12 Hour Nursing Shifts and Its Impact on Patient Safety Penelope Baker Walden University EDUC 6125 – Foundations of Research Dr. Sunil Hazari December 12, 2012 12 hour nursing shifts and its impact on patient safety. Presented by Penelope Baker

Context Hospital nurses worked 8 hour shifts until the late 1970s Now, most nurses work 12 hour shifts Hospital nurses worked eight hour shifts until the late 1970s. Now, almost all nurses work 12 hour shifts including those in the hospital where I work. (Bae, 2012; Geiger-Brown & Trinkoff, 2010a)

Background Registered Nurse (RN) demographics 2.5 million actively employed 62% work in hospitals 70% work full time Average age 45.5 years Currently there are more than two and a half million registered nurses actively employed in the United States. 62% work in hospitals and 70% work full time. The nursing workforce is aging. In 2008, the average age of an employed nurse was 45 and a half years. (U.S. Department of Health and Human Services, 2010)

Problem Nurses find 12 hour shifts and shorter work weeks satisfying Despite satisfaction, there is growing evidence 12 hour shifts… Have a negative impact on nurses’ physical health Jeopardize patient safety Prompt older nurses to seek 8 hour jobs elsewhere Nurses frequently say 12 hour shifts and shorter work weeks are very satisfying. Unfortunately, there is growing evidence 12 hour shifts have a negative impact on their physical health. There is also concern these extended shifts may jeopardize patient safety. 12 hour shifts is also a major reason for older hospital nurses resigning to take jobs in other healthcare settings which are physically less demanding. (Geiger-Brown & Trinkoff, 2010a; Geiger-Brown & Trinkoff, 2010b; Georgia Nurses Association, 2012; Stone, Du, Cowell, Amsterdam, Helfrich, Linn, Gladstein, Walsh, & Mojica, 2006)

Controversy Initial research on effects of 12 hour shifts focused on nurse satisfaction Later research examined effects of longer shifts on quality of patient care Some researchers and professional organizations recommend Returning to 8 hour shifts Based on studies showing a relationship between the number of hours worked and nursing errors Initial research on the effects of 12 hour shifts mostly focused on nurses’ personal satisfaction. That focus changed in 1982 when Vik and MacKay compared the effects of longer shifts with the quality of patient care. Controversy is brewing as a growing number of researchers and professional organizations recommend returning to eight hour shifts. They base that recommendation on studies showing a relationship between the number of hours worked and nursing errors. (Geiger-Brown & Trinkoff, 2010a; Geiger-Brown & Trinkoff, 2010b; Georgia Nurses Association, 2012; Vik & MacKay, 1982)

Review of Literature The risk of making an error was 3 times higher when nurses worked 12.5 or more hours My literature review focused on the use of 12 hour shifts and its impact on patient safety, nursing errors and retention of older nurses. A study in 2004 and replicated two years later by some of the same researchers, found the risk of making an error was three times higher when nurses worked more than 12 and a half hours in a shift. In the first study, it was noted, while errors occurred most often when shifts exceeded 12 and a half hours per day, the risks actually began to increase when shift durations exceeded eight and a half hours.   (Rogers, Hwang, Scott, Aiken, & Dinges, 2004b; Scott, Rogers, Hwang, & Zhang, 2006).

Review of Literature More than half of nursing errors involved medication administration The second most important finding in my literature review revealed... More than half of those errors involved medication administration.   (Rogers, Hwang, Scott, Aiken, & Dinges, 2004b; Scott, Rogers, Hwang, & Zhang, 2006).

Review of Literature For nurses working 12 hour shifts, 75% of the time they worked more hours than scheduled Increased reports of fatigue and difficulty staying alert when working 12 hour shifts Older workers were more sensitive to internal body clock disruptions Older nurses working 12 hour shifts experienced other physical problems My literature review also indicated... For nurses working 12 hour shifts, 75% of the time, they worked more hours than scheduled. And they frequently reported being fatigued and having difficulty staying alert during work hours. Findings related to older workers… Indicated they were more sensitive to disruptions in their internal body clock. Older workers experienced more physical problems such as needing longer recovery times between 12 hour shifts, having more sleep disturbances, and anxiety about their lack of sleep.   (Fragar & Depczynski, 2011; Reid & Dawson, 2001; Rogers et al., 2004b; Scott et al.,2006)

Review of Literature 16 U.S. states have laws regulating mandatory nurse overtime though this does not mean they work less mandatory overtime or fewer hours In 2006, researchers refuted other studies by reporting no differences in quality or patient outcomes when comparing 8 hour and 12 hour shifts This slide depicts two of the most unusual findings. * 16 states now have laws regulating mandatory nurse overtime. Unfortunately these regulations did not necessarily mean nurses worked less mandatory overtime or fewer hours.   * In 2006, a group of researchers in New York City compared 8 hour and 12 hour nursing shifts. Their results refuted other studies by not finding any differences in quality or patient outcomes. (Bae, 2012; Stone et al., 2006)

