Evidence-Based Nursing Practice

Presentation: Lab Group A

12-hour versus 8-hour shifts

Introduction
Began around 1970s

What is the current practice?

Introduction

Current practice
Current literature findings
Interventions
Implementation at a local facility
Cost analysis
Risk vs. benefit
Evaluate using SMART outcomes

PICOT Question
What is the best practice for
enhancing patient safety associated
with 12-hour versus 8-hour nursing
shifts in the acute care setting? This
project will focus on best practice
techniques that increase patient
safety in 12-hour shifts.

Current Practice
Monica Stewart

Current Practice
Hospital shifts used to be three 8hour shifts per day
8-hour shifts began to extend to 12hours in the 1980s
Currently, 12-hour shifts are
accepted universally in hospital
settings (local, statewide, and
nationally)

Current Practice
12-hour shifts frequently
extend to 13+ hours when
time is included for intershift report, unfinished
patient care, and charting
In hospital settings, 12hour shifts are viewed as a
solution to ensure service
continuity for patients and
cost effectiveness for
employers

Why did 8-hour shifts become

extended to 12-hour shifts?

The change from the traditional 8-hour

shifts was driven by the belief that 12hour shifts would:
Promote efficiencies for the employer
Improve work and life balance for
employees

Hospital Staff Nurse Perspective on

12- Hour Shifts
Many nurses are in favor of 12-hour shifts
rather than traditional 8-hour shifts because
it provides for more days off
More days off = more time for raising a
family
Nurses can chose to work several 12-hour
shifts in a row to acquire multiple
consecutive days off
Nurses who prefer shorter work hours have
generally left hospital nursing

Employers Perspective on 12-Hour

Shifts
Two 12-13 hour shifts
per day reduces shift
handovers, staffing
overlap, and extra cost
Handovers and
overlaps between shifts
are considered
unproductive and
costly
Reduced handovers
between nurses =
decrease in

Employers Perspective on 12-Hour

Shifts
Goal: Improve efficiency with no dangerous
effects on quality of care
Reality: 12-hour shifts have decreased
handover errors but raised concern of fatigue,
decreased alertness, and adverse events
How do we maintain staffing efficiency and
reduce fatigue in nurses working 12-hour
shifts?

Synopsis of Current Literature and

Strengths/Limitations

Chelsey Earnhart

Synopsis of Current Literature

Findings
8-hour-shift Nursing
Greater hospital safety
Better quality of nursing care
Decreased fatigue
Decrease in error reports and
adverse patient outcomes

Current Literature Findings Cont.

> 12-hour-shift
Nursing

Increased physical and mental fatigue levels

Mean sleep was 5.5 hours between shifts
Progressive sleepiness with each consecutive shift
Inadequate recovery between shifts
(Inter-shift fatigue)
Increase in decision regret
Lower levels of quality and safety
especially with overtime
Higher patient dissatisfaction
Patient reports of decreased
communication, poor or lack of pain
control, and a delay in receiving help

Current Literature Findings Cont.

> 12-hour-shift
Nursing Cont.

Higher dissatisfaction and burnout

Increase in pneumonia and CHF patient
deaths related to long work hours and weekly
burden (i.e. hours per week, number of days
worked in a row) due to increased fatigue

Lower levels of quality and safety

Among critical care nurses,

error reports almost doubled
after 12.5 or more
consecutive hours per week
Higher rate of overtime
hours associated with
increased risk of UTIs and
decubitus ulcers

Fatigue-Related Outcomes in
the Critical Care Setting
Sharps injury
(within the last
year): 9.6%
Medication errors:
15.1%

Patient falls with

injuries: 19.8%
Work injuries:
32.8%
Nosocomial
infections: 35.2%

Commonalities of Literature
8 hour shifts = better patient and nurse
outcomes
12 hour shifts = increased nursing fatigue
which results in numerous adverse events:
Increased work-related injuries
Decreased quality of nursing care
Decreased patient safety
- Higher rates of mortality & failure
to rescue

Lack of overtime regulation

Need for adequate breaks

Strengths of Literature
Large sample sizes
Diverse Settings
Included 12+ hour shifts &
consecutive shifts
Included caring for more than one
patient
Use of well-validated tests for
objective measurement of
variables
Extraneous variables accounted for
Fatigue independently associated with
adverse outcomes

Limitations of Literature
Lack of adequate representation of
male nurses
Majority of information gathered
through nurses self-report
Lack of adequate information on
patients experiences
Lack of sleep-deficient data over
longer periods
Lack of exploration of whether
nurses held multiple jobs
Lack of exploration of work
environment

