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Examining Patient Safety in Eight-Hour vs. 12-Hour Nursing ShiftsCrystal Bendele, Sharon Haan, Jody Montgomery, Dana Raymer and Sarah RooksFerris State UniversityAbstractNursing shift work can vary in terms of shift length. Most nurses work shifts between eight and 12 hours in duration. A literature review was performed that examined nurses working eight-hour shifts and 12-hour shifts and the subsequent effects on patient safety. The evidence indicates that when nurses work longer shifts, patient safety, as well as nurse safety is jeopardized. Overall, the literature review produced compelling evidence that nursing shifts should be limited a maximum of eight hours in duration in order to promote patient safety and reduce medical errors. Keywords: nursing, shift length, patient safety, evidence, research, error, injuryExamining Patient Safety in Eight-Hour vs. 12-Hour Nursing ShiftsThe aim of this literature review was to analyze evidence-based nursing practice in regards to patient safety and nursing shift lengths. The research question is: In hospital-based nursing, what is the effect of nursing shifts greater than eight hours in duration on patient safety, compared to nursing shifts eight hours or less in duration? A search of the scientific literature ensued using scholarly search strategies, and initially 10 articles were chosen for review. Criteria for inclusion or exclusion eventually narrowed the article total down to five articles that most directly answered the evidence-based nursing research question at hand. Further analysis of the five articles chosen included examining how the articles answered the research question, the article’s level of evidence, recommendations and findings from science, as well as an analysis of shortcomings within the articles. Evidence-based nursing practice recommendations based on setting, population, and interventions are summarized, as well as the impact these recommendations have on nursing practice. An overall review of the literature found compelling evidence that a change in nursing practice is needed, specifically that shifts longer than eight hours in duration should be eliminated, as they are a danger to patient safety. Search of the Scientific LiteratureThis section discusses research strategies used to locate relevant literature, the inclusion and exclusion process to select the most appropriate literature and lists the articles that were selected for this project.Research StrategiesIn approaching the topic of the effects of longer nursing shifts, each member of this team researched the topic and worked to identify literature most relevant to the research question. Various methods and means were utilized in the review of published literature. Databases such as CINAHL and PubMed proved useful, as did Google Scholar, and university and public libraries. The research focused on such keywords as “shift length,” “quality patient care,” “nurse staffing,” and “nursing overtime.” Inclusion/Exclusion ProcessMost literature on the subject of extended nursing hours can be divided into two main categories: literature that opposes longer shifts and literature that supports these shifts. The former category is far more prevalent than the latter; in fact, few recent studies were found that argued the benefits of extended working hours for nurses. Beyond these primary categories, the subject often splits into studies that focus on the effects such shifts have on the nursing professional, and studies that focus on the effects experienced by the patient. Most studies, however, address the effects on both populations, arguing a relationship between the two.Inclusion. The initial review of literature was based on the criteria that the articles needed to be current while remaining relevant to the issue of extended nursing shifts and the effect of shift length on patient safety. Such a review produced ten articles. Nine of the articles opposed extended working hours for nurses, while only one supported such shifts. Additionally, one article focused on the impact such hours had on nurses, one focused on the impact they had on patients, and eight addressed the impact on both populations.Exclusion. After compiling the initial literature, further exclusion was necessary. This exclusion was based on three factors: further project focus, originality, and credibility. These exclusion factors also allowed for a preliminary structure for the project.The first evaluating factor, project focus, permitted for the exclusion of certain articles on the basis that such articles only served as digressions in this project’s discussion. The goal was to keep the focus intact and eliminate these digressions. An example of such a digression would be Barker and Nussbaum’s (2011) consideration of