Running head: NURSES' WORK SCHEDULE: EIGHT HOUR VS.

TWELVE HOUR SHIFTS 1

Nurses' Work Schedule: Eight Hour vs. Twelve Hour Shifts
Soibah K. Jalloh
Frostburg State University






















NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 2

Nurses' Work Schedule: Eight Hour vs. Twelve Hour Shifts
Introduction
Given the shortage of nurses and the issue of ensuring a safe environment for both
patients and nurses an emphasis has been place upon improving nurses working lives and
personal lives through the implementation of flexible work hours. Compressed work weeks
through the use of 12-hour shifts have gained popularity as a flexible strategy for nurse retention
and satisfaction. There have been a number of studies performed, with both positive and negative
results regarding extended shifts in nursing. However, the most current studies indicate a
negative impact on nurses. These scientific studies have linked the effects of fatigue and
insufficient sleep on nurse performance and patient safety (Agency for Healthcare Research and
Quality [AHRQ], 2008). Because of these evidence based studies, The Joint Commission
(JACHO) has recently issued a new Sentinel Event Alert: Health care worker fatigue and patient
safety. The alert suggests that 12-hour shifts cause more fatigue-related preventable adverse
events (The Joint Commission website, 2011). On the other hand, research has shown that by
reducing the overlap between shifts, costs are lowered and quality of care is improved by
increasing continuity throughout the day. Evidence comparing the relative effects of eight-hour
and twelve-hour shifts on fatigue and job performance, safety, sleep, and physical and
psychological health are explored, along with continuity of care, nurse satisfaction and retention.
Part One
Research Question
Do nurses who work long shifts are more likely to experience job dissatisfaction; burnout
and would their patients' care suffer?
Problem Statement
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 3

Nurses who work long shifts are more likely to experience job dissatisfaction; burnout
and their patients' care may suffer.
Purpose Statement
The purpose of this study is to determine if nurses who work long shifts are more likely
to experience job dissatisfaction; burnout and their patients' care may suffer.
Hypothesis
Nurses who work long shifts will experience job dissatisfaction; burnout and their
patients care will suffer.
*Independent variable: Nurses working long shifts.
*Dependent variable: Are more likely to experience job dissatisfaction and burnout, and
their patients' care may suffer.
Part Two
PICO
Can lack of educating nurses about health risk associated with working longer shifts and
hospitals not offering shorter shifts to those nurses who feel too fatigued after working longer
shift contributes to: extended exposure to work- related stress, diminished communication and or
personal interaction.
Part Three
Information Search Critique Paper
General Article
The general article that I will be discussing is from The Health Risks of Shift Work:
Coping with Excessive Sleepiness. The article is written for the general population by WebMD.
The article gives basic information about shift work and how it could have a serious impact on
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 4

our health in at least two ways. Some of it may have to do with the lifestyle that shift work
encourages. The rest has to do with our biology.
I believe majority of the information provided in this article is valid because some
evidence was provided to support it clams. Two analyses of data from different studies found
that night work increased the risk of breast cancer by 50%. Working shifts on airplanes, like
pilots and flight attendants do, increased the risk by 70%. There's evidence that shift work might
increase the risk of colorectal and prostate cancer as well.
Scholarly Articles
The first scholarly article which I will discuss is Patient Safety and Quality: An
Evidence-Based Handbook for Nurses. Chapter 40: The Effects of Fatigue and Sleepiness on
Nurse Performance and Patient Safety. This information was obtained from the National Center
for Biotechnology Information (NCBI) Website by Ann E. Rogers, Ph.D., R.N., F.A.A.N.,
associate professor, University of Pennsylvania School of Nursing, and the Center for Sleep and
Respiratory Neurobiology. This site is maintained and funded by the United State (U.S)
Government and is protected by various provisions of Title 18 of the U.S. Code. Violations of
Title 18 are subject to criminal prosecution in a federal court. For site security purposes, as well
as to ensure that this service remains available to all users, we use software programs to monitor
traffic and to identify unauthorized attempts to upload or change information or otherwise cause
damage. I do not believe this site forms a bias because they have strict laws about the usage and
individuals has to go through thorough screening to post or edit any information on this site.
Also The National Library of Medicine (NLM) does not endorse or recommend products or
services for which you may view a pop-up advertisement on your computer screen while visiting
their site.
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 5


