Running Head: EFFECTS OF TYPES OF NURSING SHIFTS

Types of Nursing Shifts Registered Nurses Work Related to Patient Care

Alicia Leone, Lisa Palmer, Alyssa Streb, Tori L. McCormick and Kristy Vrona

04/07/2017

NURS 3947: Nursing Research

Dr. Valerie O’Dell

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Abstract

Identifying a problem is the first step in fixing it; the purpose of this research was to bring to

light that patients are being put at risk for a reason that is avoidable. Particularly this

investigation is aimed at proving; nursing shifts related to length and type with respect to day-

time verses midnight shifts affects overall patient safety related to medication errors. The

gathered materials came from literature reviews, surveys, qualitative studies, as well as research

models. It was found that fatigue is a major adverse effect of a registered nurse, and can cause

medications errors, errors in patient safety, and is a direct result of rotating shifts. Analyses were

assessed to conclude 12 hour shifts significantly impacted a nurse more than the usual eight hour

shifts. Night shifts seemed to have a bigger impact on sleep, with an individual mean of less than

five hours of sleep per night. Also, nurses working on rotating shifts received less sleep per night

than day-to-day shifts, or day-to-night shift. Exploring this topic while sharing it with the nursing

community will bring about acknowledgement therefore leading the nursing association into a

more secure environment.

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Whether it is a hospital, school classroom, restaurant or even over seas when a team is

down a member, it is noticeable. A nurse, teacher, chef and marine are very different careers

however each require a special set of skills which only people in that profession can preform.

With patient levels on the rise the wonderful people who have the skill set to be registered nurses

(RNs) have been faced with the challenge of extended hours and overnight shifts to provide for

patients in need. This brings to light an extreme problem with respect to medication errors and

overall safety of the patients. While members of the nursing team are faced with extended

twelve-hour shifts, overnight schedules and mandatory overtime it plays a key role in the health

and safety of not only the patients but also nurses themselves. These RNs are more likely to

make an error negatively affecting patient’s safety. Therefore the following question was

addressed; In patient care regarding; medication errors and safety, how does the type of shift

with respect to length and time affect these factors over the patient’s length of stay in a critical

care setting.

Literature Review

In order to bring light to this issue in the nursing profession, information was gathered

from OhioLINK databases specifically MEDLINE. Eleven sources were review for data

collection regarding how the types of shifts affect nursing care in a critical care setting for not

only patients but nurses as well. The factors that were affected by either midnight shifts,

extended hours and turn over shifts are medication errors, patient safety and health of nurses.
EFFECTS OF TYPES OF NURSING SHIFTS 4

Patient Safety

The type of shifts nurses work greatly impacts how the patient receives care. Patient care errors

are a major problem in hospitals and there are a variety of factors that contribute to these errors.

One of these factors would be the lack of resources evening and night shift nurses are made

available to;

US studies identified hospital activity at its peak from 7AM-7PM, Monday through

Friday. This is the time maximum resources are available in nurses’ work environments.

But peak periods only make up only 36% of the time nurses actually work. During the

remaining 64% of the time, nurses work in off-peak environments with (1) scaled back

ancillary services (2) often with fewer (and often less experienced) staff, (3) minimal

supervision and (4) strained communication with on-call health care providers

(O’Loughlin, 2010, pg. 48).

“This path demonstrates that lack of human and physical resources have the strongest influence

on why nursing care is being reported as missed” (Hair, 2013, pg. 52). Even though the evening

and night shifts make up most of the time nurses work, they have far less resources than the day

shift nurses. With less resources available nurses cannot do their job correctly, resulting in errors

related to the patient. “The adequacy of nursing resources and its relationship with why nursing

care is reported as missed is a significant influence with a coefficient of +0.61 (Hair, 2013, pg.

52). This shows how resources have the most influence on the reason why nursing care would be

missed resulting in patient care errors. Perhaps with more staffing this would be less of a

problem for evening and night shift nurses.