fatigue. Their work was too focused on breaking down the notion of fatigue, rather than addressing the concerns of this project. Similarly, an article by Trinkoff et al. (2006) was excluded due to its narrow perspective. The article concentrates too heavily on nurses’ working hours and does not provide enough relevant information regarding the dangers associated with such hours.The second evaluating factor, originality, served to further narrow the pool of source material. Many of the original ten articles presented similar information. The goal of evaluating these articles on the basis of originality was to retain necessary information, but only with the use of articles that presented the information in new ways or further built on that information. There were several articles from the initial group that were excluded on this basis. The article by Olds and Clarke (2010) was one such article that did not provide anything original on the topic.The final evaluating factor, credibility, provided a process for arriving at the most trusted of sources. When considering which articles to include and which to exclude, it was necessary to evaluate which of the preliminary sources were produced by the most credible sources. Only in doing so was it possible to ensure the credibility of this project. Some articles were excluded on the basis that other articles with similar focuses were produced by more credible researchers. For example, an article by Stone, et al. (2006) was excluded on the basis that it was produced for the use of a labor-management bargaining group; this fact suggested a bias and the article was excluded. Additionally, another article by Stone, et al. (2007) was excluded on the basis of credibility. Its exclusion was based on the fact that the study was focused on too small of a patient population; and the study’s finding came from hospitals that were too limited in number and type. The belief was that such populations were too specific and did not credibly represent the nursing environment in general.Selected LiteratureThe following five articles support the intentions of this project and meet both the primary and secondary criteria for inclusion:The Institute of Medicine’s (IOM) Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004), works to build on two of the organization’s previous reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm. What the IOM report provides is a description of changes that have taken place in the health care environment over the past several decades and the effects that such changes have had on the nursing professional. The report details the critical role that nurses play in the care of patients in the healthcare system. Additionally, it argues that the current nursing environment is not conducive to safe patient care. To this end, it provides guidelines on how the suggestions from the IOM’s previous reports can be implemented into health care organizations. The report’s objective is to further support the argument concerning the critical role of nurses, as well as to provide specific instruction on how to manage necessary changes within the healthcare system, changes that will not only improve nurses’ working environment, but also will allow them to provide safe patient care.Lockley et al. (2007) work to explain the dangers of extended nursing hours for both healthcare professionals and their patients. The article addresses both resident physicians and nurses. Lockley et al. (2007) begin by addressing circadian rhythms and sleep deprivation. Drawing on prior research, the article expounds on the negative effects of sleep deprivation on both populations of healthcare professionals, as well as the patients under their care (2007). Lockley et al. (2007) explain the effects of extended shifts on performance by demonstrating an increase in needlestick injuries and medical errors (p. 13). The researchers also note the unreliability of self-assessments of fatigue filed by healthcare professionals (Lockley, 2007, p. 8). Essentially, the article’s intentions are to identify the effects of sleep deprivation, to document the effects of such deprivation on work performance, and to call for changes in scheduling by health care administrators. Garrett (2008) expands on the discussion of nurse staffing by highlighting the pitfalls of overtime, whether this overtime is mandatory or voluntary. Overtime is often used to address staffing issues. Garrett (2008) argues, however, that this type of staffing leads to above-average job dissatisfaction in nursing when compared to other professions, which in turn, leads to nurse burnout and consequently nursing shortages (p. 1194). Therefore, compensating for shortages through the implementation of overtime only creates more of a shortage (Garrett, 2008, p. 1194). Garrett (2008) also notes