I believe the information provided is valid because lots of evidence provided to support it clams.
NCBI does not endorse or recommend any commercial products, processes, or services. The
views and opinions of authors expressed on NCBI's Web sites do not necessarily state or reflect
those of the U.S. Government, and they may not be used for advertising or product endorsement
purposes. When visiting our Web site, your Web browser may produce pop-up advertisements.
These advertisements were most likely produced by other Web sites you visited or by third party
software installed on your computer.
A study by Rogers, Hwang, and Scott found that nurses who work longer than 12-hour shift
made more errors, as did nurses who worked more than forty hours per week. A voluntary
sample of 393 hospital nurses from hospitals across the nation participated in the study. The total
number of shifts worked was 5,317; of this number forty percent exceeded 12 hours. One of the
key findings was that the work schedules of hospitals were unavoidably extended. Risks of errors
began to increase when the duration of the shift was greater than 8.5 hours, and nursing staff
were three times more likely to perpetrate an error when they worked more than 12.5 hours. The
association between errors, near errors, and overtime was evaluated while controlling for other
variables, which included age, hospital size, and type of hospital unit.
The second scholarly article assessed is titled The Effect of Staff Nurses Shift Length
and Fatigue on Patient Safety found on the National Association of Neonatal Nurses website by
Lorenz, S. G. (2008, June). 12-hour shifts: An ethical dilemma for the nurse executive. Journal
of Nursing Administration, 38(6), 297301.
I believe the information provided is valid. The incidence and effects of fatigue are
critical to every nurses professional practice. As the professional voice of neonatal nurses, the
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 6

National Association of Neonatal Nurses (NANN) recommends that education about fatigue be
incorporated into nursing curricula, that healthcare employers implement guidelines to minimize
staff fatigue, and that staff nurses maintain awareness of their own fatigue levels so that the
quality and safety of care delivered to neonatal patients are not compromised.
The Minnesota Nurses Association (2007) found that nurses are three times more likely
to make errors if they work shifts that are longer than 12 hours per day or 60 hours per week. In
addition to being more prone to making medical errors, nurses who work longer shifts
experience more neck, shoulder, and back injuries than nurses who work 8-hour shifts
(Minnesota Nurses Association). The Arizona Nurses Association (2007) published research
indicating that fatigue can cause physiological changes, including impaired concentration,
slowed reaction time, and reduced problem-solving abilities. Research on nursing fatigue clearly
identifies the need to protect both nurses and patients from the effects of bedside nurses fatigue
and sleep deprivation.
General Websites
HEAS is a psychology practice specializing in clinical consultancy work. Article by
Rosa, R., and Bonnet, M.H. (1993). Performance and alertness on eight-hour and twelve hour
rotating shifts at a natural gas utility. Ergonomics, 36(10), 1177-1193. It is noted on their
website: Our psychologists are fully trained and registered in the state and are members of a
number of professional bodies. HEASs expertise is in clinical counseling and therapy; employee
assistance programs; trauma intervention; training in personal development and health related
issues; psychological assessments in respect to occupational appraisals and medical legal reports.
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 7

I do not believe the validity of this information because this site promote work placement
and different things that I believe would affect them from being factual about their information,
and not many if any evidence was provided to support most of the clams made in this article.

