Running head: EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS

The Effects of Twelve Hour Shifts versus Eight Hour Shifts on Registered Nurses’ Health

Katie Dougher, Vanessa Gonzalez, Jackie Tabor, Catherine Garcia and Nicholette DeMarco

04/03/2017

NURS 3749: Nursing Research

Dr. Valerie O’Dell

EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 2

Abstract

The goal of this research paper was to correlate how eight hour shifts versus twelve hours shifts

affect Registered Nurses’ health and well being. The relationship between increased job stress,

increased fatigue, increased decision regret, job dissatisfaction, burnout, intent to leave, sleep

deprivation, poor patient outcomes related to incomplete nursing care, and difficulty with

organization for patient care were all explored. The research was drawn from ten different

sources. Through the research compiled, it was found that increased and extended work hours

correlated significantly with job stress, fatigue, sleep deprivation and decision regret. It was also

found that increased shift lengths increased the likelihood of job dissatisfaction leading to

burnout and the intent to leave. Furthermore, research showed how the negative effects on the

Registered Nurses carried over to lower patient outcomes and organizational outcomes. Largely,

the research concludes increased shift lengths have a negative effect on Registered Nurses’

health and well being, which then adversely affects patient outcomes.
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 3

The Effects of Eight Hour Shifts versus Twelve Hour Shifts on Registered Nurses’ Health

The required shift length of a registered nurse (RN) to work has had an increase

overtime. This is due to the increase in patients being admitted to the hospital floors as well as

staffing shortages. The increase of hours worked by registered nurses have caused many negative

effects on them. Numerous multifactorial studies have been conducted to research what effects

extended work hours can have on the Registered Nurse. These effects include increased job

stress, increased fatigue, increased decision regret, job dissatisfaction, burnout, intent to leave,

sleep deprivation, poor patient outcomes related to incomplete nursing care, and difficulty with

organization for patient care. All of the research has concluded these effects on the RN result in

decreased patient care. Therefore, the following research question was addressed: What are the

physical, mental and emotional effects of nurses working twelve hour shifts versus eight hour

shifts in the hospital setting?

Literature Review

Introduction

To target this issue in the medical field among nurses, the information was obtained

through multiple sources which include the following: CINAHL, Google Scholar, MEDLINE

and OhioLINK. Ten articles were collected and reviewed for data regarding the issue of twelve

hour and eight hour shifts affecting nurses health. The following topics will be discussed to

explain how each issue regarding twelve or eight hour shift impacts a nurses’ health: job stress,

burnout, job dissatisfaction, recovery, association of sleep and fatigue with decision regret,
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 4

effects of sleep deprivation, poor patient outcomes related to incomplete nursing care, and

difficulty with organization for patient care.

Job Stress

Arnold and Feldman’s definition (as cited in Lin, Liao, Chen & Fan, 2014, p. 605) define

job stress as “the reactions of individuals to new or threatening factors in their work

environment. Job stress causes many issues on the human body; it can affect multiple aspects of

their personal life and the people around them. Referenced by Lee in (2006). In the study of

Journal of Nursing Management​, the article had mixed results pertaining to nurses working

twelve hour shifts compared to eight hour shifts. According to Aveyard (2016), the negative

effect of shift work on many employees is documented in all industries such as nursing. During

both eight hour and twelve hour shifts nurses reported moderate job stress (Shu-Hu Lin,

Wen-Chun Liao, Mei-Yen Chen, & Jun-Yu Fan, 2014). The twelve hour shift has been

characterized as increasingly detrimental to nurses’ health by causing interruptions in circadian

rhythms, altered activity rest patterns, increased stress levels and interfering with social life

(Aveyard, 2016).

Registered Nurses often suffer from gastrointestinal discomfort related to job stress

leading to more health issues in the future compared to eight hour shifts. Nurses with increased

stress levels are 20% more likely to be sleep deprived and also report poor self-perceived health.