that such shortages increase the patient-to-nurse ratio, which also increases nurse burnout and decreases patient safety (p. 1196). Nurses, in fact, recognize the effects of a high patient-to-nurse ratio. According to Garrett (2008), nurses report that a lower number of patients per nurse allows them to give better quality care (p. 1197). The objective of Garrett’s research is to not only show the dangers of overtime, but also to demonstrate how such staffing further compounds staffing issues.Geiger-Brown and Trinkoff (2010) build on Garrett’s (2008) discussion by providing options that can decrease the negative impact long hours have on both nurses and their patients. Included in this discussion are measures that can help nurses cope with these long hours. Such measures include conscientious scheduling on the part of administrators, a consideration of nurses with increased risks, a discussion of the importance of breaks and nurses’ diets, and an acknowledgement of supportive work environments that address nurses’ needs and are free of unnecessary distractions and extraneous physical demands (Geiger-Brown, 2010, p. 358). The intent behind the article is not to support long shifts, but rather to provide information on how to best deal with extended shifts that are currently in practice.Lorenz’s article (2008) serves to interject the notion of ethics into the discussion of extended working hours. Drawing on prior research, Lorenz (2008) sets up a foundation for the dangers involved in scheduling nurses on these extended shifts (p. 299). The discussion then proceeds by questioning the ethics behind such practices. Lorenz’s (2008) objective is to move the discussion beyond merely a consideration of safety concerns and infuse it with a concern of ethics, something that is a cornerstone to nursing practice.Articles Chosen for AnalysisResearch articles and reports by Garret (2008), Geiger-Brown and Trinkoff (2010), Lockley et al. (2007), Lorenz (2008) and Page (2004), as outlined above, were reviewed and chosen for analysis based on the fact that they met inclusion criteria. Additionally, these articles were chosen because they most directly answered the research question, “In hospital-based nursing, what is the effect of nursing shifts greater than eight hours in duration on patient safety, compared to nursing shifts eight hours or less in duration?” The articles all had a common theme that directly correlates with the question in focus. The theme of the articles focused around nurses working greater than eight-hour shifts versus eight hours or less. The findings of the articles showed an association of not only compromised patient safety, but ethical implications and health risks for nurses working 12-hour shifts.Level of Evidence per HierarchyThe level of evidence per hierarchy that was most predominant in the chosen articles was systematic review. Meta-analysis is the particular type of systematic review being used in the articles. This method summarizes data from multiple studies and combines them for an analysis. This method is most predominant in the Joint Commission article (Lockley et al., 2007). Lockley et al. (2007) reviewed several studies over a three-year period on the impact of nurse work hours on patient safety. The evidence presented in the article by Lockley et al. (2007) showed that nurses working shifts greater than 12.5 hours are at a “significantly increased risk of experiencing decreased vigilance on the job, suffering an occupational injury or making a medical error” (p. 7). Not only are nurses putting patients at risk, but they are putting their own safety at risk as well. While nurses reported enjoying the flexibility of 12-hour shifts, the ethical implications of allowing this length of shift to continue despite the negative effects on patient safety is something that bears careful consideration (Lorenz, 2008, p. 301). All of the selected articles reviewed studies that show the increase in errors and “near misses” involving patients (Lorenz, 2008, pp. 299-301). Recommendations and Findings from ScienceGarrett (2008) sums up the generalized recommendation from these articles, by stating that organizations should “invest in adequate nursing staffing to improve patient safety” (p. 1191). The evidence presented makes it blatantly clear that nursing shifts greater than eight hours in duration puts both patients and nurses at a higher risk for incidence of error or injury.Analysis of ShortcomingsThe articles appeared to be primarily focused on patient safety. Other variables were mentioned briefly, like nurses preferring 12-hour shifts and staff satisfaction (Lorenz, 2008, pp. 299-301). Variables mentioned in Lockley et al. (2007) briefly mentioned nurses putting themselves at risk for injury (p. 7). Injuries included needle sticks and