One of the most common problems experienced as a result of shift work is sleep
disruption which may consequently affect sleeping patterns more generally and sleepiness at
work. Rosa (1991) examined sleep disruption in control room operators and found that 12-hour
shifts produced a one to three hour reduction in sleep over a 3.5 year period. Sleepiness increased
during both the eight-hour and 12-hour shift but there was a greater increase in sleepiness during
the 12-hour shift. However, an important finding was that there was a day-to-day recovery from
working the twelve hour shifts, indicating greater recuperation during the worker's days off.
Employees also noted that as a consequence of the 12-hour roster, more awakenings during their
sleeping period occurred despite more frequent napping. The 12-hour roster produced longer
sleep periods after a day shift or a rest day, but there was a reduction in sleep length following a
12-hour night shift. Despite the feelings of sleepiness Williamson, Gower and Clarke (1994)
state that 12-hour roistering actually reduced feelings of tiredness throughout the work week.
Other effects of 12-hour roistering in relation to tiredness included: decreased amount of time the
employees woke up feeling tired; decrease in tiredness during their shift at work and decrease in
tiredness after a day or a night shift. Thus, the effect of sleep deprivation day to day may have
little effect, but longer periods of time may increase sleepiness that may consequently increase
levels of fatigue some employee's may feel.
There is overwhelming evidence suggesting that the employee's satisfaction with the 12-
hour schedule is high. For example, Rosa and Bonnet (1993) examined employee's attitudes
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 8

towards the 12-hour schedule at a natural gas utility. The results indicate that more than 80% of
the employees voted to retain the new work schedule. An important finding was also that the
employees were happy to tolerate the increased fatigue levels to keep the schedule. Similarly,
Duchon, Keran and Smith (1994) examined 31 employees in an underground mine working an
eight-hour shift. Thirty eight percent of the employees stated that the main reason they would
change jobs is to work different hours. Eighty percent of the 12-hour shift workers reported that
they prefer working a 12-hour shift. Likewise, Walker and Eisenberg (1995) reported that 65%
of the deputies reported in favour of the conversion to the 12-hour schedule.
The second general website that was examined was a web page entitled DIETS FOR A
12-HOUR SHIFT from Livestrong website by Lucy Burns. She has been writing and editing
professionally for more than 15 years. She earned an M.F.A. in creative writing from Cornell
University and a Ph.D. in American literature from the University of North Carolina at Chapel
Hill, where she teaches writing. Burns is a certified yoga teacher and is also licensed to teach the
Gyrokinesis movement system. I was unable to obtain any information about how this article
was funded. I believe this article does present some bias because its promoting health, and has
lots of ads on their website promoting healthy living.
Im not too impressed with the quality of work or validity of this article because not
much research was conducted and very little evidence to support most of the information
provided in this article. Majority of the information provided was by one individual only with the
exception of the information obtained from American Dietetic Association.
When you're working long hours, you need a healthy, high-energy diet to keep yourself
going. On a tight schedule, it can be tempting to have coffee for breakfast and fast food on the
run for lunch. A study conducted by the American Dietetic Association showed that the further
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 9

work hours extend beyond dinnertime, the less likely workers are to eat a meal, instead of relying
on the vending machine. Such quick fixes may lead to obesity and a host of other health
problems, as well as reduced energy and focus at work.
Scholarly Websites
The two scholarly websites that were chosen were Sleep, Sleepiness, Fatigue, and
Performance of 12-Hour-Shift Nurses. Chronobiology International, 29(2), 211-219 and Nurse
Staffing and Patient Care Quality and Safety.
The quality and validity of this research is well supported with evidence and very
informative. The 12-hour shift trend started in the 1970s and 1980s when there were nursing
shortages, said Jeanne Geiger-Brown, PhD, RN, associate professor with the School of Nursing
at UMB. Hospitals and other healthcare facilities which staff 24/7 gave nurses more benefits and
bonuses, eventually leading to emphasis on 12-hour shifts (Geiger-Brown, Rogers, Trinkoff,
Kane, & Scharf, 2012).
Sleep (actigraphy), sleepiness (Karolinska Sleepiness Scale [KSS]), and vigilance
(Performance Vigilance Task [PVT]), were measured serially in 80 registered nurses (RNs).
Occupational fatigue (Occupational Fatigue Exhaustion Recovery Scale [OFER]) was assessed at
baseline. Sleep was short (mean 5.5h) between shifts, with little difference between day shift
(5.7h) and night shift (5.4h). Sleepiness scores were low overall (3 on a 1-9 scale, with higher
score indicating greater sleepiness), with 45% of nurses having high level of sleepiness (score
>7) on at least one shift. Nurses were progressively sleepier each shift, and night nurses were
sleepier toward the end of the shift compared to the beginning. There was extensive caffeine use,
presumably to preserve or improve alertness. Fatigue was high in one-third of nurses, with inter-
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 10