Also the relationship between job stress and mild psychological disorders were analyzed; the

findings revealed 48% of nurses had a mild form of psychological dysfunction (Lin, Liao, Chen

& Fan ​et al​ 2014).

EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 5

Registered nurses suffer a substantial amount of job stress compared to other medical

professionals (Lin ​et al​., 2014, Sehlen, 2009). Along with job stress the work load has an effect

on how well patient care is provided; if job stress continues for an extended period of time,

nurses may neglect their preliminary responsibilities. In turn this may lead to medical errors

affecting patient safety, burnout and possibly resignation. A survey illustrated by the National

Union of Nurses’ Associations in the Republic of China (2012) indicated nursing shortages is

about 7.2% across all hospitals and that they are lacking 7,000 nurses in the hospital setting (Lin,

Liao, Chen & Fan ​et al​ 2014). In attempt to alleviate nursing shortages in hospitals, more nurses

are required to work twelve hour shifts instead of the eight hour shifts leading to job stress. As

reported by Shu-Hu Lin, Wen-Chun Liao, Mei-Yen Chen, & Jun-Yu Fan a study conducted by

the National Union of Nurses’ Association also organized a survey regarding shift statuses of

nurses, 55.78% were dissatisfied due to high workloads and 31.34% were dissatisfied due to high

levels of stress and responsibility and gave rise to the progression of job stress. According to

Aveyard, (2016) a questionnaire about twelve hour shifts were sent to members of the American

Association of Critical Care Nurses; the questionnaire revealed an increased level of job stress

during the twelve hour shift. The stressors included emotional demands of their families along

with the patients being cared for, physical labor, medication errors, and having multiple patients

at once. The increased stresses lead to decreased motivation, decreased nurse vigilance,

difficulty concentrating, daytime sleepiness, and less intershift recovery with twelve hour shifts.

In an American study, logbooks were given to Intensive Care Unit nurses to obtain their work

hours, days off, time of day they worked, if they worked overtime, sleep patterns and near misses

or errors made (Aveyard, 2016). The study proved that there was a relation between shift length,
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 6

decreased nurse attentiveness, and error, the end result ended in stress for the Registered Nurses.

Job Dissatisfaction

As discussed above, there are many cons to nurses’ working long shifts. It is explained in

a cross-sectional study performed by C. Dall’Ora, P. Griffiths, J. Ball, M. Simon, L.H. Aiken

(2015), that some literature have reports that nurses prefer twelve hour shifts, however their

research suggests differently. “Nurses’ job satisfaction declines with longer shift lengths”

(Dall’Ora et al, 2015, p. 5-6). The contraindication between nurses actually preferring twelve

hour shifts in reality may be that they are experiencing lower job satisfaction “ is that longer

shifts may have a cumulative negative effect on well-being that nurses may be unaware of or do

not attribute to shift work” (Dall’Ora et al, 2015, p. 6). Nurses may think working three, twelve

hour shifts a week will allow them more time for recreational activities. According to Dall’Ora et

al:

Nurses may be choosing to sacrifice work satisfaction for benefits in other spheres of

life. However, this type of choice is likely to compromise nurses’ recovery sleep,

physical and psychological well-being: the stress of those long work days and the

recovery time needed may counterbalance any perceived benefit (2015, p. 6).

Therefore, a Registered Nurse is sacrificing their physical and psychological well-being working

the twelve hour shift, allowing more time at home, or participating in other recreational

activities. This causes the RN to think a twelve hour shift is more beneficial for their time, but in

the end will have lower job satisfaction because of the negative effects the extended hours cause
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 7

on them mentally and physically.

In the study performed by Dall’Ora et al it was established “that shifts of 12 hours. or

more for hospital nurses are associated with more reports of burnout, job dissatisfaction,

dissatisfaction with work schedule flexibility and intention to leave” (2015, p. 5). The likelihood

of a Registered Nurse intending to leave their job because of job dissatisfaction were “increased

by 31%” for Registered Nurses working twelve hours or more in comparison with RNs working

eight hours or less. (Dall’Ora et al, 2015, p. 6). The study also concluded that any shift longer

than eight hours were disadvantageous to nurses and their job satisfaction.