increased risk for motor vehicle accidents. Small sample sizes were also a common theme throughout the articles, and this is identified as a shortcoming because there is no standardized measurement tool.Summary of EBNP RecommendationsIn the article by Geiger-Brown and Trinkoff (2010), the authors reviewed a number of studies that examined the impact of 12-hour shifts on both nurse and patient safety. The authors found that five out of seven studies showed that nurses were more fatigued after 12-hour shifts than nurses who worked shorter shifts (Geiger-Brown & Trinkoff, 2010, p. 100). Two diary-type studies were reviewed. The first study found that nurses working longer than 12.5 hours were three times more likely to make medical errors compared to the error risks of nurses working eight and one-half hours or less (Geiger-Brown & Trinkoff, 2010). As far as work injuries, the authors reported results of studies which found that the risk of needlestick injuries and musculoskeletal injuries increased in nurses working 12-hour shifts compared to those working 8 hours or less (Geiger-Brown & Trinkoff, 2010). Geiger-Brown and Trinkoff (2010) conclude, “there is clear evidence that nurses are at risk for making more errors with longer work shifts” (p. 101).Lockley et al. (2007) discussed the findings of research conducted on the impact of work hours and sleep deprivation on both nurses and residents. The authors state that when compared to nurses working less than 12.5 hours, nurses working these longer shifts have up to three times the chance to make a mistake while providing patient care, an increased risk of needlestick injury, and they also report a decrease in vigilance while on the job (Lockley et al., 2007, p.13). The results of a study conducted on 2273 nurses regarding the risk of needlestick injuries found that “hours worked per day, weekends worked per month, working evening and night shifts, and working 13 or more hours per day at least once per week were each significantly associated with needlestick injuries” (Lockley et al., 2007, p. 13). Based upon their research, the authors of the article concluded that “extended-duration work shifts significantly increase fatigue and impair performance” (Lockley et al., 2007, p. 14) and “the hours routinely worked by health care providers in the United States are unsafe” (Lockley et al., 2007, p. 14). The authors call for the United States government to establish regulations to limit hours worked for health care providers (Lockley et al., 2007, p. 16). Garrett (2008) discusses the effects of shift length and overtime on nurse fatigue, burnout, absenteeism, and job dissatisfaction. Effects on patient outcomes were also discussed, with the author finding that long shift lengths and overtime increase the odds of a nurse making medication-related errors and other patient care errors (Garrett, 2008, p. 1196). Nurse fatigue related to long shift lengths increases risk of injuries and accidents, and lack of sleep can actually cause performance effects that mimic the effects of alcohol (Garrett, 2008, p. 1192). Reports on a study conducted of 393 registered nurses found “analysis of the data indicated that work duration, overtime, and number of hours worked per week had a significant effect on errors, with the likelihood of making an error increasing with longer work hours” (Garrett, 2008, p. 1196). This same study reported that “nurses were three times more likely to make an error when working shifts that lasted 12.5 hours or more” (Garrett, 2008, p. 1196). Impacts of high nurse-to-patient ratios were also discussed, with the author finding that higher staffing levels with lower nurse-to-patient ratios positively influenced nurse satisfaction and reduced adverse outcomes by up to 25 percent (Garrett, 2008, p. 1200). The author concludes that fatigue caused by long shifts or overtime causes the potential for medical mistakes, has a negative impact on nurses and results in increased risk of adverse outcomes for patients (Garrett, 2008, p. 1202). The next article reviewed reported recommendations of a study conducted by the Institute of Medicine to address the aspects of nursing work environments that impact patient safety and to identify improvements in nursing work environments that would increase patient safety (Page, 2004). Recommendations that did not address shift lengths included addressing leadership and management structure, knowledge and skill level of staff and creating a culture of safety (Page, 2004). The committee made a number of recommendations that addressed fatigue related to excess work hours and design and the burden of documentation. These recommendations included establishing policies that limited work hours to no more than 12 hours in a 24-hour period and no more than 60 hours in a 7-day period (Page, 