Introduction
Due to the continuous nature of patient care, many areas of the nursing profession rely on shift work to maintain 24-hour staffing. According to the Institute for Work and Health, shift work has been defined as “employment with anything other than a regular daytime work schedule” (2012). While many nurses work one specific shift, such as days shifts or nights shifts, many work rotating shifts, in which nurses are scheduled to work a combination of day, evening, and night shifts (Walsh, 2013). They may work forward shift rotations, in which they work a day to night shifts in succession, or they may work reverse shift rotations, in which they transition from night to day shifts (Institute for Work and Health, 2012). A nurse working a shift rotation may transition between shifts over a period of days or a period of weeks. Although some areas still utilize eight hour shifts, most hospital systems have transitioned to 12-hour shifts over the past two decades . There has been concern that 12-hour shift rotations are contributing to burnout and nurse fatigue. Burnout is defined as extensive frustration, emotional exhaustion, and apathy towards one’s career, and nurse fatigue is a state of physical, mental, and emotional exhaustion that nurses experience due to working long hours in stressful environments (Walsh, 2013).
Background
In the late 1970s, massive nursing shortages left many hospitals in desperate need of registered nurses. The demand for nursing jobs increased due to population demands, but not enough nurses were available for these positions (Walsh, 2013). In areas where large volumes of high-acuity patients were treated, such as Emergency Departments and Intensive Care Units, managers began to schedule nurses for 12-hours shifts rotations as opposed to the usual 8 hour shifts (Aiken, Sloan, & Stimpfel, 2012). This allowed managers to gain more hours of labor with fewer nurses, and many nurses began to prefer working three 12-hour shift rotations over five eight-hour shifts a week (Aiken, Sloan, & Stimpfel, 2012). They felt that it allowed them to spend more days of the week with their families and engaging in recreational activities. Offering 12-hour shifts became a tool used to appease nurses who were disillusioned with working five days a week, and desired shift lengths that would allow them to spend more days away from the hospital (Aiken, Sloan, & Stimpfel, 2012; Walsh, 2013).
This issue of nursing shift work and shift rotations became important because of emerging research showing the negative effects that 12-hour shifts and shift rotations can have on nurses and their patients. Although research is showing that working 12-hour shift rotations can have a negative effect on nurses and patient care, nurses and nursing management are reluctant to give up their 12-hour scheduling practices.
Issue Discussion
Some of the advantages of working 12-hour shift rotations are that nurses have more days off, providing more lifestyle flexibility( Aiken, Sloan, & Stimpfel, 2012; Walsh, 2013). Nurses who work while raising young children only need to find childcare for three days out of the week instead of five, making 12-hour shifts an attractive option for parents. In many hospital systems, nurses are encouraged to obtain their bachelors and masters degrees, and working three 12-hour shifts a week gives them the flexibility of having four days to focus on academics, rather than two. Instead of working all night shifts, which can have a significant effect on a nurse’s family and social life, they can choose shift rotations which may require them to only work one night shift a week or one week of nights a month. Nurses who must generate more income to support their families may also be able to take another job (Walsh, 2013). Nurses are generally very satisfied with working three 12-hour shifts a week, with some studies showing an 80% overall satisfaction rate regarding scheduling practices (Aiken, Sloan, & Stimpfel, 2012).
Another positive aspect of 12-hour shift rotations are fewer shift changes. Nursing errors often occur during shift changes, and 12-hour shifts reduce the amount of patient handoffs from two to one (Walsh, 2013). Managers often prefer this because they are only have to find two people to cover one 24-hour patient assignment instead of three. Also, since nurses remain with patients for 12-hours instead of eight, they have more of an opportunity to establish relationships with patients and recognize when a patient is experiencing a change in baseline. Nurses are less likely to miss days of work when they work 12-hour shift rotations, and units offering 12-hour are more likely to retain nurses (Walsh, 2013).