shift fatigue (not feeling recovered from previous shift at the start of the next shift) being most
prominent.
Agency for Healthcare Research and Quality. (2008). Patient safety and quality: An
evidence-based handbook for nurses. Retrieved from http://www.ahrg.gov/qual/nurseshdbk/
By Sean P. Clarke, R.N., Ph.D., C.R.N.P., F.A.A.N., associate professor, University of
Pennsylvania School of Nursing.
I believe the information provided in this article is valid because extensive research was
conducted and the purpose for this research was to ensure patients safety and equality. The most
recent initiative in standardizing staffing and outcomes measures for quality improvement and
research purposes was undertaken by the National Quality Forum (NQF). The mission of the
NQF is to improve American health care through consensus-based standards for quality
measurement and public reporting related to whether health care services are safe, timely,
beneficial, patient centered, equitable, and efficient. To advance standardization of nurse-
sensitive quality measures and respond to authoritative recommendations from multiple IOM and
Federal reports.
There have been a number of studies performed, with both positive and negative results,
regarding extended shifts in nursing. However, the most current studies indicate a negative
impact on nurses. These scientific studies have linked the effects of fatigue and insufficient sleep
on nurse performance and patient safety (Agency for Healthcare Research and Quality [AHRQ],
2008). Because of these evidence based studies JACHO has recently issued a new Sentinel Event
Alert: Health care worker fatigue and patient safety. The alert suggests that 12-hour shifts cause
more fatigue-related preventable adverse events (The Joint Commission website, 2011).
PART 4
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 11

Three Practice Recommendations
The first practice recommendations that can be implemented is a clinical study of
fatigued and sleep deficiency in nurses working longer shifts for an extended period of time. In
this trial, outcome can be compare such as nurses who works three twelve hour shifts in a row
versus nurses that works five eight hour shifts in a row. A variation in practice can be present
due to some nurses working multiple jobs in different clinical settings. Future studies should be
directed at better delineating outcomes of various patterns of extended shift-work and improving
safety, performance, and health outcomes of nurses working these shifts. Despite the fact that
there are many advantages for both nurses and employers utilizing 12-hour shifts; there are also
numerous disadvantages. This trial can be started in a hospital, and the outcomes can be
reviewed based on nurses shift work in these hospitals. This study should be easy to implement
because most nurses like/prefer working twelve hour shifts. The strengths of this study included
the use of actigraphy to objectively estimate achieved sleep rather than relying on subjective self-
reported sleep. Neurobehavioral performance was also measured using an objective, well-
validated test, the PVT. Limitations included that the study did not capture sleep data over
extended periods of time, so the potential for sleep deficiency over longer periods in nurses
working a second job were not assessed.
The Grading of Recommendations Assessment, Development and Evaluation (RADE)
Working Group began in the year 2000 as an informal collaboration of people with an interest in
addressing the shortcomings of present grading systems in health care. (Guyatt, et all, 2008) The
grading scheme classifies recommendations as strong (Grade 1) or weak (Grade 2), according to
the balance between benefits, risks, burden, and cost, and the degree of confidence in estimates
of benefits, risks, and burden. The system classifies quality of evidence (as reflected in
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 12