2004, p. 13). The committee also recommended, “schools of nursing, state boards of nursing, and health care organizations should educate nurses about the threats to patient safety caused by fatigue” (Page, 2004, p. 13). The committee called for more research as it relates to “effects of successive work days and sustained work hours on patient safety” and “development and testing of methods to help night shift workers compensate for fatigue” (Page, 2004, p. 324). Lorenz (2008) discussed the results of a review of literature that focused on the risks and benefits of 12-hour shifts. The literature reviewed was divided into three categories: studies that found positive outcomes related to 12-hour shifts, studies that found conflicting evidence regarding 12-hour shifts, and studies that found negative effects of 12-hour shifts on medical error rates and nurse health (Lorenz, 2008). Lorenz (2008) reported that the first study conducted in 2000 found that nurses working 12-hour shifts reported increased quality and amount of care, but that the study limitations were significant because the sample size was small and there was no valid measurement tool used to test quality and amount of care (p. 298). The next study found that 12-hour shifts had the potential of improving patient care and nurse satisfaction, but once again, the sample size was small (N=23), and there was no reliable and valid tool used to measure patient care and nurse satisfaction (Lorenz, 2008, p. 298). The third study was similar to the previous two that were reported, but the fourth study was much larger (N=805). The fourth study concluded that nurses working 12-hour shifts were more satisfied than nurses working eight-hour shifts and that there was no impact on patient outcomes (Lorenz, 2008, p. 298). The fifth and sixth studies showed conflicting evidence regarding the impact of 12-hour shifts, so the authors of the studies were unable to state definitively whether or not 12-hour shifts had negative or positive impacts on patient safety and nurse satisfaction and health (Lorenz, 2008, pp. 298-299). The seventh study found that “risks of errors began to increase when the duration of the shift was greater than 8.5 hours, and nursing staff were three times more likely to perpetrate an error when they worked more than 12.5 hours” (Lorenz, 2008, p. 299). The final study was conducted with a sample of 502 critical care nurses in the United States (Lorenz, 2008, p. 299). The results of this study found that “the longer duration of work, the greater the risk of errors and near errors because of the diminished vigilance of the nurse” (Lorenz, 2008, p. 299). Lorenz (2008) then examined whether or not 12-hour shifts are ethical based upon the eight studies reviewed on the topic of 12-hour shifts. The author called for regulations to be developed that would restrict the number of hours worked and urged administrators to understand the data related to the effects of long shift lengths and to take steps to reduce the risk of medical errors related to fatigue caused by long shift lengths (Lorenz, 2008, p. 301). Lorenz (2008) also recommends that future studies be done that examine the relationship of other variables such as age or experience with shift length and the impact of these variables on patient safety. Recommended Change in Nursing PracticeThe literature review clearly shows that patient safety is at risk when nurses work shifts greater than eight hours in duration, compared to working shifts eight hours or less in duration. The majority of studies indicate that nursing fatigue negatively impacts patient safety. One study found that risks of errors began to climb when the shift lasted longer than 8 hours, and when shifts lasted longer than 12.5 hours, the risk of nursing staff making an error increased threefold (Lorenz, 2008, p. 299). Garrett (2008) states that a when a nurse is tired, the effects can be compared to alcohol impairment (p. 1192). Garrett (2008) cites research that shows that performance is similar to having a blood alcohol level of 0.05 percent after going without sleep for 17 hours (p. 1192). Not only do nurses working long shifts put patient safety at risk, but they may also violate the nurse’s code of ethics, which is to do no harm. According to the Code of Ethics of the American College of Healthcare, “the fundamental objectives of the healthcare management profession are to maintain or enhance the overall quality of life, dignity and well-being of every individual needing healthcare services” (Lorenz, 2008, p. 299). Based on this code of ethics, and based on the information, evidence-based nursing practice would recommend that 12-hour shifts be eliminated. Although 12-hour shifts are popular with nurses because of the flexibility, patient safety must take precedence (Lorenz, 