Introduction:
The evidence for the number of nursing
vacancies in the United States has been well documented and predicted through
the years. Many healthcare
organizations, scholars and educational institutions have made valid attempts
at addressing the nursing shortage, but the problem still remains. The staffing issue with nursing has
left organizations with little choice but to explore methods that maximize the
utilization of time and staff.
This pursuit gave birth to longer shift lengths in the nursing field, a
move that has been met with mixed reviews. In 2004, the Institute of Medicine (IOM) published a
comprehensive report on nursing practices called Keeping Patients Safe (KPS). KPS highlighted some of the unsafe
conditions that patients can be subjected to and the extensive working hours of
registered nurses (1). Recently
published article highlighted what some consider a disturbing trend of
hospitals only offering 12-hour shift options, and even questioned if the
12-hour shift should be scrapped altogether (2). Geiger-Brown et al 2010, in that three-part publication
reviewed the many concerns associated with the 12-hour work shift and the effects
upon nurses and patients. In
contrast, a previous literature review from 2008 on shift length demonstrates
the lack of evidence to draw conclusions as to the effects either for or
against one shift over another (3).
One of the critical areas nursing
leadership must focus on as staffing challenges increase is workforce retention. There have been many attempts to
address staffing shortfalls and retention with nursing, although there are
areas that require deeper investigation; nursing satisfaction, as it relates
specifically to the 12-hour work shift and what affects this may have upon
patient safety. This review will
highlight some of the evidence on nursing 12-hour shift satisfaction and the associated
benefits or consequences.
Methods:
The exploration of research spanned a
number of English-language journals from the following computerized databases:
CINAHL (1982-2012, June) and MEDLINE (1966-2012, June) both accessed through
the EBSCO – HOST service.
Additional resources such as Health Source: Nursing/Academic Edition and
Wolters – Kluwer Health were utilized for manual retrieval of sources. Keyword variations used were: nurse,
satisfaction, shift, length, extended, retention, staffing, under-staff,
workload, 12-hour, turnover, fatigue and retention. Keyword strategies generated the following results: (nurse
satisfaction) yielded (CINAHL = 7758), (MEDLINE = 7766); (nurse satisfaction)
AND (extended shift) yielded (CINAHL = 2), (MEDLINE = 1); (nurse satisfaction)
AND (12 hour) yielded (CINAHL = 16), (MEDLINE = 14); (nurse satisfaction) AND
(fatigue) yielded (CINAHL = 53), (MEDLINE = 55); (nurse satisfaction) AND
(turnover) yielded (CINAHL = 519), (MEDLINE = 569); (nurse satisfaction) AND
(shift length) yielded (CINAHL = 20), (MEDLINE = 11); (nurse satisfaction) AND
(retention) yielded (CINAHL = 824), (MEDLINE = 515); (nurse satisfaction) AND
(workload) yielded (CINAHL = 410), (MEDLINE = 426); (nurse satisfaction) AND
(staffing) yielded (CINAHL = 497), (MEDLINE = 446); (nurse satisfaction) AND
(understaff) yielded (CINAHL = 47), (MEDLINE = 64). Total unfiltered search results produced: CINAHL = 10,146,
MEDLINE = 9,867. Results were then
narrowed to the search variations of nurse satisfaction AND 12-hour, fatigue,
shift length, extended shift. Narrowed
results generated: CINAHL = 91, MEDLINE = 81. Further polishing of the data removed duplicated results
found between the two databases, thesis and or dissertations results, non-English
translated sources and abstracts or editorials. Of the reduced selection there was a total of 21 articles used
in this review.
Results:
Current published research on registered nurses
working 12-hour shifts and satisfaction is limited and somewhat fragmented. Notably, there have been some in-depth
literature reviews published, for example from Estabrooks et al (2008), and
more recently from Geiger-Brown et al (2012). Published research is lacking enough large-scale studies to
investigate the relationship between 12-hour shifts and satisfaction. Current data finds disparity on perceptions
of satisfaction and outcomes, which may or may not be influenced by a number of
variables such as geographic location, unit size, time and length of shift and
socioeconomic factors.
Fatigue:
Fatigue associated consequences related
to shift length has been well documented and found to manifest both physical
and psychological effects leading to reduced performance and motivation, slowed
reactions, satisfaction and outcomes (1, pg.12). These fatigue symptoms can be either chronic or acute
depending on frequency of fatigue exposure, and can be attributed to
musculoskeletal complications and a decline in overall health. Some findings on fatigue indicate generation
may be of influence as younger and or less experienced nurses have been shown
to have higher levels compared with those working less hours and or more
experience (4). Fatigue associated
safety concerns extend beyond the patient and reach the nurses themselves through
increased needle sticks, musculoskeletal problems, drowsy driving, suppressed
immune systems and metabolic disorders.
