Running head: NURSING SHIFT LENGTH 1

Nursing Shift Length: Eight Hours Compared to Twelve Hour Shifts

Audra Brooks
Ferris State University




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Abstract
This analysis takes a close look at nursing shift lengths and its effects on quality of care and
patient safety in acute care setting. By assessing the healthcare environment, making inferences,
and understanding implications and consequences, one will be able to learn how the patient,
healthcare worker, and the acute care facilities are all affected. Theory will be used in
understand nursing disciplines and show how they relate to this issue. Lastly, recommendations
will be made on ways to improve quality and safety for patients, healthcare workers, and acute
care settings.


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Nursing Shift Length: Eight Hours Compared to Twelve Hour Shifts
Patient quality of care and safety is always at the forefront of all healthcare providers
minds. The issue at hand is how many hours nurses can work before fatigue contributes to
errors and ultimately creates negative outcomes for patients. This analysis will compare eight
hour versus twelve hour shift length. According to TJC (2011), the impact of fatigue from
inadequate sleep or insufficient sleep can lead to a number of problems (p. 1). Some of the
issues that can contribute to errors in the healthcare setting from lack of sleep, or the length of
shifts, are lapses of attention or inability to stay focused, compromised problem solving, memory
lapse, impaired communication, diminished reaction time, slowed information processing and
judgment, and loss of empathy. Any one of these can contribute to errors and negative outcomes
for patients.
In the early nineteenth century, nursing student began to train in hospitals for twelve hour
shifts. In the early twentieth century, the National Recovery Act of 1933 excluded nurses from
restrictions on maximum work hours. During this time frame the American Nurses Association,
also known as ANA, requested nurses work eight hours. Due to nursing shortages, hospital
restructuring and cost containment, twelve hours shifts were reinstated in the 1980s to 1990s.
Since then twelve hours shifts for nurses have been gaining popularity. Twelve hour shifts allow
nurses more time to be at home and hospitals the benefits of not having to use agency nurses. In
recent times, studies have shown that there is less absenteeism, fewer handoffs, and better
employee morale. However, one study has shown that
most hospital staff nurses work extended hours, with most working at least 12
consecutive hours. These long hours may be impacting patient safety and quality. These
studies found that nurses working shifts of 10 hours or longer were associated with worse
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reports of patient care quality and over all safety grades compared with nurses working 8
to 9 hours (Witkoski Stimpfel & Aiken, 2013, p. 125).
A study that was used in a positions statement from the National Association of Neonatal Nurses
in July 2007, states that nurse are three times more likely to make errors if they work shifts
longer than 12 hours per day, and in addition nurses who worked those long hours were more apt
to experience more neck, shoulder, and back injuries than those nurses who worked 8-hour
shifts.
One can conclude from information that has been gathered from several research articles
that working less than 12 hours shifts will improve patient safety and quality of care. One way
the patient safety and quality of care is improved is by eight hours shifts allowing them to attain
better quality of sleep, just by allowing more hours dedicated for sleep. If a nurse works eight
hours instead of twelve hours, this allows for the possibility of four more dedicated hours to
sleep, thus reducing fatigue which could lead to poor concentration, response time, and errors.
According to a position statement made by the National Association of Neonatal Nurses
(NANN) in 2008, fatigue can cause psychological changes.
After investigating this issue, one can conclude that there are three areas affected by the
variance of shift length: the nurses, patient, and the acute care setting. Safety is a big concern for
both the patient and the nurse. When errors are made, patients health are put at risk for injury,
and could cause a lengthier stay. Nurses can be affected by strain and stress on the body
increasing the chance of injury or reprimand or loss of job. Research has shown that needle
sticks become more prevalent from exhaustion, or lack of focus. Cost affects all three areas; the
patient with an increased length of stay could experience increased copays and lose income.
Nurses, if injured, have loss of pay and loss of productivity. The acute care setting will have
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increased costs due to having to pay for errors, loss of revenue, loss of productivity from nurses,
and injuries sustained to both the patient and the nurse. The acute care setting could also receive
negative feedback from negative patient outcomes and thus loose revenue from poor reputation.
This analysis will include how three different theories can demonstrate how this issue
could be looked at through a collaborative and interdisciplinary perspective. An assessment of
the healthcare environment will consist of the exploration of a system framework by considering
policies, resources, quality and safety issues that may be related to this issue, what the possible
inferences and implications are for both sides, and lastly, the recommendations for quality and
safety improvements.