Another major contributing factor to patient care errors would be rotating shifts and night

shift nurses not getting adequate sleep resulting in sleep deprivation. “A study of representative
EFFECTS OF TYPES OF NURSING SHIFTS 5

sample from the Midwest found 32% of night shift workers and 26% of rotating shift workers

reported long-term insomnia and excessive sleepiness” (Drake, Roehrs, Richardson, Walsh,

Roth, 2004, pg.17) Nurses working night-shift and rotating shifts get around six hours of sleep a

day. This is two hours less than the recommended amount of time they should be sleeping. Sleep

is a biological need just like eating and drinking. Getting less sleep puts nurses at risk for making

patient care errors. (CDC, 2011, pg.16) “Declines in neurocognitive performance lead to higher

rates of fatigue-related injury and worker errors”(Folkard, Lambardi, 2006, pg.18). “Compared

with day shifts, risks are 15% higher for evening shifts and 28% higher for night shifts”(Castro,

2010, pg.18) With less sleep nurses are not able to perform to the best of their ability. A persons’

brain is not able to process information well with sleep deprivation, also it can cause lapses in

judgment and attention. This affects nurses especially who work evening shifts and night shifts

who do not get the recommended amount of sleep. This puts them at risk for making more

patient care errors and potentially harming a patient. “A sleep-deprived person cannot reliably

force him or herself to stay awake and alert. Studies of medical residents suggest motivation,

training and longer experience living with restricted sleep does not make a person more resistant

to the negative performances of sleep-deprivation” (Artnedt, Owens, Crouch, Stahl, Carskadon,

2015, pg. 17). Even if a nurse is used to not sleeping enough, he or she is still at risk for making

patient care errors. The only way to help the effects of sleep-deprivation is to get an adequate

amount of sleep no matter which shift a nurse may work. Sleep is so important for not only the

nurses, but the patients they are taking care of.

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Medication Errors
Medication errors are a huge concern in the demanding field of health care today and

they can be caused from several reasons such as long work hours and fatigue. Medication errors

continue to happen even though there are guidelines to follow during the medication process of

prescription, transcription, dispensing, or administration (Hewitt, 2010). “A 2000 report by the

Institute of Medicine (IOM), which indicated 44,000-98,000 people die each year in hospitals

due to medical errors, focused national attention on patient safety and awareness of potential

harm (Kohn, Corrigan, & Donaldson, 2000). Nurses are the final check point of making sure that

a medication is going to be delivered safely, so they will receive the final blame even though

there are multiple members of the health care team involved such as pharmacists and physicians

(Hewitt, 2010). According to a literature review by Carlton and Blegen (2006), “found

medication errors to occur due to incorrect drug calculations, lack of knowledge, failure to

follow protocol, time pressures, fatigue, staffing levels, inexperience, design deficiencies, and

inadequate equipment” (p.160). There were also many studies done to determine what a nurse

specifically perceives as the cause of so many medication errors.

Distractions, failure to follow the five rights of medication administration, failure to

follow protocol, fatigue or exhaustion, poor physician handwriting, confusion between

drugs with similar names or similar packaging, confusion regarding infusion devices and

miscalculations, length of shift, excessive daytime sleepiness, and events on the unit

requiring higher priority were noted throughout these studies (Hewitt, 2010, p.160).

One of the main causes of medication errors happen when nurses are tired and they are

experiencing a heavy workload on a long shift, or just a long shift in general. There were four

studies done to determine if nurses being tired and having an increased workload contributed to
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medication errors, and these studies findings were in agreement with another study by Rogers

and colleagues (Hewitt, 2010).

Rodgers and colleagues who examined work patterns of staff nurses in hospitals

determine if a relationship existed between the number of hours worked and the

frequency of errors. Their findings revealed not only the number of hours worked per

week had a significant effect on errors, but also the likelihood of making an error was

three times higher when nurses worked 12.5 hours or more in a shift. More than half of

the errors involved medication administration (Hewitt, 2010, p.165).