Burnout and Intent to Leave

Alongside job dissatisfaction is job burnout and intent to leave. It was reported in the

study by Dall’Ora et al (2015), when Registered Nurses work extended hours, or more hours

than scheduled; they are more likely to report burnout, on top of their job dissatisfaction. A

cross- sectional study performed by A. Witkoski Stimpfel, D. M. Sloane, and L. H. Aiken also

found “Increases in shift length were associated with significant increases in the odds of burnout,

job dissatisfaction, and intention to leave the job” (2012, p. 2504). The percent of RNs who

reported burnout and intent to leave increased dramatically as their shift length increased.

Witkoski Stimpfel et al also found, “The odds of burnout and job dissatisfaction were up to two

and a half times higher for nurses who worked longer shifts than for nurses who worked shifts of

8–9 hours” (2012, p. 2504). Job burnout of the Registered Nurse can lead to many other

unfavorable outcomes on the nursing floor. Including but not limited to, decision regret, fatigue,

job stress and sleep deprivation. . “The odds of these unfavorable outcomes were highest for
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 8

nurses who worked shifts of more than 13 hours” (Witkoski Stimpfel et al, 2012, p. 2505).

Extended shift lengths for RNs cause many different negative effects on them, which in turn lead

to a cascade effect of other negatives for the RN and the hospital.

Sleep Deprivation

Of the 16 million Americans that work in the healthcare and social assistance job

industry, “32%, or 5 million, workers report they do not get enough sleep” (Caruso, 2013). A

recommendation for 7-8 hours of sleep is important to maintain life and health and to work

safely (Caruso, 2013). “Sleep duration of 7-8 hours a night is associated with a lower risk of

obesity, diabetes, high blood pressure, myocardial infarction, and cerebral vascular accidents as

well as a reduced risk for injuries and errors” (Caruso, 2013, p.16). A study of 23 Australian

nurses stated that “getting less sleep was significantly related to increased likelihood of making a

patient error and a decreased likelihood of catching someone’s else’s error” (Fallis, McMillan, &

Edwards, 2011). Nurses sleep duration between 12-hour shifts is on average 5.5 hours (Caruso,

2013).

Sleep deprivation impairs many types of performance: reduces the ability to concentrate;

slows reaction time; and reduces the ability to remember and learn new facts and motor

skills. Sleep deprivation also leads to irritability, bad mood, reduced communication

skills and ability to cope with the emotional demands of the workplace. Researchers

report that decision-making ability deteriorates and risk-taking behavior increases. In

addition, reduced situation awareness can impair a nurse’s ability to respond to patient

care needs (Caruso, 2013, pp. 17-18).

EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 9

Nurses need to have awareness of the risks that are associated with working extended

hours. When comparing the incidence of work related injury or errors between 8 hour shifts and

12 hours shifts, “they found that nurses had over three times the odds of making an error when

working 12 or more hours, compared with 8.5 hour shifts” (Caruso, 2013). “Findings from the

US National Postgraduate Medical survey indicate that, when compared with day shift work,

night work was associated with double the risk of percutaneous injury (needlestick and

lacerations) posing serious hazards of transmission of bloodborne pathogens” (Fallis, McMillan,

& Edwards, 2011, p.3). Studies also found that “95% of those who worked night shifts reported

automobile-related injuries and near accidents that occurred driving home following night shift”

(Fallis, McMillan, & Edwards, 2011). Studies indicate that when nurses have a nap break while

they are working, they report “more vigor, less fatigue, and less sleepiness” (Fallis, McMillan, &

Edwards, 2011). Nurses also reported even a “single 30-minute nap break between 2AM and

3AM had a significant positive impact on subjective and objective measures of alertness in

hospital workers” (Fallis, McMillan, & Edwards, 2011).