Theory
Theory is an important part of nursing. Ferris State University uses Nursing Theory as the
foundation of their curriculum.
Nursing theory was developed to describe nursing. It allows nurses to describe, explain,
predict, and control desired outcomes of nursing care practice. Theories allow for testing
knowledge through research and for expanding the nursing knowledge base to meet the
healthcare needs of patients in an ever-changing society. (Taylor, Lillis, LeMone, &
Lynn, 2011, p. 71)
Nursing is based upon theoretical or conceptual frameworks. These theoretical/conceptual
frameworks not only guide the nursing profession by addressing the four central concepts found
in nursings metaparadigm, but also serves as the hypothesis testing that adds to the nursing body
of knowledge (Maville & Huerta, 2013, p. 29). Therefore, nursing theories are based, and also
influenced by, other processes and theories. It is imperative that nurses understand other theories
outside nursing, and how they can be applied to nursing.
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Non-nursing Theory
Ludwig Von Bertalanffy developed the General Systems Theory in the 1920s. His
theory emphasizes the relationship between the whole and its parts and describes how parts
function and behave. It has been helpful to nursing theorist in describing the relationship
among people, health, and their environment (Maville & Huerta, 2013, p. 29). There is one key
point that relates to the issue of nursing shift lengths. That is that systems are composed of
subsystems in hierarchy. All levels work together and if one element is changed it also affects
all other subsystems. If a nurse has worked ten hours of an exhausting twelve hours shift, this
exhaustion could create have lack of focus, loss concentration and reduced speed of reaction
time. This contributes to medical errors, patient safety issues, and negative patient outcomes.
For example, if the patient is due for blood pressure medication and the nurse has had this patient
for two days in a row and his or her blood pressure has stayed within normal limits. The nurse,
without checking the patients current blood pressure and pulse might give that medication.
Then thirty minutes later the patient could get up to use the restroom and fall. One can see that
one step in proper medication administration was missed, a medical error occurred and patients
safety and outcomes were at risk.
Nursing Theories
Imogene King developed the Theory of Goal Attainment in 1971. It is based upon a
system that there is a continual exchange between people and their environment. According to
Maville (2013), Kings theory identifies a person environment consisting of both of the persons
internal and external environment. Internal and external interactions are in continuous
interaction. "The patient is a personal system within a social system; the nurse and the patient
experience each other and the situation, act and react, and transact (Taylor et al., 2011, p. 74).
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This theory can be applied to the issue of whether eight or twelve hour shift, are better for patient
safety and quality of care because each individual persons internal and external environment
will affect the other. Whatever the nurse does or feels can or will affect the patient.
Caring is an important aspect and component of nursing. Caring should take place in the
healthcare setting every time there is a patient-nurse interaction. Jean Watson developed the
Theory of Human Caring in 1979. Nursing is concerned with promoting and restoring health,
preventing illness, and caring for the sick (Taylor et al., 2011, p. 75). Caring can make a
difference to the patients well-being. This theory really looks at the role of a nurse, and how
that role has effects on the patients health. The patient is relying on the nurse to provide a safe
and nurturing environment. If a nurse is not working up to his or her full potential due to their
work environment and level of exhaustion, the patient could experience adverse effects of the
care received.
Assessment of Healthcare Environment
When assessing the healthcare environment and shift lengths, one can determine that
twelve hour shifts could be beneficial for patients and acute care settings. However, there are
some flaws that need to be addressed regarding safety and quality care. By looking deeper into
how healthcare determines and assesses safety and quality policies, procedures and standards and
standards can be examined to address these issues. A framework called A Human Factor
Framework can help to make sense of the different areas of concern for patient safety and quality
in regards to nursing shift lengths. According to this framework to err is human, meaning that
humans have limitations, and cannot do every task perfectly every time. If, by chance, a nurse
does something wrong, the patient could be affected.
