Back in 1989 was the first time the 12-hour shift was used as an attempt to help staff nursing units, critical care units in particular, during a nursing shortage. The original idea was for it to be only an experiment or a pilot test; i.e. a short-term solution. But before we knew it, the 12-hour shift expanded to being used to every type of unit throughout the hospital where the pilot test was conducted, and then externally to many other hospitals. For a period of time, the 12-hour shifts were used to supplement the traditional 8-hour shifts in the staffing of nursing units, but gradually over time the 8-hour shifts started to become a thing of the past. For quite some time the 12-hour shift in many locations became the only staffing option, which provided nurse researchers an opportunity to more closely study the impact of the 12-hour shifts on nurses and patients. Certainly, in the 1990s we did not fully understand the impact, but now we do. This blog will briefly discuss the cumulative effect of 12-hour shifts on nurse fatigue and on patient outcomes.
In 2004, the American Nurses Association published a position statement on appropriate nurse staffing, describing it as the right types of nurses for the right types of patients in the right clinical setting. Also in 2004, the Institute of Medicine’s “Keeping Patients Safe” report included numerous studies about the negative impact of 12-hour shifts on patient safety, with the primary implication being on nurse staffing and nurse fatigue. This then led to recommendations that nurses should work no more than three consecutive 12-hour shifts, no more than 60 hours in a seven-day pay period, and that shifts should not be longer than 12 1/2 hours. The report also strongly encouraged hospitals to limit the amount of overtime, both voluntary and involuntary. Theoretically, nurses control the amount of voluntary overtime they agree to accept, but involuntary (or mandatory) overtime is different. As defined in the Fair Labor Standards Act, employers can require involuntary overtime, but nineteen states have since enacted legislation prohibiting the use of mandatory overtime in high risk settings.
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Despite these recommendations and cautions, nurse staffing continued to rely on 12-hour shifts, even in the face of research evidence that clearly shows the impact of fatigue on nurses and patient safety. Therefore in 2014, the American Nurses Association published another position statement indicating a joint responsibility between an employer and a nurse to work together to properly staff a nursing unit and an ethical responsibility for both parties to do their best to ensure nursing units are staffed safely.
Outcomes of Fatigue
Anything that disrupts one’s circadian rhythm impacts how one sleeps, so the amount of sleep in the 24-hours before a shift impacts not only how alert the nurse is during the shift but also her short-term memory. Nurse fatigue often causes patient safety events that can manifest as procedural (e.g. needle stick injuries), documentation, or medication errors. The most often studied patient safety event is medication errors. In one study the risk for errors increased after even only 8.5 hours of work, whereas after 12.5 hours, the risk of errors increased by a factor of three. In this study the average amount of shift overtime was 55 minutes, and half of the 8-hour shifts exceeding 10.5 hours.
Another result of fatigue can be nurses dozing off at work or when driving home following the completion of a shift. Studies report the number of motor vehicle accidents and near (and multiple near) misses experienced by nurses, along with those nurses who have been in multiple car accidents. Tragically, nurses have also died after falling asleep at the wheel driving home from work.
While younger nurses seem to prefer 12-hour shifts, studies also note that they report feeling more pressure, more stress, being less able to handle emergency situations due to fatigue, and lower levels of emotional resilience. Conversely, the more experienced nurses who seem to prefer working the traditional 8-hour shifts, have reported being better able to handle stressful situations. The National Institute of Occupational Health and Safety’s (NIOSH) has an extensive list of research studies reporting patient nurse outcomes due to fatigue. Clearly, shift work needs to be more closely monitored, along with specific action steps to limit the number of consecutive shifts worked.
The National Institute of Occupational Health and Safety’s (NIOSH) free resources include policies, procedures, webinars, checklists and toolkits health care organizations can use.
The “Healthy Nation, Healthy Nurse” initiative sponsored by the American Nurses Association has available a toolkit, an app, and a self-assessment for nurses to evaluate their stress, sleep and fatigue. Some have suggested mitigating nurse fatigue is as simple as asking a nurse if she is tired but, unfortunately, another recent study found that nurses are not able to assess their own fatigue. One nurse researcher who pioneered studying the impact of fatigue on nurses has long called for the profession to adapt and to adopt a fitness for duty assessment, one that a nurse would be required to complete prior to accepting any voluntary overtime.
Other recommendations include having policies which clearly define the allowed number of consecutive shifts worked, minimum time off between shifts, limits on the amount of voluntary overtime, a policy that monitors the use of paid-time-off, and considering either moving back to 8-hour shifts or, at a minimum, offering other shift options in addition to 12-hour shifts exclusively. Some final words of caution are to be on the lookout for “Super Nurse Syndrome;” that is, those nurses who will not call in even when they are truly ill, sleep deprived or fatigued. In particular, be aware of units with peer pressure cultures where nurses are expected to work even on a scheduled day off. Or for the staffing coordinator that uses a “guilt trip” to ask nurses to volunteer to work overtime—there’s a name for this-–it’s called coerced voluntary overtime. These super nurses won't ever just say no because they don’t want to disrupt their unit’s esprit de corp.
After the pandemic the amount of stress and fatigue reported by nurses is even more significant, which is why I have shared ways to mitigate nurse fatigue and how to keep our patients safe.
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