confidence in estimates of effects) as high (Grade A), moderate (Grade B), or low (Grade C)
according to factors that include the risk of bias, precision of estimates, the consistency of the
results, and the directness of the evidence. (Guyatt, et all, 2008) I believe that this
recommendation for the clinical trial is strong, with strong quality of evidence. Researchers
found that sleepiness increased during both the 8-hour and 12-hour shift but there was a greater
increase in sleepiness in the 12-hour shift. (Rosa, 1991)
The second practice recommendation that should be implemented is nurses working 12-
hour shifts would need a healthy, high-energy diet to keep them going. A study by the American
Dietetic Association showed that the further work hours extends beyond dinnertime; the less
likely workers are to eat a meal, instead relying on vending machines. Such quick fixes may lead
to obesity and a host of other problems, as well as reduced energy and focus at work ("Diets for a
12-hour shift", 2011). Nurses lunch and dinner breaks are frequently interrupted with patient
issues or there simply isnt enough staff to relieve them. Also, many hospitals do not offer
nutritious meals on night shifts. I believe not getting enough sleep increases the likelihood of
eating badly and of being less likely to exercise. The recommendation of healthy and high-
energy diet is a strong recommendation with mod evidence. By educating hospitals of the need
for completely relieved breaks for nurses and providing nutritious food for nurses, it would help
improve the quality of care that nurses provides.
The third practice recommendation that could be implemented is to reduce or eliminate
extended shifts. Studies of extended nursing shifts have shown that nurses report insufficient
sleep, poor quality sleep and fatigue (Chan, 2009). The impact of shift duration on patient safety
is another major concern. In 2000 the IOM published To Err is Human where the healthcare
industry was forced to confront the fact that medical errors kill up to 98,000 patients in the
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 13

American hospital system each year. In addition, the IOM report Keeping Patients Safe:
Transforming the Work of Nurses, cited extended work hours as a source of nurse fatigue.
Ethical principles that are relevant include autonomy; it is the obligation of the hospital leaders
to give the nursing staff adequate information about the effects of extended work hours on both
their performance and their health. The decision to work 12-hour shifts should be voluntary. The
ethical principle of beneficence obligates the hospital to identify processes that result in a greater
benefit over the risk for the patient. This includes the concept of not directly causing harm or
nonmaleficence. This recommendation for reducing or eliminating extended shifts is strong with
low evidence. Increased productivity and reduced errors is the ultimate goals for
reducing/eliminating extended shifts.
Conclusion
The research comparing the differences between 8-hour and 12-hour shifts is not conclusive.
Although the 12-hour shifts often have positive effects on employees satisfaction and retention,
there is a growing body of evidence that 12-hour nursing shifts have a number of consequences
for employers, nursing staff, and patients. Policies should be refocused on the work schedule as a
means of improving patient care and nursing working conditions. Further studies on staff
scheduling practices that look more closely at the relationship between extended work hours and
safe care of patients, need to be done.





NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 14










References

Agency for Healthcare Research and Quality. (2008). Patient safety and quality: An evidence-
based handbook for nurses. Retrieved from http://www.ahrg.gov/qual/nurseshdbk/
Chan, M. F. (2009). Factors associated with perceived sleep quality of nurses working on
rotating shifts. Clinical Nurse Journal, 18, 285-293. Retrieved from
Diets for a 12-hour shift. (2011). Retrieved from http://www.livestrong.com/article/445281-
diets-for-a 12-hour-shift/
Geiger-Brown, J., Rogers, V. E., Trinkoff, A., Kane, B. R., & Scharf, S. M. (2012). Sleep,
sleepiness, fatigue and performance in 12-hour shift nurses. Chronobiology International,
29(2), 211-219. Retrieved from hyyp://chron
Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schnemann HJ, GRADE
Working Group. Going from evidence to recommendations. BMJ 2008 May 17;336
(7652):1049-1051.
Institute of Medicine (IOM) (2004). Keeping patients safe: Transforming the work environment
of nurses. Report of the committee on work environment for nurses and patient safety.
Washington, DC: Author
Lorenz, S. G. (2008, June). 12-hour shifts: An ethical dilemma for the nurse executive. Journal
of Nursing Administration, 38, 297-301. doi: 10,1097/01.NNA.0000312785.03341.80
NURSES' WORK SCHEDULE: EIGHT HOUR VS. TWELVE HOUR SHIFTS 15

Rogers, A. E., Hwang, W. -T., Scott, I. D., Aiken, L. H., & Dinges, D. F. (2004). The working
hours of hospital staff nurses and patient safety. Health Affairs, 23, 202-212. doi:
10.1377/hlthaff.23.4.202
Rosa, R. (1991). Performance, alertness and sleep after 3.5 years of 12-hour shifts: A follow up
study. Work & Stress, 5, 107-116. Retrieved from
http://www.heas.com.au/publications/twelvehour.htm.