With being a nurse, there comes a lot of shift work you have to do during your twelve and a half

hour shift and it contributes to workers being tired and exhausted. “Excessive daytime sleepiness

(EDS) was noted to have a significant relationship to occupational errors, including medication

administration errors” (Suzuki, Ohida, Kanieta, Yokoyama, & Uchiyama, 2005). There was a

study specifically done to determine the number of reported errors, types and severity of errors,

and units on which errors occurred during three nursing shifts in one hospital (Hewitt, 2010).

The results were “decreased staffing puts higher demands on available staff, which in turn may

lead to increased workload; increased workload may lead subsequently to increased fatigue. Both

increased workload and fatigue affect nurses’ ability to focus on tasks such as medication

administration” (Hewitt, 2010, p.165). If nurses are too tired to perform at the best of their ability

and they have too much work on their shoulders or they are constantly interrupted during a shift,

there is a higher chance that they will not follow the standard medication administration protocol

(Hewitt, 2010). The nurses role is a big part of the medication administration process and it

needs to be taken seriously because this is a real and frightening event in health care today.
EFFECTS OF TYPES OF NURSING SHIFTS 8

Fatigue
Fatigue related to working long hours or extended shifts is a common disadvantage as a

registered nurse working in a hospital. The Occupational Safety and Health Administration

(2013) cautions people against working more than 8 hour shifts as longer shifts may result in

reduced alertness. Nurses must juggle patients with complex diseases, as well as care for them in

timely manner. Once exhaust sets in, it may diminish a nurses ability to provide care for patients.

Fatigue is correlated to nurse performance and chronic fatigue is related to the number of hours

worked (Barker & Nussbaum, 2011). There is also evidence that nurses who work consecutive

12 hour shifts do not recover between shifts (Geiger-Brown et al., 2012).

A set of analyses was done to assess the potential impact of non-shift factors on sleep

factors. Nurses sleep duration between shifts was adversely affected by work schedules and was

particularly short between two consecutive night shifts (Geiger-Brown et al, 2014). The mean

sleep duration for nurses between two day shifts was 6.79 hours. The mean sleep duration

between two night shifts was much less, - 5.68 hours (Brown, 2014 p. 293). Geiger-Brown et al

(2014) also assessed sleep duration and fatigue in hospital registered nurses who worked

consecutive shifts. Although only nurses who worked three consecutive shifts were considered,

Geiger-Brown et al (2014) reported that sleep was short (mean, 5.5 hours) and that 45% of

nurses reported a high level of sleepiness. Additionally, Scott et al (2014) investigated the

relationship between nurses work schedules. They found that study participants reported sleeping

a mean of 6.70 hours before a shift and only 20% of participants slept at least 6 hours before all

of the participants’ recorded shifts (Scott et al, 2014). In addition to patient safety concern, there

is an increased risk of injury in fatigued health care workers (Rogers, Hwang, Scott, Aiken, and

Dinges, 2004).
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Following fatigue, many other adverse effects directly impact nurses. “Extended work

hours were a contributing factor in needlestick injuries among nurses” (Trinkoff, Le, Geiger-

Brown, & Lipscomb, 2007). According to Brown and Thomas (2003), those working 12 hour

shifts had a higher medical cost per injury than those who worked 8-hour shifts. Also, nurses

driving while drowsy can contribute to accidents, as well (Scott et al., 2006). As a result, “nurses

who work long shifts are more likely to be burned out, dissatisfied with their job, and intend to

leave their job within a year (Stimpfel, Lake, Barton, Gorman, & Aiken, 2013; Stimpfel et al.,

2012). Rogers, Hwang, Scott, Aiken, and Dinges (2004) recommended the “routine use of

twelve-hour shifts should be curtailed” (p. 210).

An evidence-based practice Rosswurm and Larabee (1999) model was used in another

study to guide the processes needed to conduct the study. An extensive review of the literature

revealed 35 studies related to nurses fatigue and shift length. The literature review indicated shift

length is associated with nurse fatigue and is a growing concern in the United States with the

routine shift lengths of 12 hours (Martin 2013, p 82). Although some nurses may have an option

to work 8 hour shifts, most do not.