2008, p. 299).Further research and more studies need to be conducted to support the finding that nurses working shifts longer than eight hours make more errors. Other variables, such as the nurse’s age and experience, may also contribute to the medication error rate. Future studies should examine these variables and how they affect patient safety (Lorenz, 2008, p. 301). More research could also explore the correlation of nurses working successive days in a row and patient safety (Page, 2004, p. 6).Maintaining staffing with 12-hour nursing shifts does offer advantages for nurses, patients, and hospital administration; and these advantages must be considered. Nurses who work 12-hour shifts can maintain full-time status working three days a week, allowing for more flexibility in their personal lives. Patients receiving care from nurses working 12-hour shifts experience more consistent care, because there are less shift-to-shift staffing changes. Hospital administration also fiscally benefits from staffing with 12-hour nursing shifts because fewer employees can be hired to cover the necessary staff nursing hours, which reduces costs such as paid benefits associated with retaining employees. One impact of eliminating 12-hour shifts could be less flexibility for nurses, which may decrease job satisfaction. Also, patients might receive less consistent care because of more frequent shift-to-shift handoff, and this may increase error rates as well. Eliminating 12-hour nursing shifts could increase administrative costs related to human resources and employee benefits. While these impacts are speculative in nature, they warrant additional research in regards to best staffing practices relating to nursing shift length and patient safety.The goal of nursing should be to use evidence-based practice to promote quality outcomes for patients (Burns & Grove, 2011, p. 4). Clearly, patient safety is the most important aspect in patient outcomes. A report published in 1999 by the Institute of Medicine states that 98,000 deaths occur in hospitals every year as the result of medical errors that are preventable (Lorenz, 2008, p. 297). ConclusionThe implications of not changing evidence-based practice to eight-hour shifts instead of the popular 12-hour shifts that most hospitals use for staffing is that more patients will continue to be harmed or die from these errors. The United States needs to regulate and establish safe limits on working hours for health care providers in the same way they regulate other industries (Lorenz, 2008, p. 301). Evidence-based nursing practice should prompt changes that would limit hospital-based nurses to work only eight-hour shifts, in order to reduce error rates, and thus promote patient safety.ReferencesBarker, L. M., & Nussbaum, M. A. (2011). Fatigue, performance, and the work environment: A survey of registered nurses. The Journal of Advanced Nursing, 67(6), 1370-1382. doi: 10.1111/j.1365-2648.2010.05597.xBurns, N., & Grove, S. (2011). Understanding nursing research: Building an evidence-based practice, 5th Ed., Maryland Heights, MO: Elsevier Saunders.Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. AORN Journal, 87(6), 1191-1204. doi:10.1016/j.aorn.2008.01.022 Geiger-Brown, J., & Trinkoff, A. M. (2010). Is it time to pull the plug on 12-hour shifts? The Journal of Nursing Administration, 40(3), 100-102. doi: 10.1097/NNA.0b013e3181d0414eLockley, S. W., Barger, L. K., Ayas, N. T., Rothschild, J. M., Czeisler, C. A., & Landrigan, C. P. (2007). Effects of health care provider work hours and sleep deprivation on safety and performance. The Joint Commission Journal on Quality and Patient Safety, 33(11), 7-18. Lorenz, S. G. (2008). 12-hour shifts: An ethical dilemma for the nurse executive. The Journal of Nursing Administration, 38(6), 297-301. doi: 10.1097/01.NNA.0000312785.03341.80Olds, D. M., & Clarke, S. P. (2010). The effect of work hours on adverse events and errors in health care. Journal of Safety Research, 41(2), 153-162. doi:10.1016/j.jsr.2010.02.002Page, A. (Ed.) (2004). Keeping patients safe: Transforming the work environment of nurses. Retrieved from , P. W., Du, Y., Cowell, R., Amsterdam, N., Helfrich, T. A., Linn, R. W., Mojica, L. A. (2006). Comparison of nurse, system and quality patient care outcomes in 8-hour and 12-hour shifts. Medical Care, 44(12). 1099-1106. Stone, P. W., Mooney-Kane, C., Larson, E. L., Horan, T., Glance, L. G., Zwanziger, J., & Dick, A. W. (2007). Nurse working conditions and patient safety outcomes. Medical Care, 45(6). 571-578. doi:10.1097/MLR.0b013e3180383667Trinkoff, A., Geiger-Brown, J., Brady, B., Lipscomb, J., & Muntaner, C. (2006). How long and how much are nurses now working? The American Journal of Nursing, 106(4). 60-71. ................
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