They sought to determine if shift length and a nurses’ health would cause a decreased ability to care for their patients. Surveys were used to find how many nurses complained of sleep disorders associated with shift length. Research went into detail, comparing “night shift workers” vs. “day-shift workers”; “female” vs. “male” nurses, “adaptive” vs. “non-adaptive” nurses, and a questionnaire regarding sleep (Admi et al 2008). Sleep patterns are interrupted among nurses working night shifts, and rotating shifts so Admi et al (2008) also sought to see how sleep disturbances affect a nurses’ health. “Shift work is now a major feature of work life across a broad range of industries. Over 20% of workers in industrialized nations are shift workers, and about 10% of them are diagnosed as having sleep disorders” (p. 250)The study found that gender, age and weight were more significant factors than shift length regarding the well-being and overall health of nurses. Regarding patient safety, Admi et al (2008) states “during the 1-year research period, 205 clinical errors and adverse incidences (e.g., medication errors, patient falls) were reported by 201 night shift nurses. No significant differences were found between the group of 153 adaptive nurses (45%), and the group of 48 non-adaptive nurses (37%)” (p. 254).Study Three Barger et al (2006) sleep disorder specialists in Boston conducted a study to determine if medical interns working extended shifts, (defined as equal to or greater than 24 hours) were at a greater risk of making medical errors and jeopardizing patient safety. Their research was in response to the results of Lockley et al (2004) in which critical-care units reduced the rates of significant medical errors and attention failures by eliminating extended duration shifts.The relationship between intern medical errors and actual patient’s safety was examined to find out if any related harm to patients could be prevented. During months that the Interns worked at least one extended- duration shift they were three to seven times more likely to report at least one fatigue- related significant medical error (Barger et al. 2006). Also, a fatigue- related adverse event was increased by between seven to eight times. When interns worked five or more extended shifts, the likelihood of a fatigue- related adverse event that resulted in a fatality increased by 300%.Study Four Keller (2009) wrote a summary of the information found on the number of hours nurses work and mistakes made. “Nurses working shifts in excess of 8 hours report more medication errors, difficulty staying awake and actually falling asleep during work hours, a decrease in productivity the last 4 hours of the shift, and an increased risk of errors and near errors associated with decreased vigilance (Lockley et al., 2007; Scott et al., 2007; Smith et al. 1998). Nurses and interns have both reported impairment in critical thinking abilities. The risk of an error almost doubles when nurses work 12.5 or more consecutive hours (Scott et al.). Nurses suffer more needlestick injuries during extended shifts and needlestick and biological fluid exposure rates increase during the last 2 hours of a 12-hour shift (Lockley et al.).” (p. 498) This demonstrates most nurses make mistakes towards the end of their shift. Fatigue can have an impact on the patient if the proper precautions are not in place.Study FiveBerger and Hobbs (2006) defined shift work as work hours that are scheduled outside of the daylight hours. Shift work affects approximately 24% of healthcare professionals including RN’s (Berger, Hobbs, 2006). The studies examined night shift work and sleep disturbances, hormone levels, and how shift work disrupts the body’s internal sleep-wake cycles. One study finding demonstrated that completing challenging tasks by 4am reduced patient care errors.Study 6The final study in our review (Stone, Du, Cowell, Amsterdam, Helfrich, et al. 2006) was conducted in 13 New York area hospitals in response to a labor dispute. The purpose was to evaluate differences’ in outcomes when nurses worked 8 hour shifts vs. 12 hour shifts. The 99 hospital units involved offered 8 or 12 hour shifts based on their current resources and situation; and nurses responding in the survey were able to self-select the unit in which they were working based on experience and seniority. The first area of interest was administrative, evaluating recruitment and turnover, staffing and related costs, and absenteeism. Secondly the nurses’ satisfaction and safety were evaluated, including burnout, intention to stay, scheduling and job satisfaction. And finally, patient safety, our topic of study, was evaluated using three measures: (a) medication errors; (b) falls; and (c) decubitus ulcers. Incident reports from nine hospitals, and 68,034 patient discharge abstracts showed no differences in patient outcomes from units staffed as 8 hour vs. 12 hour shifts (Stone et al. 2006). They did show that most nurses working 12 hour shifts were more satisfied with scheduling, missed fewer shifts, reported less burn out and emotional exhaustion, and overall, reported higher job satisfaction. Units with 12 hour shifts also had lower vacancy rates and it took less time to fill positions in those units (Stone et al. 2006).Acknowledged limitations of this study include geography and demographics. All hospitals were from a limited urban location, nurses are union represented and the population that includes a higher percentage of minorities than national average. Rural or non-union regions may show different results. Within this scope, Stone et al. (2006), concluded that most nurses were more satisfied with 12 hour shifts, patient outcomes were not affected, and choice in shift lengths provides for a more positive work environment. They suggest that others continue this research.Conclusion and RecommendationsThe prevailing conclusion across the studies we found is that more research is needed to form a clear picture of the relationship between patient safety and a nurse’s shift length. That said, we were able to uncover some noteworthy trends. Shifts 12.5 hours and greater were likely to result in nurses being at risk to commit errors as fatigue and sleep deprivation set in, which effects patient safety. There was conflicting data regarding the effects, if any, comparing an 8 hour shift to a 12 hour shift; which merits a closer look at the study methodologies and measurements used. Additionally the data suggests that time of the day is a significant factor in a nurse’s level of drowsiness and consequently the likelihood of committing an error, with 40% of drowsiness episodes and 23% episodes of sleep occurred between midnight and 6 am CITATION Article \t \l 1033 (Stone, 2006).None of the studies conformed exactly to another in methodologies and when this is the case its unreasonable to assume one set of results is relevant to the nursing profession as a whole. There are excellent questions raised with good ‘jumping off’ points for future study. It is our suggestion that continued study is merited; with care taken to have a clear purpose and solid definitions of tangible measures.ReferencesAdmi, H., Tzischinsky, O., Epstein, R., Herer, P., & Lavie, P. (2008). Shift work in nursing: Is it really a risk factor for nurses' health and patients' safety? Nursing Economics, 26(4), 250-7.Barger, L.K., Ayas, N.T., Cade, B.E., Cronin, J.W., Rosner, B., Speitzer, F.E., Cseizler, C.A. (2006). Impact Of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures. PLoS Medicine, 3(12), 2440-2448. Keller, S. M. (2009). Effects of Extended Work Shifts and Shift Work on Patient Safety, Productivity, and Employee Health.?AAOHN,?57(12), 497-502. Scott, L. D., Rogers, A. E., Wei-Ting, H., & Zhang, Y. (2006). Effects of critical care nurses' work hours on vigilance and patients' safety. American Journal of Critical Care, 15(1), 30-7. Berger, A. M., & Hobbs, B. B. (2006). Impact of shift work on the health and safety of nurses and patients. Clinical Journal of Oncology Nursing, 10(4), 465-71. Stone, P. W., Du, Y., Cowell, R., Amsterdam, N., Helfrich, T. A., Linn, R. W., Gladstein, A., Walsh, M., Mojica, L.A. Comparison of Nurse, System and Quality Patient Care Outcomes in 8-Hour and 12-Hour Shifts. Medical Care Vol. 44, No. 12 (December 2006), pp. 1099-1106 ................
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