Nationwide there are 1,617,200 nurses working in hospitals (American Nurses

Association, 2011). Multiple research studies prove that there is a high correlation between

fatigue and working 12 hour shifts. According to Gold et al (2014), nurses who rotated (worked

both day or evening shifts and night shifts) were twice as likely to nod off while driving to or

from work than were nurses who worked only day or only evening shifts. Not only do nurses

face fatigue working regular hours, but rotating shifts also impacts their sleep-wake cycle in a

tremendous way. Nurses should understand the effects of fatigue related to extended working

hours and should modify their schedule to prevent these adverse effects.
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Effects on Nursing Staff

As a child the phrase never judge a book the cover comes up a lot, and with this research

paper the reference is prevalent as well. Not only are the effects such as medication errors and

patient safety endangerment addressed but deeper in the chapters lie why these errors take place.

A doctor with bronchitis would never preform an open- heart surgery on a patient due to the

patient catching this infection and being put in danger, so why is it different when nurses are

over worked and sleep deprived? It is explained best in an article written by Stanojevic, Simic,

Milutinovic, which elaborates on the fact that inadequate amounts of sleep and poor sleep cycles

affect mental and physical behavior while awake. Some of the disorders related to lack of sleep

that nurses are at risk for are obesity, inflammatory bowel disease, arterial hypertension and even

cancer due to the reduced levels of melatonin produced at night (Stanojevic et al. 2016, p.183-

187). More than eighty percent of articles done on this topic are geared towards the patients

themselves. Coming to a realization that implementing ways to protect the nurses from being

overworked will in turn protect the patient and the hospital as a whole. According to Stanojevic,

et al. nurses who work twelve-hour shifts compared to eight-hour shifts are three times more

likely to make an error regarding medication administration or contribute to patient safety

accidents (Stanojevic et al. 2016, p.185). With that being said it is clear to see that overworked

nurses like a surgeon with bronchitis are putting the patient at risk, especially in a critical care

setting where the patients are immunocompromised. By referring to Scott et al. in the article by

Stanojevic, et al.;

The study of intensive care unit nurses, conducted in the United States, suggests that

during the twenty-eight day study period errors were reported in 27% of nurses, “almost
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errors” in 38% and 20 % of nurses fell asleep at lease once during that period of their

overnight shift. (Stanojevic et al. p. 184-185)

With these statistics, undoubtedly extended work hours and lack of sleep may not be exactly like

preforming a surgery with a severe infection however these factors do need to be looked at as

comparable.

After covering who, what, when and where, now comes the why. Reading information

explaining that length of shift and type of shift does indeed affect patient care proves the point

being made, but there could never be an understanding made until the why is addressed. So why

does working extended hours and long shifts affect patient care? As mentioned before, going

deeper beyond the title is imperative. The simple answer is because the nurse is tired and cannot

think clearly, but in this research investigation this simple answer just will not do. A biological

clock is a familiar term meaning that due to sleeping habits and patterns a person becomes

accustomed to going to sleep and waking up at the same time. Although the theory behind a

biological clock is true, the body never actually functions at normal levels from getting sleep

during the day and having full use at night. Referencing Stanojevic, et al. the circadian

pacemaker radiates signals to the circadian modulation of sleep pressure. This particular

pacemaker is influenced by environmental factors such as light and social factors which could be

the different types of television shows played later than midnight (Stanojevic et al. 2016 p.185).

Understanding that the body may adjust to but cannot be trained to work extended hours and

midnight shifts is primitive for hospitals to understand for the safety of the nurses and patients as

well. Stanojevic, et al. then go on to explain;

The circadian wake promoting signals decreasing during the evening hours with an

increase of homeostatic sleep pressure, resulting in the onset of sleep. Therefore, altered
EFFECTS OF TYPES OF NURSING SHIFTS 12

levels of melatonin due to prolonged exposure to light result in desynchronization

between the internal hormonal environment and external environment, explaining poor

sleep quality of nurses working night shifts. (Stanojevic et al. 2016 186).

