'Decision Regret' in Nurses Linked to Fatigue

Calling twelve-hours shifts "one of the worst things we ever did," the author of a study on inadequate sleep among nurses is calling for leaders to encourage strategic napping and shorter shifts.

14 comments on "'Decision Regret' in Nurses Linked to Fatigue"
Sara-Ann Lipson (5/7/2014 at 5:20 PM)

When we started doing 12 hour shifts in San Francisco, when I worked there, we got a total of 1.5 hours in breaks. Some nurses used their breaks for a power nap. In Nevada you are lucky to get your 30 minute lunch. Also when these long shifts were started we were not allowed to work more than 2 shifts in a row. It is quite common in Las Vegas for nurses to have 2 full time jobs. The rest of the world works an 8 hour day. So nurses are working 1.5 days every shift. Patients deserve to have well rested nurses, on their toes. Too much is riding on their alert minds for them to be sleep deprived at all let alone on a long term basis. I loved 8 hour shifts. Sure, I like the idea of having to go in only 3 days a week but we owe it to our patients to have a nurse that is alert. I think the real reason the 12 hour shifts caught on, like everything else is it was a huge benefit to the hospital's bottom line. Cut out an en tire shift? Cut out all those dollars in benefits? They couldn't wish for a better moneymaker.Has anyone done a study on the amount of nurses working 12 hour shifts to see if divorce rates have increased, substance abuse increased other mental health issues have surfaced?I doubt the outcome of such studies reflect positively. People who work 12 hour shifts also bring up continuity of care. So they take really good care of a group of too many patients and then they are off for 4 days? When we worked 8 hour shifts we had much better continuity of care because we worked more days than we had off.There is a lot to be said about working 8 hour shifts. I would even say 10 hour shifts are OK but there just are not enough hours in the day for 12 hour shifts to be appropriate or safe for the nurses OR the patients. We have not taken into account that they are 12.5 hours, the commute time to and from work, the household chores/upkeep even for single nurses. It is past time to reevaluate the long term effects of long term sleep deprivation and think about the nurses, patient safety and NOT how much money can be trimmed from the nursing budget so administrators can have huge paychecks.
mary koloroutis (4/20/2014 at 8:29 PM)

I have been troubled in the disruption in continuity on some units due to 12 hour shifts [INVALID] obviously some patients are benefited by 12 hour shifts such as labor and delivery and emergency departments [INVALID] continuity is improved. What has really troubled me is hearing that there is a practice of nurses working as per diem nurses in other hospitals after also working 3 twelve hour shifts [INVALID] so literally working 5-6 12 hour shifts per week. Nursing leaders tell me there is nothing to be done about what nurses do in their time off schedule, but I do believe that if this is, in fact, a common practice, that safety and nurse burnout are hugely impacted [INVALID] pilots have limits for the safety of their passengers. What is a reasonable "limit" for nurses to safeguard both patient and their own well being?
David Ascherl RN (4/8/2014 at 11:13 PM)

I for one feel that 12 hr shifts are one of the Perks of being a nurse. Where else can you work 3 days a week & have 4 days off. Yes I get tired at times but not so tired that I am not able to make critical decisions. I have worked in ICU's & ERs for the last 23 yrs and would not take a position if it was an 8 hr/day, 5 day a week job. I love having 4 days off with my family. The trick is my wife and I had an aggreement when we were raising our children. Whoever was working that day or night had no other responsibilities than to come home and sleep. The parent that was at home was in complete 100% charge of the house and children. The mistake I see most nurses makeing is that they try to be SUPERMOMS!! They work 13 hr shifts and then come home and make breakfast or supper, help with the homework, or clean house. Then they get inadequate sleep and expect to be able to go back to work again and be productive. That is just crazy. I loved our set up because then I also was able to experience my children as they grew up instead of just being the bread winner. Now that my children are grown my wife and I try to schedule our days together so we can have our days off together. And 4 days a week off with the woman you love is a heck of a lot better that just 1 or 2. Sure for single moms this may not be an option and I feel for their situations. Nut please don't advocate taking away my 12 hr shifts after I've worked the last 23 yrs to finally get to a point where my wife & I can enjoy it.
marie (4/8/2014 at 5:21 PM)