Proposed Interventions
Brittany Huonker

Work-Related Fatigue
Other industries have developed
strategies for fatigue management
Health care industry has not
developed fatigue management
programs for nurses

Fatigue Countermeasures Program

for Nurses
Fatigue management and sleep
hygiene education
Strategies for staff nurses:
Minimize sleep loss
Maximize sleep duration
Improve sleep quality
Enhance vigilance at work
Incorporate naps into daily routine
Use caffeine wisely

Fatigue Countermeasures Program

for Nurses
Strategies for institution:
Arranging adequate staffing to allow for
completely relieved breaks without
penalty
Meals
Coffee
Naps

Infeasibility of Fatigue
Countermeasures Program for
Nurses

Requirement for increased number of

staff nurses
Costly for institutions to hire more
staff nurses

Interventions
Sleep/fatigue in service for new staff
and pre-existing staff on the unit
Structural scheduling to ensure that
nurses are not working three 12-hour
shifts in a row
Two mandatory 30 minute breaks
Meal
Nurses preference

Overall Application and

Implementation to Nursing Practice at
a Local Facility

Katherine Yeh

Work-Related Fatigue
Strategies typically include education
and training, compliance with hours of
service regulations, appropriate
scheduling practices, work-setting
fatigue countermeasures, changes in
workplace design and technology, and
fatigue management research.

Interventions
1. Sleep/Fatigue in
service for new hires
and pre-existing
staff on the unit
2. Structured
mandatory
scheduling rules
3. Two mandatory 30minute breaks

Example Setting
Adult Medical Surgical Unit at the
Banner-University Medical Center

Sleep/Fatigue In-Service
Performed once every 6 months for
one month with multiple dates
Group sessions
Staff Nurse Themes and Focused
Group Topics
Awareness
Restfulness
Lifestyle Control

Sleep/Fatigue In-Service
Nurse Manager Themes and Focus Group Topics
Ease of Program Implementation
Employee/Employer Partnership
Research Engagement
Work Culture
Physical Environment
Emotional Turmoil
Lack of Organizational Support
Professional/Organizational Culture
Perceptual Dissonance

Structured Scheduling
Purpose: Elimination of fatigue
through enforcing no three 12-hour
shifts will occur in a row for nursing
professionals
Implementation:
Collaboration between nursing manager
and employees on the unit
1) Preference Survey
2) Structured Schedule Template

Structured Scheduling:
Preference Survey

Structured Scheduling:
Structured Schedule Template
Nursing managers will have a structured
scheduling template for standardization
Day Patterns with rotation schedule

Mon/Wed/Fri
Sun/Tues/Thurs
Tues/Thurs/Sat
Wed/Fri/Sun
Thurs/Sat/Mon
Sat/Mon/Tues

Preferences

Mandatory Breaks
Break 1: Meals only
Break 2: To the nurses discretion
Ex. Charting, napping, social interaction with other
coworkers on break

Buddy System
At the beginning of shift
during report

Structured handoff
Turned into charge nurse
for validity and
acknowledgement

Mandatory Breaks: Handoff

Tool

Cost Analysis
Kevin Cornett

Whats It Cost???
Before we can
determine the cost
of these programs,
we need to
examine the cost
of NOT
implementing
them.

Never Event - Reminder

Never Events are events that, due
to their preventable nature, are not
covered by Medicare, Medicaid, or
most insurance companies,
essentially causing the hospital to
absorb the cost, losing most/all
money for that treatment.

Cost of Never Events Decreasing

Safety
Nursing fatigue compromises patient
safety, as previously discussed.
How???
2 Most Common Never Events:
Pressure Ulcers (39%)
Falls (30%)

A lot of these are preventable by

nursing staff!
AHRQ patient safety network never events. (n.d.) Retrieved March
25,2015, from http://psnet.ahrq.gov/primer.aspx?primerID=3

Cost Analysis of Never

Events
Pressure Ulcers
(Stage IV,
including
associated
complications):
~$130,000 for
treatment

Brem, H., Maggi, J., Nierman, D., Rolnitzky,L., Bell, D., Renner, R.,
Vladeck, B. (2010). High cost of stage IV pressure ulcers. The
American journal of Surgery, 200(4), 473-77.

Cost Analysis of Never

Events
Falls! The
average cost of
treatment for
falls in 2013 was
between $15,000
- $20,000.