Disrupted metabolic patterns resulting from reduced sleeping schedules
attributed to working extended hours may be linked to an increased likelihood
for obesity problems (5). Han et
al, research indicates greater than 50% of surveyed nurses were considered to
be overweight and this could be linked to shift length and or workplace design
(5).
With growing concern in the area
of fatigue related working conditions, the Institute of Medicine in 2004
specifically called for more research on working hours and fatigue factors in the
nursing field (1, pg. 324), a sentiment echoed by nearly every article cited in
this review. But, not all evidence
on fatigue with shift length is aligned.
One study of a single unit found nurses who worked the 12-hour shift
reported having better sleep quality when compared to those on the 8-hour
shift, but it is important to highlight the small sample used in this study (6).
Patient Safety:
Fatigue induced from longer
shifts like that of the 12-hour option raises concerns about patient care
errors. Geiger-Brown et al,
suggest that if patient errors are occurring then it is possible that nurse’s
vigilance is being compromised by fatigue (2). This was the focus of KPS, to improve the nursing
environment to reduce the threats to patient safety. With this consideration it is important to focus on
satisfaction because some research has indicated workload plays a factor in
satisfaction (7). Can patient
safety be affected by nurse satisfaction?
It appears that team dynamic, organizational support and workplace
design hold a significant weight in nursing satisfaction and continuity of
care, implying disruption, burnout and rotating or floating nurses in and out
of different units has adverse affects on both (8)(9)(10)(11)(6). Evidence implies nurses in
unsatisfactory work environments appear to have greater disruptions, which can
lead to a myriad of compromised scenarios that may translate into unsafe
environments for patients. Some of
which may include adverse events, hospital acquired infections, medication
errors and hand-off errors. Along
with the potential for compromised patient safety there is evidence these
disruptions can lead to waste. Storfjell
et al, analyzed these costs and found considerable waste through
non-value-added wage activities reaching $1 million annually (12). Storfjell et al, identified fragmented
work environments and design as the most problematic non-value-added waste
drivers attributing to reduced nurse-patient time and job dissatisfaction (12). These organizational problems are also measured
in nurses’ perceptions of quality of care and satisfaction (11). These factors, if not addressed by
leadership appear to have a lasting impact as found in another study. Nurses who left their first position
cited patient safety issues as concerns with the working conditions as some of
the influencing reasons (13).
One may question if better
staffing rates or a different shift options would ease the potential risks to
patients? Lea et al, conducted a
trial study on hybrid shift mix that provided more nurses on the floor with a
two 12-hour, two 6-hour schedule which resulted in decreased sporadic sick
days, improved continuity of care, use of less contracted workers and increased
satisfaction attributed to more leisure time (14). An additional examination comparing shift lengths of 8-hour and
12-hours found improved patient satisfaction and staff satisfaction when teams
were not disrupted by shift patterns or new rotation of staff members to other
teams, suggesting improving teamwork design may lead to improved satisfaction
and continuity of care regardless of shift length (9).
Satisfaction:
As shown, research indicates there
is probability of health related complications associated with the 12-hour
shift length, but how does this tie into job satisfaction? Research on satisfaction and shift
length unveils some contrasting evidence but, trends point to positive nurse
satisfaction with 12-hour shifts. A
three-month study on 12-hour shift effects found mixed results with nurse morale
perceptions but also found nurses appeared to support 12-hour shifts, as 83%
had a favorable opinion of flexibility with 12-hour shift (8). Then, there is research that challenges
claims that there are correlations between sleep quality and job satisfaction (15). Two studies found that shift length,
flexibility and shift pattern all affect satisfaction in the nursing profession
(15)(16).
Stone et al 2006, compared the
8-hour shift with the 12-hour shift and also discovered some disparities among
satisfaction rates, 77% of 12-hour nurses were satisfied compared with only 51%
of 8-hour nurse who were satisfied (17). Stone et al 2006, also noted that the
12-hour units have lower job openings when compared with the 8-hour shift and
that the 8-hour shift took longer to staff (17). An additional investigation between role stress of 8-hour
and 12-hour shifts of nurses found little statistical difference of
satisfaction between the two shifts, yet did find raised levels of fatigue
among the younger nurses on the 12-hour shift pattern (4). Another study found an even higher
margin of satisfaction among 12-hour nurses, 92%, but once again with this
study the small sample must be considered (6).
Expanding upon satisfaction with
shift length, a study of newly licensed nurses intention to stay found there
was decreased satisfaction with required overtime (18). Additionally, a Taiwan based study
measured intent to stay and level of satisfaction and found there is a
correlation between job satisfaction and intent to stay or leave the current
place of employment citing shift and wages among the factors affecting
satisfaction (19). In a Turkish
study there was evidence of nurses who left the profession citing unfavorable
working conditions and satisfaction (20).