Controversy Revisited Returning to 8 hour shifts may be ideal, but not practical If 12 hour shifts are eliminated, nurses may become dissatisfied Unless research provides overwhelming evidence 12 hour shifts are detrimental to nurses and patients, hospitals will continue offering 12 hour shifts and nurses will continue working those shifts. As I previously shared, the issue of 12 hour shifts is increasingly controversial. While returning to eight hour shifts may be ideal, in reality it may not be practical. If 12 hour shifts are eliminated, nurses may become increasingly dissatisfied with their jobs and working conditions, or may resign to take positions in other hospitals where 12 hour shifts are still available. Secondly, unless future research provides overwhelming evidence that 12 hour shifts are detrimental to nurses and patient safety, in my opinion hospitals will continue offering 12 hour shifts, and nurses will want to continue working those shifts. (Geiger-Brown & Trinkoff, 2010a; Geiger-Brown & Trinkoff, 2010b; Georgia Nurses Association, 2012; Montgomery & Geiger-Brown, 2010; Rogers et al., 2004b)

Proposed Solution Minimize 12 hour shifts Limit work hours to 12 hours in a 24-hour period Schedule sufficient recovery time between 12 hour shifts Leave work at end of shift, 100% of time Create a mixture of 4 hour, 8 hour, and 12 hour shifts Eliminate overtime Reduce medication administration errors with use of bedside medication verification systems Based on my literature review, I propose the following recommendations: Minimize the use of 12 hour shifts (Scott et al., 2006). Limit nurse work hours to no more than 12 consecutive hours in a 24 hour period (Scott et al., 2006). Schedule sufficient recovery time between 12 hour shifts to minimize fatigue (Fragar & Depczynski, 2011). Ensure nurses leave work at the end of their scheduled shifts, 100% of time (Geiger-Brown & Trinkoff, 2010b). Create work schedules which include 4 hour, 8 hour, and 12 hour shifts; providing opportunities for older nurses and younger nurses with children to work shorter shifts (Geiger-Brown & Trinkoff, 2010b). Eliminate overtime (Rogers et al., 2004b). Reduce medication administration errors with the use of bedside medication verification systems. (Fragar & Depczynski, 2011; Geiger-Brown & Trinkoff, 2010b; Rogers et al., 2004b; Scott et al., 2006)

Proposed Solution Use fatigue risk-management software to identify schedules promoting fatigue Respect nurses’ days off – no extra work days or training classes Avoid scheduling night shift staff meetings for 7:30 a.m. Implement 12 hour shift nursing policies based on guidelines from the Joint Commission and the American Nurses Association In addition I propose: Using fatigue risk-management software to identify shift schedules promoting fatigue (Geiger-Brown & Trinkoff, 2010b). Respecting nurses’ days off; no extra work days or training classes on days off (Geiger-Brown & Trinkoff, 2010b). Avoiding scheduling night shift staff meetings for 7:30 am so those nurses do not have to extend their work time. And implementing nursing policies based on guidelines for 12 hour shifts from The Joint Commission and the American Nurses Association. (Geiger-Brown & Trinkoff, 2010b; Rogers et al., 2004b; Scott et al., 2006; The Joint Commission, 2012; The American Nurses Association, 2012)

Proposed Solution Design and implement e-learning modules Minimizing fatigue and promoting alertness Improving sleep and internal body clock functioning My proposal includes these final recommendations: Design and implement two e-learning modules One for minimizing fatigue and promoting alertness during work hours A second e-learning module for improving sleep and internal body clock functioning during non-working hours. (Berger & Hobbs, 2006)

Next Steps Present key findings and proposal to nursing stakeholders… Vice President & Chief Nursing Officer Clinical Directors Clinical Managers Clinical Educators Develop effective solutions by working with members of these direct-care nursing councils… Nursing Research and Evidenced-Based Practice Council Nursing Quality Council The next steps in this process include: Presenting my key findings and proposal to these nursing stakeholders: The Vice President & Chief Nursing Officer Clinical Directors Clinical Managers And Clinical Educators To develop effective solutions, I will need to work with members of these direct-care nursing councils: Nursing Research and Evidenced-Based Practice Council Nursing Quality Council

Discussion Most significant finding, the risk of making an error was three times higher when nurses worked more than 12.5 hours in a shift Nurses on 12 hour shifts worked more hours than scheduled 75% of the time These studies did not explore level of harm to patients when errors made Patient safety was compromised As previously stated, the most significant finding showed the risk of making an error was three times higher when nurses worked more than 12 and a half hours in a shift. Nurses on 12 hour shifts also typically worked more hours than scheduled, 75% of the time. The potential for patient harm related to nursing errors is a very serious matter. Studies examined in my literature review did not explore the level of harm to patients when errors were made. Regardless of how the issue is viewed, patient safety was compromised, whether the error resulted in no harm, death, or somewhere in between the two extremes. (Rogers et al., 2004b; Scott et al.,2006)

Conclusion Evidenced-based strategies for 12 hour shifts need to be implemented in every hospital and accepted by every nurse Nurses get what they want, 12 hour shifts Patients get what they want, patient care without errors To conclude, evidenced-based strategies such as the ones presented here need to be implemented in every hospital and accepted by every nurse so that nurses and hospital administrators get what they want, 12 hour shifts, while patients get what they want, patient care which is free of errors.