With this scientific approach the question of why is answered thoroughly. With patient levels on

the rise and the twenty-four hour care provided by hospitals there is not an option to cut all

twelve hour shifts and midnight workers, however many errors may be prevented if rotating

shifts are taken into account.

Effects of Rotating Shifts

According to (Lin, P., Chen, C., Pan, S., Chen, Y., Pan, C., Hung, H., & Wu, M. (2015)

p308) A rotating shift is defined as a work schedule that includes the day shift (from 8 a.m. to 4

p.m.), evening shift (from 4 p.m. to 12 midnight or from 2 p.m. to 10 p.m.) and night shift (from

12 midnight to 8 a.m.) in some kind of rotation. Rotating from night shifts to day shifts is a

common schedule in the nursing field. Nurses who worked rotating shifts apparently had

increased risk of over commitment and effort reward imbalances compared with those who

worked day/non-night shifts (Lin, P., Chen, C., Pan, S., Chen, Y., Pan, C., Hung, H., & Wu, M.

(2015) p311). The over commitment component is a coping mechanism that can have health

effects such as emotional exhaustion (Lin, P., Chen, C., Pan, S., Chen, Y., Pan, C., Hung, H., &

Wu, M. (2015) p312).

Rotating shifts have also been proven to have a serious effect on the health of the nurses

working them. “People follow a 24-hour period for their daily activities, called biological

rhythms. Biological rhythms are effective in controlling human behavior and performance, sleep-

wake control, digestion, secretion of adrenaline, body temperature, blood pressure, pulse and

other vital signs” (Majid, S., Masoudi, I., Moghadamnia, M., Sharif, M., & Barzegar, M. (2014)).

Rotating shifts can cause a disruption in biological rhythms because of the constant change in the
EFFECTS OF TYPES OF NURSING SHIFTS 13

body. Over time these changes in the body can be linked to causing negative long term effects on

cardiac and pulmonary systems. Researchers found that women working rotating night shifts for

five or more years appeared to have an increase in cardiovascular disease (CVD) mortality and

those working 15 or more years appeared to have an increase in lung cancer mortality

(Carpenter, 2015).

Rotating shifts can be a difficult adjustment of sleep and wake schedules. “Concerning

chronic fatigue reported statistically significantly higher in the group of rotating shift workers

compared to other nurses” (Ferri, P., Guadi, M., Marcheselli, L., Balduzzi, S., Magnani, D., & Di

Lorenzo, R. (2016). “Fatigue, poor sleep quality and dangerous drives home were found in

nurses who could not adapt to shift work. A descriptive study of 12 nurses in the USA who fell

asleep while driving home indicated that although they were scared, they could not address this

problem” (Vitale, S. A., Varrone-Ganesh, J., & Vu, M. (2015).

Rotating shifts can also negatively affect the nurse after her shift. The frequent changes in

schedule can ultimately affect the nurse’s home and family life. “A survey was conducted where

the common practice is shift rotation every 7 days. The nurses reported difficulties in: meeting

family responsibilities, attending social functions, getting sufficient sleep and a lack of family

cooperation” (Vitale, S. A., Varrone-Ganesh, J., & Vu, M. (2015) p 71). “For most nurses that

work on a rotating shift, they will have complications and undesirable effects on their normal

life, and many of them are not manageable” (Majid, S., Masoudi, I., Moghadamnia, M., Sharif,

M., & Barzegar, M. (2014)). According to (Ferri, P., Guadi, M., Marcheselli, L., Balduzzi, S.,

Magnani, D., & Di Lorenzo, R. (2016)) rotating shift nurses reported the lowest degree of job

satisfaction. All of these factors begin to distinctively affect the nurses working them. Chronic

fatigue, poor sleep quality, emotional exhaustion, low job satisfaction, and serious health related
EFFECTS OF TYPES OF NURSING SHIFTS 14

issues can all eventually have a negative impact on the nurse’s health, quality of performance,

safety and patient care.