Although there a many advantages of working 12-hour shift rotations, the disadvantages may be having a significant effect on the nursing profession. Nurses who work shifts longer than ten hours have over twice as like to want to leave their jobs in comparison to nurses working only eight hour shifts (Aiken, Sloan, & Stimpfel, 2012). Nurse fatigue is common in nurses who work 12-hour shifts, and according to the Emergency Nurses Association, nurse fatigue is significantly more severe in those who work night and rotating shifts (Walsh, 2013).
The nature of shift work can also have a signicant impact on patient outcomes and satisfaction. Nurses who work 12-hour shifts may often need to stay up to 13 or 14 hours depending on staffing and patient needs, and patient satisfaction levels are significantly lower when their nurses work longer than 13 hours (Aiken, Sloan, & Stimpfel, 2012). When nurses work longer than 13 hours, patients are more likely to report dissatisfaction with their care (Aiken, Sloan, & Stimpfel, 2012). The longer nurse are at work, the less likely they are to engage in appropriate hand hygiene, which can contribute to patient infection rates (Dai et al., 2013). Unsurprisingly, Nurses who work shifts longer than 12 hours who are more likely to experience burnout, which is also correlated with higher rates of hospital-acquired urinary tract infections in patients (Aiken et al., 2012).
Working 12-hour shifts rotations has also been linked to increased rates of medication errors, patient harm, and other sentinel events. According to Sentinel Event Alert released by the Joint Commission, the likelihood that a nurse will make a clinical error increases threefold when a nurse has worked longer than 12-hours (The Joint Commission, 2011). Nurses who work longer than 12-hours shifts are also more likely to report providing below satisfactory and low-quality patient care than nurses who work eight hour shifts (Aiken, Sloan, & Stimpfel, 2013). Analysis of sentinel events and nursing errors has determined that they are much more likely during a nurse’s second or third 12-hour shift, demonstrating the effect that nurse fatigue can have on patient care (Scott, 2010). A devastating example of this occurred in 2007, when a labor and delivery nurse meant to administer an antibiotic through a patient’s intravenous line, but accidentally administered an epidural medication instead. The patient, a young mother, died almost immediately. The nurse made a series of clinical errors that allowed the fatal mistake to happen. It was discovered that the nurse had worked a 16 hour shift the day before, and had not slept adequately before starting her next shift.
Take a stand on the issue and make a case for your personal position. Use references to justify the rationale for your position. (7 points)
I think that 12-hour shift rotations should be available to nurses, but nursing management and policymakers need to make a coordinated effort to decrease nurse fatigue. The issue is not necessarily working 12-hour shifts, but 12-hour shifts that frequently turn into 14 or 15 hour shifts. Nursing and patient care outcomes are similar for nurses working 8 and 12-hour shifts, but working longer then 12.5 hours is associated with negative outcomes (Walsh, 2013). Mandatory and voluntary overtime should be restricted for nurses working 12-hour shifts, and nursing management should abstain from calling nurses in on their days off (Aiken, Sloan, & Stimpfel, 2012). Nurse managers should make an effort to schedule forward shift rotations for employees who work primarily rotating shifts, because these allows their bodies to adjust more easily to the change in schedule. If possible, nurse administrators should establish permanent shift schedules instead of rotating assignments, which reduce fatigue by allowing nurses to become accustomed to a specific sleep and wake pattern (Walsh, 2013). Instead of scheduling nurses for three 12-hour shifts in a row, nursing management should consider other shift patterns, such as scheduling two days in succession, giving one day off, and then scheduling the third shift in the rotation to increase shift recovery time.
Future Importance
This issue will be important to me in my future practice because I plan on working in the Emergency Department, where 12-hour shifts are the norm. Due to the patient volume and acuity of patient care, I may end up working overtime and being called in on my days off. It is important that I make sure to sleep well before 12-hour shifts and speak with my nurse manager if I feel that I am experiencing a level of fatigue that could interfere with my nursing judgement. It is likely that there will be days where I will be asked to stay longer or work a double, and I need to think about how working extra hours will impact my patients and my personal health.