Twelve- hour rotating shifts are associated with many poor health habits or health

conditions. Studies found that workers are more prone to “obesity, smoke, low physical activity,

and higher alcohol consumption” (Caruso, 2013). Some shift workers reported an increase in

“psychological complaints including bad mood, depression, irritability, anxiety and personality

changes, and difficulty with personal relationships” (Caruso, 2013). Workers that smoke to cope

with the shift demands, “are at somewhat higher risk for cardiovascular disorders; data supports

a possible link with cardiovascular disease, including myocardial infarction, chest pain, and high

blood pressure” (Caruso, 2013). Also, the smoking population has “an increased risk for
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 10

ischemic strokes” (Caruso, 2013). As stated in the article by Caruso, “breast cancer is increased

by 48% while working night shifts; two of three studies found an increase in prostate cancer”

(Caruso, 2013). Working longer shifts “is associated with adverse reproductive outcomes for

women” (Caruso, 2013). “A review by Frazier & Grainger (2003) reported that shift work was

associated with a modest increase in spontaneous abortion, preterm birth, and reduced ability for

women to become pregnant” (Caruso, 2013, p.19).

Fatigue​ ​and Recovery

The 12- hour shift has become more common in hospitals compared to the traditional

eight hour shift. Numerous nurses prefer the 12- hour shift for the reason that they have greater

flexibility in scheduling and can balance work and life. According to Chen, K. Davis, Daraiseh,

Pan, L. Davis (2014), even though 12- hour shifts have their benefits, there is an increasing

concern on the negative impact on nurse fatigue levels. Windwood et. al. explains fatigue and

how it is a feeling of a lack of energy that can develop after temporary acute activity and can be

relieved by rest. However when a person continually repeats those activities under long periods

of time and are unable to recover that’s when chronic fatigue sets in. Chronic fatigue is

characterized by continuous acute activity over long periods of time and characterized by

unrelieved physical and mental exhaustion as cited in (Chen ​et al​, 2014). Caruso ​et al​. (2004),

Geiger-Brown & Trinkoff (2010), mentioned

Furthermore, a high level of acute fatigue accumulated over long working hours may lead

to a decline in vigilance, given the evidence that the 12- hour shifts are associated with

increased medical errors, workplace injuries and drowsy driving compared to a 8- hour
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 11

shifts (Chen ​et al​, 2014, p. 594).

Multiple studies (Mcgettrick & O’Neil 2006, Dwyer et al. 2007, Richardson ​et al​. 2007)

reported nurses preferred 12- hour shifts when it came to balancing work and life, furthermore

nurses perceived that 12-hour shifts improved fatigue and recovery outcomes as cited in (Chen et

al, 2014, p. 598). This study was a cross-sectional, descriptive design and shows moderate levels

of chronic fatigue and intershift recovery. This shows there is an unhealthy fatigue- recovery

process in nurses performing 12- hour shifts (Chen ​et al​, 2014, p. 598).

​Decision Regret

According to Scott, Arslanian-Engoren, M. Engoren (2014), inadequate sleep and

decision regret among health care providers can affect patients in the critical care units since they

are more vulnerable to health care errors. Patients in critical care have illnesses combined with

unstable critical status and need high risk medications and interventions. Critical care unit nurses

provide most of the care and should be alert and recognize changes. Van-Griever, Meijman

(1987), identified “inadequate sleep, an inevitable consequence of extended work shifts(ie,≥ 12

hours) contributes to loss of situational awareness and creativity, compromised problem solving

and decision making,” Scott, Rogers. Hwang, Zhang (2006) mentioned “ and decreased alertness

on duty, further jeopardizing patient safety.” As cited by (Scott ​et al​, 2014 p. 21). According to

Zeelenberg (1999), Zeelenberg, Dijk, Manstead, Pligt (1998)“Decision regret is a negative

cognitive emotion that occurs when the actual outcome and the desired or expected outcome

differ and reflects concerns that the wrong decision had been made.” As cited by Scott et ​al​,

(2014 p. 21). In this study Scott ​et al​, (2014) discusses the registered nurses and the vital role as
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 12

a member of a health care team. Critical unit nurses that are fatigued and are sleep deprived put

themselves and their patients at serious risk.

