Increased Nurse Work Hours & Patient Safety Effects

The impact that hospital staffs’—and particularly nurses’—long working hours can have on patient safety has become a hot topic in healthcare. While many workplaces implement 8-hour shifts, hospitals have long relied on 12-hour ones to operate. Working three, 12-hour shifts is often highly appealing to nurses who, in theory, stand to benefit from additional “weekend” days that allow them to spend more time with their family or pursuing other areas of interest.

But despite the perks of a 12-hour workday, the different effects of an 8-hour vs. 12-hour nursing shift on patient outcomes are not to be ignored. According to recent research, longer shifts for hospital nurses lead to an increase in errors, burnout, and patient dissatisfaction, putting a hospital’s long-term viability in jeopardy.

As more and more nurses begin working even longer days in response to the COVID-19 pandemic, it’s important to take a step back and investigate the relationship between 12+ hour nursing shifts and patient safety, and how hospitals can ensure they’re protecting the health and well-being of patients and staff alike.

The History of the 12-Hour Nursing Shift

Twelve-hour nursing shifts emerged in the 1970s and quickly gained traction among healthcare professionals. Nurses liked the idea of working fewer days each week and hospitals found that the new arrangement made scheduling easier, allowing them to assign fewer shifts per nurse.

In the decades that followed, the 12-hour shift continued to increase in popularity with little opposition. It was only in the wake of the early 2000’s watershed To Err is Human report, which claimed that upwards of 98,000 people die in U.S. hospitals every year due to preventable medical errors, that the public began questioning how work hours and patient safety might be intertwined. The topic has been debated ever since, with a growing body of evidence suggesting that longer days are risky for nurses and their patients.

Are 8-Hour Shifts Better Than 12-Hour Ones?

There are distinct advantages and disadvantages associated with 8- and 12-hour shifts and healthcare administrators have yet to come to a consensus on whether or not one is inherently better than the other. In most cases, it depends on the individual team and their workplace culture.

Benefits of 8-Hour Shifts

When implemented effectively within a healthcare institution, an 8-hour workday can help:

• Minimize Fatigue: Nursing is an extremely rewarding, yet physically and emotionally demanding, profession. Even 8 hours on the job can be tiring, much less 12 hours—especially when those 12 hours turn into 13 or 14 hours due to overtime. In fact, studies show that nurses accrue a considerable sleep debt while working successive 12-hour shifts, leading to higher levels of fatigue that may translate into mistakes in patient care.
• Curtail Burnout: Burnout, which is defined as a state of physical, emotional, and mental exhaustion as a result of prolonged stress, is a major issue within nursing. According to the research, nurses working 10-hour shifts or longer are two and a half times more likely to experience burnout and job dissatisfaction, leading to high turnover rates. With an estimated one-million nurses set to retire by 2025, hospitals can’t afford to lose any additional members of their staff.
• Reduce Errors: In a study of nearly 400 hospital nurses, researchers found that the risk of making an error increased when nurses worked overtime or extended shifts (those longer than 12 hours). During the study’s 28-day data-gathering period, 199 errors and 293 near-errors were reported. The majority of these errors and near errors involved the administration of medication, followed by procedural errors (18%), charting errors (12%), and transcription errors (6%). This data is too powerful to ignore, as even the smallest error can directly impact a patient’s health and well-being.
• Decrease Health Complications: Long hours and high stress levels in nursing can lead to serious health conditions among nurses, including gastric ulcers, musculoskeletal disorders, diabetes mellitus, metabolic syndrome, obesity, cardiovascular disease, and cancer.

Benefits of 12-Hour Shifts

Despite the disadvantages associated with 12-hour shifts, there are several advantages. When implemented effectively, a 12-hour workday can help:

• Minimize Patient Turnover: For most patients, a stay in the hospital is marked by fear and uncertainty. The last thing they want during this time is to be bounced from nurse to nurse, hindering their ability to form meaningful connections with the very people in charge of their care. Longer shifts significantly decrease patient handoffs—instead of three or more nurses attending to a patient during a single day, only two nurses are needed per patient during a 12-hour shift. With fewer handoffs come higher patient satisfaction ratings and fewer opportunities for miscommunication and error.
• Improve Scheduling: From an administrative perspective, longer shifts make scheduling significantly easier. Rather than scheduling three, 8-hour shifts to cover the 24-hours the hospital is open, managers can schedule two, 12-hour ones. This minimizes scheduling conflicts and allows managers to spend less time producing the schedule and more time tackling other pressing priorities.
• Increase Work-Life Balance: For many nurses, the 12-hour workday offers more flexibility than the standard 8-hour day. While 12-hour shifts leave little-to-no free time on scheduled workdays, they provide nurses with four full days off each week. This minimizes the amount of time nurses spend commuting to and from the hospital and provides them with more freedom for other pursuits, like raising a family, furthering their education, or even working a second job.
• Boost Morale: In many cases, the flexibility that accompanies longer shifts can help boost morale among nurses. Data from nurses in four states showed that more than 80% of nurses surveyed were satisfied with scheduling practices at their hospital. But while longer shifts can boost morale and even improve retention for some hospitals, they can also lead to burnout. Hospital administrators must pay close attention to their staff and monitor employee engagement levels at all times to determine if longer shifts are helping—or hindering—their teams.

Do Nurses Prefer 12-Hour Shifts?

While there are benefits associated with both 8-hour and 12-hour shifts, a majority of acute care nurses prefer 12-hour ones because of the work-life balance they offer. Many nurses also believe that these longer shifts allow them to provide better care by increasing the amount of time they spend with each patient. The more involved a nurse is with a patient during their shift, the better equipped they are to notice the nuances of that patient’s particular condition and side effects. These small details often help nurses provide more effective pain management and pinpoint sudden changes in the patient’s condition.