Aside from the effects of fatigue or patient safety, the limited evidence
on satisfaction is trending toward higher satisfaction with nurses who work the
12-hour shift. But one might ask
if this indicates the 12-hour shift is better? Does staff satisfaction outweigh safety? With concerns like those it is
understandable why the ethical debate gains traction and highlights the
difficulties with balancing these variables while facing staffing shortages.
Discussion:
Work related satisfaction and fatigue has been examined in
other industries where workers are faced with extended shift lengths. There are various industry segments with
regulations in place to monitor the amount of hours worked for safety reasons,
but nursing has been able to avoid similar safety regulations with only a few
states implementing hour or patient load mandates (21)(16)(1, TABLE C-1, Appendix C: (384-436)). There are even calls to review the ethical consequences for
extended working hours in nursing (16).
Aiken et al, found that nurses from a patient ratio mandated state such
as California reported having more satisfaction and better retention compared
with states with no such mandate (22).
KPS claims redesigned systems will make no difference if staff levels
are not improved, as the problems with fatigue and errors will continue (1, pg.
316).
Ultimately, with the current
state of research, examining satisfaction and the effects of the 12-hour shift in
nursing will be important to close the evidence gaps. The previously highlighted issues are primarily focused on
the nursing population but they have a multidisciplinary reach in healthcare. The disparity of samples between published
studies indicates the need for more large-scale, non-experimental, mixed-method
studies to focus in on the evidence of satisfaction and the 12-hour shift. Examining this area of nursing should
add value to the industry by revealing what effects the 12-hour shift has
patients and nurses. We must seek
to acquire a better understanding for what correlations exist among this
multifaceted, multidimensional problem as to help nursing leadership better
understand how to balance satisfaction, fatigue and patient safety. It would be recommended that a broad sample
survey of hospital employed registered nurses will advance the understanding of
these matters and be essential moving forward as leaders navigate the growing
pressures on the nursing workforce.
It is important for leadership to not become complacent in believing that
excellence is static measurement, but an ever-moving goal of quality
improvement.
Table 01: Literature Review of RN
Satisfaction and 12-Hour Shift
Citation
|
Sample/Design
|
Aiken et al, 2002
|
10319 nurses / Cross-sectional
|
Aiken et al, 2010
|
22336 nurse sample /
Cross-Sectional
|
Bloodworth, 2003
|
Follow up study
|
Bowles et al., 2005
|
352 useable surveys /
Descriptive. 12-Hour shift
highest cohort.
|
Dwyer et al., 2007
|
12 useable surveys /
Quantitative.
|
Estabrooks et al., 2012
|
Lit Review
|
Geiger-Brown et al., 2010
|
Lit Review
|
Gok et al., 2011
|
134 useable surveys /
Descriptive.
|
Han et al., 2011
|
2103 useable surveys /
Cross-sectional.
|
Hoffman et al., 2003
|
208 useable surveys /
Descriptive Cross-Sectional. Hospital nurses on 8, 10, 12-hour shifts.
|
Josten et al., 2003
|
Lit Review
|
Kalisch et al., 2008
|
Focus group.
|
Kovner et al., 2009
|
1933 useable surveys /
Cross-sectional. Hospital nurses.
|
Lorenz, 2008
|
Lit Review
|
Ma et al., 2009
|
1016 useable surveys /
Cross-Sectional
|
Richardson et al., 2003
|
41 useable surveys /
Descriptive.
|
Ruggiero, 2005
|
247 useable surveys /
descriptive and correlational.
|
Stone et al., 2006
|
805 useable surveys /
Cross-Sectional.
|
Storfjell et al., 2009
|
18 Units from 3 Hospitals /
Descriptive Study
|
Tellez, 2012
|
10449-13849 / Cross-sectional
|
Unruh et al., 2011
|
414 nurses / Tailored Design
Method.
|
Works
Cited:
(1).
Rogers, A. Institute of
Medicine. Keeping Patients Safe:
Transforming The Work Environment Of Nurses. National Academies Press, Washington DC. 2004. Print.
(2).
Geiger-Brown, Jeanne. Trinkoff, Alison. Is It Time To Pull The Plug On 12-Hour Shifts? March 2010. J Nurs Adm. VOL. 40, No. 3.
(3).
Estabrooks, C. A. Cummings,
G. G. Olivo, S. A. Squires, J. E. Giblin, C. Simpson, N.
Effects of Shift Length on Quality of Patient Care and Health Provider
Outcomes: Systematic Review. Qual
Saf Health Care. 2009;18:181-188.
(4).
Hoffman, Amy. Scott,
Linda. Role Stress and Career
Satisfaction Among Registered Nurses by Work Shift Patterns. J Nurs Adm. Vol, 30. No, 6. 337-342.