In our study, the majority of nurses reported moderately high fatigue, significant sleep

deprivation, and daytime sleepiness, all of which affect their ability to be alert, vigilant,

and safe. Furthermore, the nurses were not likely to sufficiently recover from their

fatigue-related states during non-work periods (Scott ​et al​, 2014).

Additionally Winwood, Winefield, Dawson, Lushington (2005) states nurses who were unable to

recover from acute fatigue compared to those who were able to recover are more at risk for

becoming chronically fatigued. Trinkoff, Storr, Lipscomb (2001) referenced nurses may perhaps

experience injuries, illnesses, and absenteeism.

Patient Outcomes

There is a prevalent issue in the healthcare industry of chronic nursing staff shortages.

This issue pushes nurses who are currently working to make up for this problem by working

extended work hours. In the article “Nurses’ extended work hours: Patient, nurse, and

organizational skills”, the aim behind this study was to examine Thailand’s nurses’ extended

work hours and the correlation to patient, nurse, and organizational outcomes. This article

included 1,524 participants who were registered nurses across 90 hospitals in Thailand. It was

found that extended work hours were “positively correlated with patient identification errors,

development of a pressure ulcer while under the hospital’s care, communication errors, and

patient complaints” (Kunaviktikul et al., 2015). Nurses working these extended shifts were

“significantly more likely to perceive all adverse patient outcomes, including all four patient
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 13

outcomes than participants working less than or equal to eight hours per week” (Kunaviktikul et

al., 2015).​ ​This was based from the findings with the data collected in the study by Kunaviktikul

et al. (2015) it was stated that “communication errors, patient identification errors, patient

complaints, patient pressure ulcers occurring while under the hospital’s care, and errors in

medication administration occasionally occurred at rates of 33.86%, 25.00%, 24.21%, 22.32%,

21.73%, respectively” (p. 389). In the study conducted by King’s College London’s National

Nursing Research Unit et al., it was shown that “a growing number of UK nurses are working

12- hour shifts but that the practice could pose risks to patient care” (cited in Sprinks, 2015)

Organizational Outcomes

Extended work hours are becoming more common for registered nurses, and in the study

by Kunaviktikul et al. (2015), the results propose that extended work hours were “negatively

correlated with organizational productivity” (p.391). The result of this study suggests that the

longer length of a shift did not alter the results of organizational outcomes, however it was found

in the article by Kunaviktikul et al. (2015) that of the 1,524 registered nurses who participated in

the study, a moderate level of organizational commitment (41.47%) was found with extended

work hours (p.390).

Conclusion

In conclusion, the question of the effects of twelve hour shifts versus eight hour shifts on

registered nurses’ health in relation to job stress, job dissatisfaction, burnout, recovery,

association of sleep and fatigue with decision regret, and the effects of sleep deprivation were

discussed. Studies show that job stress was extremely negative on the nurses’ health, including
EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 14

physically and socially. It was also shown in studies that burnout and intent to leave by

registered nurses were highest among those working longer shifts. It was shown that the acute

fatigue can be corrected with rest, but caused chronic fatigue caused by extended periods of long

shifts had adverse effects on the nurses’ physical and mental health. It was also found that the

association of sleep fatigue with decision regret lead to issues such as compromised problem

solving and decreased awareness and how these were especially important to critical care nurses

and their patients.

EFFECTS OF TWELVE HOUR SHIFTS VERSUS EIGHT HOUR SHIFTS 15

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