Safety is most important in every profession. Whether it is knowing how many children

in a classroom one person can be responsible for, washing hands and managing equipment safely

in a kitchen, complying to protocol in the Marine Corps to ensure safety of the United States, and

even getting enough sleep to safely provide care for patients in a hospital; it is evident that safety

comes first. Throughout this investigation it is clear to see that sleep habits, length of shifts, and

type of shifts with respect to daytime verses nighttime play a major role in patient safety in a

critical care setting. Knowing that fatigue not only puts the patients in danger but the nurses

themselves is the first step for hospitals implementing a plan for change. This is not a problem

that can be fixed overnight but with innovation, trial and error, and pure determination the

nursing field will become a safer force for every person involved.
EFFECTS OF TYPES OF NURSING SHIFTS 15

References

Allen, A. H., Park, J. E., Adhami, N., Sirounis, D., Tholin, H., Dodek, P., Rogers, A., Ayas, N.

(2014). Impact of Work Schedules on Sleep Duration of Critical Care Nurses. American

Journal of Critical Care, 23(4), 290-295. doi:10.4037/ajcc2014876

Blackman, I., Henderson, J., Willis, E., Hamilton, P., Toffoli, L., Verrall, C., Abery, E.,

Harvery, C. (2014). Factors Influencing Why Nursing Care is Missed. Retrieved from

journals.ohiolink.edu

Carpenter, H. (2015, Jan. & feb.). Preliminary data released from ANA’s HRA. Retrieved

March 29, 2017, from

http://eps.cc.ysu.edu:2063/ehost/pdfviewer/pdfviewer?sid=e3b89358-6572-439d - 8d71-

a296258a7fca%40sessionmgr4008&vid=0&hid=4107

Caruso, C. (2013, March 13). Negative Impacts of Shiftwork and Long Work Hours.

Retreived from journals.ohiolink.edu

Ferri, P., Guadi, M., Marcheselli, L., Balduzzi, S., Magnani, D., & Di Lorenzo, R. (2016,

September 14). The impact of shift work on the psychological and physical health

of nurses in a general hospital: a comparison between rotating night shifts and day

shifts. Retrieved March 30, 2017, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5028173/pdf/rmhp-9-203.pdf
EFFECTS OF TYPES OF NURSING SHIFTS 16

Hewitt, P. (2010). Nurses’ Perceptions of the Causes of Medication Errors: An Integrative

Literature Review. MEDSURG NURSING, 19(3), 159-167.

Lin, P., Chen, C., Pan, S., Chen, Y., Pan, C., Hung, H., & Wu, M. (2015, May 08). The

association between rotating shift work and increased occupational stress in nurses.

Retrieved March 30, 2017, 308-312. from

https://www.jstage.jst.go.jp/article/joh/advpub/0/advpub_13-0284-OA/_article.

Majid, S., Masoudi, I., Moghadamnia, M., Sharif, M., & Barzegar, M. (2014). A Survey of

Physical, Psychological, and Social Health Indices in Shift Working Nurses. Retrieved

March 29, 2017, from

http://ijhr.iums.ac.ir/article_7655_84b89a61f45745e0af6a8ccd7dcb06af.pdf

Martin, D. M. (2015). Nurse Fatigue and Shift Length: A Pilot Study. American Journal of

Critical Care, 33(4), 81-87.

Stanojevic, C., Simic, S., Milutinovic, D., (2016). Health Effects of Sleep Deprivation on

Nurses Working Shifts.183-188

Vitale, S. A., Varrone-Ganesh, J., & Vu, M. (2015, July 27). Nurses working the night shift:

Impact on home, family and social life. Retrieved March 30, 2017, from

http://www.sciedu.ca/journal/index.php/jnep/article/view/7294/4497