I have worked 8 hour shifts and 12 hour shifts. I believe that 12 hour shifts, while longer are not a problem. Many nurses who work 8 hours spend extra time charting and do not get out on time. Working 4 extra hours and receiving more days off are beneficial to energizing yourself again to face the unit. Working 8 hours and staying extra to finish or cover for staffing purposes, does not allow enough time for the staff member to recover and be ready to face another day.
Kathleen Swarthout (3/18/2014 at 2:40 PM)

I find 12 hour shifts very fatiguing for myself, but I am older. Younger nurses like them because they can spend more time with their families. One good thing about 12 hour shifts is that a nurse cannot be forced to work a "double" (or even manipulaed into working one), but can be manipulated into working more than the full shift "until we can get someone else to come in." I have not seen any hosptials do any studies on when errors occur during shifts. Do more errors occur at the end of a shift? At what time of day do more errors occur? There have been studies that show that more erors happens when staffing levels are low. I prefer 8 hour shifts, but think that there could be a mix of 8 and 12 hour shifts to fit the needs and capacities of individual nurses. Shifts which all start at the same time actuallly leave the floor with less coverage during "shift change." Why not stagger the times so the busier times have a larger staffing presense?
MSH (2/24/2014 at 6:34 PM)

Having worked 8, 10 and 12 hour shifts during my career as well as having worked in a facility with a "Cloud Room" (a quiet/nap room) I can state without hesitation that what sounds good on paper can be a nightmare in terms of implementation. Just as a 12 hour shift is actually a minimum of 13 hours, a 15 minute nap is never just 15 minutes away from the patient. Some staff will invariably abuse the time allotments. Some will drift off after 10 minutes and begin counting their time from that point. Some will manage to nap every night while others are too wound up to relax and exit the Quiet Room even grumpier than they entered. Others will resent those who manage to nap once or twice a shift, regardless of what is happening on the unit. The list of snags goes on and on. Over the course of a year I watched a great idea devolve into a source of considerable staff discord. I agree with the writer who stated 12 hour shifts contribute to compassion fatigue. I agree with the writer who stated every nurse is an individual with unique scheduling needs. I agree with the writer who stated that our profession needs to address the issue of fatigue. Interns and residents, patients, nurses [INVALID] who in healthcare rests anymore?
SDM (2/7/2014 at 7:36 PM)

As everyone is unique and requires different accommodations, both twelve and eight hour shifts should be utilized. We shouldn't have an all or none mentality. While it does take more effort with scheduling, the mix of shifts allows more staff to meet their individualized needs for sleep and life outside of work. This results in improved staff morale & job satisfaction, leading to improved patient care and safety!
Carolyn Schur (1/29/2014 at 7:54 PM)

Shift length is a complex issue. For starters, best practice requires that no more than 2 or 3, 12-hr. shifts should be worked in a row. Many nurses commonly work 3 or 4 shifts in a row. Even though the study author supports shorter shifts, she also states that other factors like no breaks, understaffing, patient acuity and the nurses' own views of their value to their patient, also contribute to the fatigue. Given these other factors and the fact that 8-hr. schedules often require working 5 or more shifts in a row and have their own issues with fatigue and patient safety, let's not assume that getting rid of 12-hr. shifts is the end-all and be-all for healthy and safe nurses.
Julian Hernandez (1/18/2014 at 7:31 PM)

Can you provide any examples of hospitals or health systems where these changes have been made? I.e. adding quiet rooms or areas for nurses to catch a quick nap during their 12-hour shifts? Any pilot programs out there to keep an eye on? Of course, in looking at a normative behavior model, a pilot program would explore methods for making these 15-minute naps not mandatory, but the normal, acceptable behavior. If a majority of nurses believe that only they can give their patients the best care, then perhaps an internal employee campaign could use that insight to urge a behavior change. Messages like, "We know you care for your patients, and want the best care for them. Imagine how a 15-minute nap during your shift would make you an even BETTER caregiver." Fascinating problem to have. Lots of intriguing potential solutions.
David Hofmann (1/17/2014 at 5:02 PM)

FYI ... my colleagues and I have a working paper where we show that hand hygiene compliance declines significantly over the course of a shift. This effect is moderated by work intensity such that the more intense the work, the faster the rate of compliance decline. Hours off work predict compliance rates upon return to work (more hours off, higher returning compliance). Paper can be viewed here: http://dx.doi.org/10.2139/ssrn.2320114
Laura Mahlmeister RN PhD (1/17/2014 at 4:08 PM)