Cost of falls among older adults. (2014, September 22). Retrieved

March 25,2015, from

Cost Analysis of Nursing

Shifts
Its actually cheaper to pay 3 sets of
nurses for 8H shifts than to pay 2
sets of nurses for 12H shifts.
The added cost arises in providing
company utilities to the extra set of
nurses and TRAINING them.
This causes 12H shifts to cost less
money to the hospital, making them
more feasible.

Time is Money
Cost of the Break program
Med/Surg floor at Banner-UMC, 8 Nurses
employed at an average pay rate of
$30/H
8 Nurses * ($30*1H)
Total cost of an alternating break
schedule:
$240/Shift * 2 Shifts = $480/Day.

That Seems Like A LOT!

Compare this $480 loss with the cost
of a SINGLE Stage IV Pressure Ulcer
($130,000)
It really isnt that much, given that
the research supports taking breaks
to decrease nursing fatigue in 12H
shifts.

Ultimately,
12H shifts are the most cost effective
but with the highest rates of adverse
patient events.
8H shifts are the least cost effective,
with the lowest rates of adverse
events.
Lets shoot for a middle ground.

Proposed interventions: Risk versus

benefit to the institution, nurses and
the patient

Michelle Splaver

Sleep/fatigue in service for new

hires and pre-existing staff on the
unit
Risks to the
institution:
Costly
Time consuming
Difficult finding
professionals to
host the inservice
Difficult to
spread the
word
Lack of
organizational
support

Risks to the
nurse:

Risks to the
patient:

Time
None
Consuming

Sleep/fatigue in service for new

hires and pre-existing staff on the
unit
Benefits to
the
institution:
Increase
nursing
staff
quality of
care
Decrease
never
events
Improve
reputation

Benefits to
the nurse:

Learn new
techniques to
prevent
fatigue
Increased
awareness of
personal
health
Increased
patient care
Decrease
fatigue
Decrease
burnout

Benefits to the
patient:
Improved
satisfaction with
nurse quality of
care

Structured scheduling to ensure

that nurses are not working three
12-hour shifts in a row
Risks to the
institution:
Schedulin
g
difficultie
s
Decrease
d staff

Risks to the Risks to the

nurse:
patient:
Minimal
availability
Decreased
satisfactio
n

Less nurses
who personally
know patient

Structured scheduling to ensure

that nurses are not working three
12-hour shifts in a row
Benefits to
the
institution:
Increase
nursing
staff quality
of care
Decrease
never
events
Improve
reputation

Benefits to
the nurse:
Decreased
fatigue
Decrease
burnout
improved
profession
satisfactio
n

Benefits to the
patient:

Improved
satisfaction
with nurse and
quality of care

Two mandatory 30 minutes

breaks: one break for a meal and
the second break being up to the
nurses discretion
Risks to the
institution:
Costly

Risks to the
nurse:

Difficulty
finding the
proper
time
Constant
worry about
patients
Increased
chance of
error due to
poor handoff
report

Risks to the
patient:

Uncomfortable
asking other
nurses for
assistance

Feelings of
decreased
quality of care

Two mandatory 30 minutes

breaks: one break for a meal and
the second break being up to the
nurses discretion
Benefits to
the
institution:
Increase
nursing
staff quality
of care
Decrease
never
events
Improve
reputation

Benefits to
the nurse:

Mental
break
Decrease
fatigue
Decrease
burnout
Provide time
for charting
without
disruption
Improved
profession

Benefits to the
patient:

Increased
quality of care
from their
primary nurse
leads to
overall
improved
satisfaction

Evaluation
Marissa Lizarraga

SMART Outcome: Education

The nurses will report an increase in
knowledge in regards to healthy sleep
patterns and fatigue management,
which will be measured by a pre and
post-in service survey completed prior
to and at the completion of the in
service.

Education:
Pre-In Service Survey
1. How long does it usually take you to fall asleep after coming home
from a 12-hour shift?
A. Less than 30 minutes
B. One hour
C. More than two hours
2. Please list one way in which you use to help you get to sleep at
night.
3. How rested/energized do you feel getting up from your time of
sleep?
A. Hardly rested/energized
B. somewhat rested/energized
C. very rested/energized

Education:
Pre-In Service Survey
4. In your opinion, how does your time of sleep impact your mental
health?

5.In your opinion, how does your time of sleep impact the safety and
quality of care of your patients?

6. In your own words, how would you define fatigue?

Education:
Post-In Service Survey
1. After completing the Sleep Alertness and Fatigue Education in
service, I have a better understanding of what fatigue means.
A.
B.
C.
D.