(5).
Han, Kihye. Trinkoff,
Alison. Storr, Carla. Geiger-Brown, Jeanne. Job Stress and Work Schedules in
Relation to Nurse Obesity. J Nurs
Adm. Vol, 41. No, 11. 488-495.
(6).
Dwyer, Trudy. Jamieson,
Lynn. Moxham, Lorna. Austen, Debbie. Smith, Karen. Evaluation of the 12-Hour Shift Trial in a Regional
Intensive Care Unit. J Nurs
Mang. 2007. 15. 711-720.
(7).
Josten, Edith. Ng-A-Tham,
Julie. Thierry, Henk. The Effects of Extended Workdays on
Fatigue, Health, Performance and Satisfaction in Nursing. J Adv Nurs. 2003. 44(6). 643-652.
(8).
Richardson, Annette.
Dabner, Nichola. Curtis,
Sarah. Twelve-hour Shift on ITU: A
Nursing Evaluation. Nurs Crit
Care. 2003. Vol, 8. No, 3. 103-108.
(9).
Kalisch, Beatrice. Begeny,
Suzanne. Anderson, Christine. The Effect of Consistent Nursing Shifts
on Teamwork and Continuity of Care.
J Nurs Adm. 2008. Vol, 38. No, 3. 132-137.
(10).
Unruh, Lynn. Nooney,
Jennifer. Newly Licensed
Registered Nurses’ Perceptions of Job Difficulties, Demands and Control:
Individual and Organizational Predictors.
J Nurs Mang. 2011. 19. 572-584.
(11).
Aiken, Linda. Clarke,
Sean. Sloane, Douglas. Hospital Staffing, Organization, and
Quality of Care: Cross-National Findings.
Nurs Out. 2002;50:187-94.
(12).
Storfjell, Judith. Ohlson,
Susan. Omoike, Osei. Fitzpatrick, Therese. Wetasin, Kanokwan. Non-Value-Added Time: The
Million-Dollar Nursing Opportunity.
J Nurs Adm. 2009. Vol, 39. No. 1. 38-45.
(13).
Bowles, Cheryl. Candela,
Lori. First Job Experiences of
Recent RN Graduates: Improving the Work Environment. J Nurs Adm. 2005. Vol, 35. No, 3. 130-137.
(14).
Lea, A. Bloodworth, C. Modernizing the 12-hour Shift. Nurs Stan. 2003. Vol, 17. No, 19. 33-36.
(15).
Ruggiero, Jeanne. Health,
Work Variables, and Job Satisfaction Among Nurses. J Nurs Adm. 2005. Vol, 35. No, 5. 254-263.
(16).
Lorenz, Susan. 12-Hour
Shifts: An Ethical Dilemma for the Nurse Executive. J Nurs Adm.
Vol. 38, No 6. 297-301, 2008.
(17).
Stone, Patricia. Du,
Yunling. Cowell, Rhabia. Amsterdam, Norma. Helfrich, Thomas. Linn, Robert. Gladstein, Amy.
Walsh, Mary. Mojica, Lorraine. Comparison of Nurse, System and Quality
Patient Care Outcomes in 8-hour and 12-Hour Shifts. Med Care.
December 2006. Vol, 44. No, 12.
1099-1106.
(18).
Kovner, Christine. Brewer,
Carol. Greene, William. Fairchild, Susan. Understanding New Registered Nurses’
Intent to Stay at Their Jobs. Nurs
Econ. March-April 2009. Vol, 27. No, 2. 81-98.
(19).
Ma, Jui-Chi. Lee,
Pi-Hsia. Yang, Yuh-Cheng. Chang, Wen-Yin. Predicting Factors Related to Nurses’
Intention to Leave, Job Satisfaction, and Perception of Quality of Care in
Acute Care Hospitals. Nurs Econ.
May-June 2009. Vol, 27. No 3. 178-202.
(20).
Gok, Aysen. Kocaman,
Gulseren. Reasons for Leaving
Nursing: A Study Among Turkish Nurses.
Cont Nurs. 2011. Vol, 39. No, 1. 65-74.
(21).
Tellez, Michelle. Work
Satisfaction Among California Registered Nurses: A Longitudinal Comparative
Analysis. Nurs Econ. March-April
2012. Vol.30, No. 2.
(22).
Aiken, Linda. Sloane,
Douglas. Cimiottie, Jeannie. Clarke, Sean. Flynn, Linda.
Seago, Jean. Spetz,
Joanne. Smith, Herbert. Implications of the California Nurse
Staffing Mandate for Other States.
Health Ser Res. 2010.
Aug;45(4):904-21.
The final draft was originally completed and submitted for a grade on, August 01, 2012