As data questioning the effectiveness of the 12-hour shift surfaces, many nurses are pioneering a movement to defend their coveted schedule. With the help of nurse unions and hospital management, this movement has gained traction in states like California, where a 2015 amendment to the California Labor Code was signed to protect the 12-hour shift.

Though the preference for 12-hour shifts is by no means universal, it is clear that employee engagement improves when nurses have a say in the creation of their schedule. Many nurses want to have the option of 12-hour shifts, even if they may not want those shifts right away. Hospitals hoping to recruit and retain high-quality nurses must work closely with their staff to implement a schedule that meets the needs of all key stakeholders.

How Does Overtime Work for Nurses?

Many of the concerns with 12-hour shifts are tied to nurse overtime and patient safety. It is not uncommon for 12-hour shifts to turn into 13-, 14-, 15-, or even 16-hour shifts through voluntary or mandatory overtime. With each added hour, the risk of error and nurse burnout rises, increasing the health and well-being of patients and employees.

Nurse overtime typically occurs as a result of understaffing, meaning that nurses who work beyond their 12-hour shift are often already stretched too thin. To ensure they accomplish all of their given responsibilities within the span of their shift, many of these nurses will avoid engaging their patients in friendly dialogue—a critical component of optimal patient care. Without that dialogue, patients can become more agitated, increasing their chance of trying to do too much without the help of their nurse, perhaps experiencing a fall, for example.

Given that any shift, regardless of its length, is likely to be accompanied by overtime as a result of staffing shortages, hospitals must evaluate the dangers that are posed by having a long shift to begin with. Once they address these scheduling concerns, administrators can begin tackling how to reduce overtime in healthcare on a more systemic level.

The Overall Impact of the Extended Shift

There’s no question about it—extended nursing shifts put patients in jeopardy. According to a sentinel event alert published by the Joint Commission, the fatigue associated with extended shifts can result in:

• Lapses in attention and inability to stay focused
• Reduced motivation
• Compromised problem solving
• Confusion
• Irritability
• Memory lapses
• Impaired communication
• Slowed or faulty information processing and judgment
• Diminished reaction time
• Indifference and loss of empathy

Each of these increases the chance of adverse events, including medical errors and patient injuries, that lead to lower patient satisfaction ratings.

But patients aren’t the only ones at risk. Long work hours have also been connected with an increase in needlesticks and other occupational injuries among healthcare professionals, in addition to heightened psychological distress. This is due, in large part, to the fact that nurses may underestimate the true toll a long shift can take on their mind and body.

Nurses must spend a significant amount of time during their four days off recovering from their three long, exhausting days at work. This extensive recovery period ultimately detracts from the quality of their time off—especially for nurses who work night shifts. Healthcare professionals working the night shift must change their sleep schedule entirely during their days off to ensure they can spend quality time with family and friends.

A high-stress, exhaustion-driven work environment also interferes with the creation of a healthy, collaborative workplace culture. When nurses impart stress when speaking with their colleagues, it can discourage open and honest communication, contributing to the creation of a stressful, hierarchical environment that promotes lateral violence.

Improving Patient Safety Through Education and Culture

For as long as nurses continue to advocate for 12-hour shifts, it will remain up to hospitals to ensure these schedules don’t harm patients or create a toxic workplace culture. By putting patient safety at the forefront of their reform efforts, hospital administrators can set themselves up for sustained success.

But before hospital administrators begin making any large-scale changes, they are encouraged to take a step back and assess their existing efforts to build a culture of safety. Once they have a strong understanding of their current landscape, they can then begin identifying how to better support nurses moving forward and ensure that both patients’ and staff’s health doesn’t suffer as a result of long shifts. Some concrete steps healthcare leaders can take to build this culture of safety include:

• Listening: While taking the time to listen to employees is critical in any profession, it is especially important in a healthcare setting. Leaders are encouraged to set up a regular, manageable cadence of one-on-one meetings with nurses and other staff members to evaluate their caseloads and identify where support is needed. Providing nurses with space to express their concerns and frustrations also opens the doors to communication, increasing employee engagement and, as a result, patient satisfaction.
• Promoting Continuing Education: Every nurse enters the workforce with a slightly different level of experience and educational background. By regularly assessing their employees’ skills and taking steps to fill knowledge gaps through continuing education programs, hospital administrators ensure their nurses have the skills they need to improve patient safety.
• Rethinking Staffing Practices: Overtime is one of the leading causes of compromised patient safety in hospitals. Shifting the culture around overtime should be a top priority for hospitals looking to reduce employee fatigue and protect their patients. Instead of resorting to extended hours to address staffing issues, hospitals should strive to create a better balance of permanent and contingent staff, improve their float pool management, expand online staffing capacity, implement systems to optimize their operations, and adopt technology-enabled forecasting of patient demand and staffing needs.
• Adopting a Safety Mindset: The most important step hospital leaders can take to improve patient safety is adjusting their mindset. Studies show that transforming the hospital culture requires a transformation of priorities. That means shifting priorities from getting the most out of nurses to emphasizing patient safety above all else—even if it costs more to do so.

Build a Culture of Patient Safety

Transforming your hospital culture to encourage patient safety can be challenging. Relias has the tools you need to confidently begin this journey, including white papers, skills assessments, educational guides, and beyond. Combined, our extensive array of resources will help ensure your entire team is equipped with the knowledge they need to provide the highest quality care, boosting patient satisfaction and employee retention ratings alike.