For young, new and enthusiastic novice nurses 12 hour shifts may work beautifully. But as a nurse who practiced into her 40th year as a nurse, 12 hour shifts were impossible and luckily the unit I worked on had voted for 8 hour shifts. Not enough time has been spent studying the effects of aging, the demands of mastering increasingly complex clinical technology, lack of adequate lunch breaks - or no lunch breaks and sleep deprivation on the quality and safety of work for nurses working 12 hour shifts. (safety for BOTH nurse and patient). Several studies did find an association between working beyond 8 hours and medication errors. Hopefully, additional evidence will lead to an improvement in work hours.
Eva Francis (1/17/2014 at 12:54 AM)

I strongly believe that the 12 hours shift is contributing to an era of disengaged staff. Staff are exhausted and especially working in a busy fast paced ER and Critical Care Unit Agreed that those long hours should be revisited especially in this challenging healthcare climate
kit (1/16/2014 at 10:35 PM)

I am an nurse epidemiologist and a NP. You have many insights on nursing safety to report. Still I believe that you need research on the following : 1- Safety assessment per Charge RN. I believe that we need comparator data in states where there are mandated nursing ratios versus the majority. 2- Safety assessments on the acuity mix and on the ability of charge RNs to protect breaks. Again I would compare that data in states where there is collective bargaining versus the majority. 3-Safety assessments on the ability of charge nurses to collaborate with management in underserved units. Since the staffing data can be extrapolated quickly with an electronic bed board, I wondered how many facilities use that real time data. In other words do they move stay quickly to reduce inter hospital staffing variation 4- Safety assessments in hospitals where nurses have RRT units. For example I would like to see their assessments on the capacity for RNs to get a break off their units. My perspective is that the RNs know they need breaks badly but are monitoring too many patients with too much acuity. My impression, from working in three Magnet facilities and multiple community hospitals, is reality has kept the RNs cynical regarding the aggregate poor safety monitoring for patients. So nursing needs a voice beyond the head RN.. Safety data should be extrapolated and reported to the hospital epidemiology committee. Moreover that safety committee should have a non punitive process of adjudicating RN staffing problems. They should report to the DON and to the DOM, as opposed to keeping budgets and political might at the unit level. Many problems occur when attending staff aren't available. That is why we have safety aberrations on nights and weekends. Unfortunately those same periods may be staffed with RNs who have less political authority. So until the patients matter the most, our budgetary priorities will prevail and the best RNs will remain defensive. Furthermore, our risk management teams understand that personal injury attorneys must extrapolate $ 100, 000 per case, or cases will be settled out of court. That is why the average family has little recourse in today's hospital setting. Safety data, including the RN training and shifts worked should be transparent, as you indicated. Like you I would also like to see 12 hour shifts minimized. That could only occur, I believe if a nursing positions is entitled to benefits with less than five days worked per week. This is similar to what pilots have and would reduce the likelihood of nurses leaving. (ie 30 hours per week would entitle them to benefits.. RNs might work three 10 hour shifts one week, followed by four eight hour shifts. We would need some short shift workers to help with overflow as well). As you indicated there are leaders who understand RNs don't like being in the hospital five days a week. Naturally their burnout is especially high where the casemix is complicated. RN burnout is also positively correlated to where survival curves are limited... (Like the Geriatric units and the MICUs).. So I think that we need to do subpopulation questionnaires. We can then use the data from these tools to help units establish teams that can provide respite for nurses. That team concept is chiefly critical when RNs cannot gather more energy to care for patients with limited outcomes. They are not alone after all, as we know that the US has more Plastic Surgeons per capita than Gerontologists. The reason seems to be that surgeons are better paid with less comorbidity to address. So RNs are truly like their medical partners. That is they are humans who need a breaks when the outcomes are constrained by the patient themselves. Thanks in advance for considering these issues. I look forward to seeing more
Stefani Daniels (1/14/2014 at 6:15 PM)

Not only are 12 hr shifts hard on the body, they are poor models of care coordination. Continuity is lost, new relationships have to be built, and time is wasted just to find out what happened while the nurse was off duty. Given the national average LOS of 4.8, the old 5 day schedule with dedicated weekend staff (the old Baylor 12 hr weekend shifts) always seemed to me to work the best.


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