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Due to being human, errors are inevitable. There have been several government agencies
that have developed standards of care that must be met for reimbursement or accreditations. The
Joint Commission has set national quality and safety goals that healthcare systems must meet to
retain their accreditation. Likewise, Centers for Medicare and Medicaid Services (CMS) have
required faculties to pay for the cost of errors. The Joint Commission developed a rating system
based upon health care systems meeting quality and safety indicators for a good score. Some
of these quality and safety indicators are fall prevention, prevention of ventilator acquired
pneumonia, and skin assessment, just to name a few. Systems like the Braden skin assessment
are used to help nurses assess a patients skin for breakdown. These systems are put in place to
help prevent errors that happen due to human error. Will these systems like the Braden skin
assessment, fall assessment and medication pixis or bar code scanning for administering
medications prevent errors from happening if nurses are exhausted from twelve hour shifts? The
answer would be no. One cannot assume because there are systems in place to prevent errors
that errors will not happen. However, with these systems in place they certainly have helped to
prevent human errors and saved many undue injuries to patients. It would also be wrong to
assume that there would not be any errors if nurses are required to only work eight hour shifts
rather than twelve. Systems only work if the person using it demonstrates a quality and safety
focused mindset.
Inferences/Implications/Consequences
Research has shown that patient safety and quality of care decreases as nursing shift
lengths get longer. According to systemic review by Cummings, Olivo, Giblin, & Simpson
(2009), they concluded that the areas in healthcare for the patient that were influenced the most
from twelve shift lengths were quality of care for patient and healthcare providers outcomes.
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The areas of quality of care that were affected positively were patient recovery times, patient
mortality, and length of hospital stays. However, the areas negatively affected were quality of
patient care.
There was a significant relationship between shift lengths and the numbers of nursing
errors, with more errors occurring on longer (12-hs +) shifts. with regards to healthcare
provider wellbeing, one study determined that nurses who worked a compressed schedule
(i.e., work 12 h/day x 7 days, then off x 7 days) reported significantly higher levels of
overall, wellbeing than nurses who worked other shift schedules. (Estabrooks et al., 2009,
p. 184)
Research from this review has shown that there are more physical and psychological complaints
with increased shift lengths. The areas of complaints were more stress and exhaustion, increased
neck, shoulder, and back pain, reported increased drug and alcohol use, and more fatigue.
However, when investigating the aspect of job satisfaction, this review found mixed findings
depending upon which study was looked at. The consequences of this issue have several areas of
concern. They are patient safety, quality of care, and cost. Previously in this analysis patient
safety and quality have been discussed. Lets take a closer look at cost. With increased errors
and shift lengths comes an increased cost for the patient, healthcare workers, and acute care
settings. Patients could be affected by having to spend more time in the hospital away from
family and jobs. There could be increased pain and suffering. Healthcare workers are at risk of
injury and loss of productivity. The acute care setting can be affected negatively by loss of
reputation which causes loss of revenue. There is also an increased cost due to injury to patient
and staff, and education required to fix the issue. Lastly, there could be a loss of accreditations
from the government. After looking at research data about the differences between eight hour
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and twelve hour shifts, this topic could benefit from further research, new policies, and
procedures.
Recommendations for Quality and Safety
Quality and safety is not a new concern with regards to nursing, Florence Nightingale
was concerned about the safety and quality of care given to British troops back in 1855. So, what
does quality really mean to nursing?
The Institute of Medicine defines quality as the degree to which healthcare services for
individuals and populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge..quality is based upon an interaction
among relative actors who agree about standards (the norms and values) and components
(the possibilities). (Mitchell, P., 2008, p. 1)
Quality indicators were then developed from these principles. The components of quality of
care are centered on conceptual components of quality rather than measured indicators: quality
of care is safe, effective, patient centered, timely, efficient, and equitable. Thus, safety is the
foundation upon which all other aspects of quality care are built (Mitchell, P., 2008, p.1).
Safety does not merely prevent the harm of patients. There are many different aspects in
healthcare that contribute to a safe environment. Emphasis is placed on the system of care
delivery that prevents errors, learns from the errors that do occur, and is built on a culture of
safety that involves healthcare professionals, organizations and patients (Mitchell, P., 2008, p.
2). Nurses have always strived to prevent errors, falls, and harm to their patients, but in recent
years have worked diligently not only to prevent injury to patients but developing interventions,
and improve their communication and management skills to provide better outcomes where
safety and quality of care are improved for the patient.