Acknowledgements Images used in this presentation obtained from three sources Microsoft Corporation: www.Office.com iStockphoto: http://www.istockphoto.com/index.php Meritus Medical Center, 11116 Medical Campus Road, Hagerstown, Maryland, 21742 Images comprised of actual employees functioning in dual roles of nurses and patients

References Bae, S. (2012). Nurse overtime, working conditions, and the presence of mandatory nurse overtime regulations. Workplace Health & Safety, 60(5), 205-214. Retrieved from DOI: 0.3928/21650799-20120426-01 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), 465-471. Retrieved from DOI: 10.1188/06.CJON.465-471 Fragar, L. J., & Depczynski, J. C. (2011). Beyond 50. Challenges at work for older nurses and allied health workers in rural Australia: a thematic analysis of focus group discussions. BMC Health Services Research, 11(1), 1-13. Retrieved from DOI: 10.1186/1472-6963-11-42 Geiger-Brown, J., & Trinkoff, A. M. (2010a). Is it time to pull the plug on 12-hour shifts? Part 1. The evidence. Journal of Nursing Administration, 40(3), 100-102. Retrieved from DOI: 10.1097/NNA.0b013e3181d0414e

References Geiger-Brown, J., & Trinkoff, A. M. (2010b). 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. Retrieved from DOI: 10.1097/NNA.0b013e3181ee4295 Georgia Nurses Association (2012). GNA Reference Reports: Adopted 2011 Georgia Nurses Association Action Report, 12 hour shifts and fatigue. Georgia Nursing, 72(1), 7-8. Retrieved from http://ezp.waldenulibrary.org/login?url=http://search.ebscohost.com/login.aspx? direct=true&db=rzh&AN=2011446899&site=ehost-live&scope=site 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. Retrieved from DOI: 10.1097/NNA.0b013e3181d40e63 Reid, K., & Dawson, D. (2001). Comparing performance on a simulated 12 hour shift rotation in young and older subjects. Occupational & Environmental Medicine, 58(1), 58-62. Retrieved from http://oem.bmj.com

References Rogers, A. E., Hwang, W., & Scott, L. D. (2004a). The effects of work breaks on staff nurse performance. Journal of Nursing Administration, 34(11), 512-519. Retrieved from Accession Number: 00005110-200411000-00007 Rogers, A. E., Hwang, W., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004b). The working hours of hospital staff nurses and patient safety: both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours at a stretch. Health Affairs, 23(4), 202-212. Retrieved from DOI: 10.1377/hlthaff.23.4.202 Scott, L.D., Rogers, A. E., Hwang, W., & Zhang, Y. (2006). Effects of critical care nurses’ work hours on vigilance and patients’ safety. American Journal of Critical Care, 15(1), p. 30-37. Retrieved from http://ezp.waldenulibrary.org/login?url=http://search.ebscohost.com/login. aspx?direct= true&db=rzh&AN=2009096375&site=ehost-live&scope=site

References Stone, P. W., Du, Y., Cowell, R., Amsterdam, N., Helfrich, T. A., Linn, R. W., Gladstein, A., Walsh, M., & Mojica, L.A. (2006). Comparison of nurse, system and quality patient care outcomes in 8-hour and 12-hour shifts. Medical Care (MED CARE), 44(12), 1099-1060. Retrieved from Western Maryland AHEC, Interlibrary Loan with Medical Library, Perry Point VA Medical Center, Perry Point, Maryland, 21902. The American Nurses Association (2012). Position statements: opposition to mandatory overtime, Registered nurses’ responsibility in all roles and setting to guard against working when fatigued. Retrieved from http://www.nursingworld.org/ The Joint Commission (2012). Hospital national patient safety goals for 2012. Retrieved from http://www.jointcommission.org/assets/1/6/2012_NPSG_HAP.pdf U.S. Department of Health and Human Services (2010). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved from http://bhpr.srsa.gov.healthworkforce/rnsurvey/initialfindings2008.pdf

References Vik, A. G., & MacKay, R. C. (1982). How does the 12-hour shift affect patient care? Journal of Nursing Administration, 12(1), 11-14. Retrieved from Western Maryland AHEC, Interlibrary Loan, Source Unknown.