Strongly Agree
Agree
Disagree
Strongly Disagree

2. List one interesting fact that you learned at the in service that you
didnt know previously.
3. List one strategy that you will use to help decrease the amount of
time it takes you to fall asleep after coming home from your 12hour shift.

Education:
Post-In Service Survey
4. After completing the in service, I have a better understanding of
how my fatigue directly impacts patient safety and care.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree
5. After completing the in service, I have a better understanding of
how my fatigue directly impacts my mental health.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

Education:
Post-In Service Survey
6. My view on the importance of sleep and fatigue management
changed from what it was prior to attending the in service.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree
7. Overall, the Sleep Alertness and Fatigue Education in service was
beneficial in increasing my knowledge on the subject matter.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

SMART Outcome: Nurses

The nurses will report a decrease in
fatigue and an ease of intervention
implementation, measured by a postintervention survey, within a 6 month
period.

Nursing Fatigue:
Post-Intervention Survey
1. In the past six months, how many times would you say you
were able to take your two required 30 minute breaks during
your 12 hour shifts?
A. Never
B. I was able to take at least one 30 minute break during one
of my 12-hour shifts
C. I was able to take at least one 30 minute break during
each of my 12- hour shifts
D. Almost always

Nursing Fatigue:
Post-Intervention Survey
2. Taking at least one required 30 minute break during my 12-hour
shift made me feel refreshed.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree
3. Taking at least one required 30 minute break during my 12-hour
shift helped me to be more vigilant with patient needs and changes
of condition.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

Nursing Fatigue:
Post-Intervention Survey
4. The structured scheduling allowed me to feel more refreshed when
coming into work.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree
5. Overall, the required 30 minute breaks and structured scheduling
were easily implemented on the unit.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

Nursing Fatigue:
Post-Intervention Survey
6. Overall, I enjoyed the required 30 minute breaks and structured
scheduling interventions.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree
7. Overall, the implemented required 30 minute breaks and
structured scheduling helped reduce my fatigue during my shifts.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

SMART Outcome: Patients

The nurse manager and charge nurse
of the unit will report an increase in
patient safety, measured by a pre and
post-intervention survey, within a 6
month period.

Patient Safety:
Pre-Intervention Survey
1. Within the past year, patient falls have occurred
A. Never
B. Rarely
C. Occasionally
D. Frequently
2. Over the past year, the nurses on my unit have consistently been
vigilant to patients needs and patients changes of condition.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

Patient Safety:
Pre-Intervention Survey
3. Within the past year, wrong drug administration has occurred
A. Never
B. Rarely
C. Occasionally
D. Frequently
4. Within the past year, wrong medication dose has been given
A. Never
B. Rarely
C. Occasionally
D. Frequently

Patient Safety:
Pre-Intervention Survey
5. Within the past year, nosocomial infections have occurred
A. Never
B. Rarely
C. Occasionally
D. Frequently
6. Within the past year, how many pressure ulcers have
you as charge nurse or nursing manager come in contact
with?
A. 0-10
B. 10-20
C. 30-40
D. 40 and up

Patient Safety:
Post-Intervention Survey
1. Within the past six months, patient falls have occurred
A. Never
B. Rarely
C. Occasionally
D. Frequently
2. Within the past six months, I have noticed an increase in vigilance
of the nurses.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

Patient Safety:
Post-Intervention Survey
3. Within the past six months, wrong drug administration has
occurred
A. Never
B. Rarely
C. Occasionally
D. Frequently
4. Within the past six months, wrong medication dose has been
given
A. Never
B. Rarely
C. Occasionally
D. Frequently

Patient Safety:
Post-Intervention Survey
5. Within the past six months, nosocomial infections have occurred
A. Never
B. Rarely
C. Occasionally
D. Frequently
6. Within the past six months, how many pressure ulcers have you as
charge nurse or nursing manager come in contact with?
A. 0-10
B. 10-20
C. 30-40
D. 40 and up

Patient Safety:
Post-Intervention Survey
7. In my opinion, due to the implementation of the required 30
minute breaks and structured scheduling, patients have received an
increase in the quality of care given by the nurses.
A. Strongly Agree
B. Agree
C. Disagree
D. Strongly Disagree

Summary
Current practice and literature
findings
Fatigue Countermeasures Program
for Nurses
Cost Analysis of never events
Risk versus benefits to the
institution, nurse, and patient
SMART outcomes with pre- and postintervention surveys