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American Nursing Association Standards of Practice
The ANA, has provided expectations and competencies on how a professional nurse
should act and preform in their publication called Scope and Standards of Practice. As a
professional nursing organization for all registered nurses, the ANA has assumed responsibility
for developing the scope and standards that apply to the practice of all professional nurses
(2010, p. 1). The standards of professional nursing practice are duties that all registered nurses
are expected to perform with proficiency.
The ANA nursing standard number ten states that a registered nurse contributes to the
quality of the nursing practice. Within this standard it states that it is the responsibility of
registered nurses to analyze factors related to quality and safety. Tools like the Braden skin
scale, and fall risk assessments are used to monitor quality, safety and effectiveness, and
formulate recommendations to improve the nursing practice or patient outcomes. These tools
have been developed to help nurses keep patients safe and are a required assessment to make
sure that nurses are meeting safety and quality of practice standards.
According to the ANA, standard eleven is related to communication. A registered nurse
must communicate effectively in a variety of format in all practice areas. Ways that the nurse
can meet this standard are by assessing their communication skills when interacting with
patients, their families, or other coworkers. It is necessary for nurses to communicate effectively
by disclosing observations or concerns related to hazards and errors in care or the environment.
Good verbal and nonverbal communication skills are imperative in any healthcare setting. These
are important skills to keep patients safe and to improve quality of care in any healthcare setting.
The ANA standard twelve states that the registered nurse demonstrates leadership in the
professional practice setting and the profession. The registered nurse will participate in efforts to
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influence healthcare policies that involve healthcare consumers and the profession (ANA 2010,
p. 55). Leadership also includes developing conflict resolution a communication skills.
Healthcare is continuously changing and this requires that a nurse be able to change. This may
involve the nurse to be proactive and participate in developing new policies and procedures to
influence quality of care and safety for the patient. Other examples, for providing leadership are
to speak up when a situation arises that requires change, and holding others accountable for their
actions.
The ANA standard thirteen reads the registered nurses collaborate with the healthcare
consumer, family, and others, in conduct of nursing practice. The registered nurse partners with
others to effect change and produce positive outcomes through the sharing of knowledge of the
healthcare consumer and/or situation (ANA 2010, p. 57). Collaboration with other members of
the interdisplinary team is imperative to provide care for patients that is focused on safety and
quality care to have positive patient outcomes. Updating patient activity levels on kardex or
white board in the patients rooms at the beginning of a shift are useful ways to collaborate
effectively with others of the team like nurse techs, patient transport, and physical therapy to
keep a patient safe and provide quality care.
Using the standards set by the ANA, nurses are able to use leadership and communication
to improve patient outcomes while providing a safe and improved quality of care. Lastly,
collaborating with other members of the interdisplinary team to develop new policies and
procedure will contribute to quality of practice.
QSEN Competencies
QSEN is an organization that provides quality safety education for nurses. They address
educating nurses about knowledge, skills, and attitudes to improve quality and safety for
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healthcare systems. Using QSEN competencies the three areas that nurse working long hours
could be affected are safety, patient centered care, and quality improvement.
No matter where the setting is for healthcare, providing safe care for patient is at the top
of the list. We all know how important this is. It is our jobs as nurse to minimize the risk of
harm to patients. With regards to the length of nursing shifts, by making sure to come to work
well rested, eating a healthy diet and staying stay fit, nurses can provide a safe quality focused
health care environment for patients.
Patient centered care is care that is designed around the needs of a specific patient.
Nurses can strive to provide patient centered care by being compassionate, and providing patient
focused coordinated care no matter how long shifts are. We can do this by making sure to take
our breaks, not overscheduling ourselves, and making sure to use good communication skills
when working with the patient and other interdisplinary team members.
Quality improvement is a process where all settings in healthcare work to continuously to
improve every process. Nurses in particular can facilitate quality improvement by helping
patients meet desired outcomes. Another way that nurses can help to improve quality is to listen
carefully, and by explaining what is being done before doing a procedure or explaining why.
Getting involved in helping to develop new policies is another way to participate in quality
improvements.
Conclusion
Patent safety and quality of care go hand in hand in any healthcare setting. Research has
shown that the topic of nursing shifts length requires more investigation. Improvements can be
made regardless of eight hour nursing shifts or twelve. Education can be an important aspect of
this issue. Using education to inform and teach healthcare providers and administration of the
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different ways to reach the ultimate goal of improving the quality of care and patient safety could
be by developing new policies and procedures.





















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