Study: Long nursing shifts linked to burnout, job dissatisfaction, negative patient assessments

Experts urge administrators to guard against excessive overtime, consecutive 12-hour shifts, and rotating between day and night shifts

While the 12-hour work day has become the norm for nurses, there is new evidence that such longer shifts are not necessarily a good idea, especially when nurses work several consecutive days involving 12-hour shifts, or they are required to put in excessive amounts of overtime. A new study, co-authored by Amy Witkoski Stimpfel, PhD, RN, a post-doctoral fellow at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia, PA, found that nurses working these longer shifts are more likely to experience burnout and job dissatisfaction, and patients suffer consequences as well. The researchers found that not only are patients less satisfied when the nurses who are caring for them work longer shifts, but patient outcomes are negatively impacted, too.

The three-year study, which was published in the journal Health Affairs, was the first to look at the relationship between nurse shift length and patient assessments of their care, according to researchers.1 It involved nearly 23,000 registered nurses from four states: California, New Jersey, Pennsylvania, and Florida.

The researchers report that the nurses working shifts of 10 hours or longer were up to two and a half times more likely to experience burnout and dissatisfaction with their jobs than nurses working shorter shifts. Furthermore, seven out of 10 patient outcomes were adversely impacted by the longest shifts.

Confront the disconnect

Despite the negative consequences of longer shifts, nurses still tend to prefer the 12-hour schedules, perhaps because these schedules typically enable nurses to work fewer days of the week, acknowledges Witkoski Stimpfel. “It seems as though there is a disconnect there,” she explains. “We do see, both anecdotally and in this work, that the nurses are overall really satisfied with their scheduling, and it seems like they are participating in choosing their schedules. But at the same time, those are the nurses who are the most burned out.”

In the study, 65% of the nurse participants worked shifts of 12 to 13 hours. The researchers report that as shift lengths increased, so did the likelihood that the nurses would report burnout or an intention to leave their jobs.

Furthermore, in hospitals that had higher proportions of nurses working longer shifts, there were also higher proportions of patients providing poorer overall assessments of how well the nurses communicated, how well their pain was controlled, and how responsive the nurses were when the patients needed help.

While it is not entirely clear why nurses would choose schedules that result in more burnout and dissatisfaction, Witkoski Stimpfel advises organizations to find out what their staff and administrators know about this issue. “Then do some staff education to help them start doing self-scheduling, and if they are choosing these [longer shifts], watch out for multiple consecutive long shifts in a row, and any rotating between day shifts and night shifts,” she explains.

Another good option for management is to offer more flexibility in the hours nurses can choose to work. “Some places are starting to implement shifts as short as four hours, and they allow for nurses to come in and work [for shorter stints] during peak times or shift changes,” observes Witkoski Stimpfel. “This helps to give options to nurses who don’t want to work such long hours.”

Management can also take steps to enable nurses to say “no” to overtime or “no” to coming in on scheduled days off, adds Witkoski Stimpfel. “At some hospitals, if you get a call to come in, it is expected that you come in,” she says.

Consider flexible scheduling options

One health system that has introduced new solutions in the nurse shift arena is the Cleveland Clinic. In 2008, the health system launched a program that enables nurses to choose to work six hours or less on an as-needed basis. “The program was aimed at helping nurses who had left the workforce to be stay-at-home moms to be able to come back into the workforce, and so it got the name ‘parent shift,’” explains Nancy Albert, PhD, RN, CCNS, NE-BC-FAHA, FCCM, the Cleveland Clinic’s senior director, Nursing Research and Innovation.

However, Albert points out that the program is not just used by parents. She notes, for example, that many nurses choose to work the parent shift while they are students working toward advanced nursing degrees. “It is really meant to help units and floors overcome the burdens associated with incoming patients, patients being discharged, or patients going to the lab, X-ray, or other parts of the hospital for tests or treatments,” she says.

While meeting the needs of nurses, the parent shift provides staffing flexibility to administrators. Duing the day shift, There is a lot going on in terms of nurses being interrupted and trying to do the best job they can for patients, explains Albert. “Having a nurse come in at 10 a.m. and having them stay until 2 p.m. can offer the nurse who is assigned as a patient care giver a lot of relief.”

A parent-shift nurse can enable a staff nurse to take a lunch break, but she can also help to ensure that patients get their medicines on time, or get to tests and procedures when they are supposed to, says Albert. “Every manager who uses these parent-shift nurses may use them in a different way,” she says.

Several EDs within the Cleveland Clinic Health System make use of the parent-shift nurses, according to James Bryant, RN, MSN, CEN, CCRN, NEA-BC, the associate chief nursing officer for Emergency Services. He explains that each ED is able to use these nurses in a customized way to meet the specific needs of the facility. The approach also enables the EDs to offer the nurses added scheduling flexibility, and he notes that a handful of nurses in Cleveland Clinic EDs take advantage of this option.

Ability to delegate is key

Nurses who choose to work the parent shifts are able to select the days and hours that they want to come in as long as these shifts also meets the needs of the nurse manager in their unit or department, explains Albert. “There has to be a good match between the desires of the nurse and the manager on that floor. Then it works wonderfully,” she says.

However, in exchange for this flexibility, there are significant trade-offs. Parent-shift nurses receive no benefits, and they receive lower salaries than regular staff nurses. “There has to be an incentive for someone to work full-time and also to work a full shift,” explains Albert. “The parent-shift nurses may not have a full patient assignment, so they don’t have the same level of stress or the same burdens that a typical staff nurse would have.”

Despite these trade-offs, the parent shift has proven popular with nurses who may not be able to work on a full-time basis, but want to maintain their skills and stay involved in their profession. “The parent-shift people don’t have to work any holidays, so it offers them great flexibility, and they get the rewards of having some interaction on the worksite, and keeping up-to-date in their skills,” says Albert.

A key advantage for Cleveland Clinic hospitals is that these nurses are fully trained and oriented to the culture on the floors where they work. “It is not like we are bringing on people who are strangers to the floor; these are team members,” says Albert. “They enable us to ensure that we are delivering the highest quality of care even when there are unit stressors going on like a lot of admissions coming in at once, or patients who need to travel to other floors for tests or procedures.”

While nurse managers who elect to make use of parent-shift nurses must provide for these nurses in their budgets, there is no evidence that the approach has presented any administrative challenges, says Albert. However, for the program to work, she stresses that staff nurses need to feel comfortable collaborating with and delegating tasks to the parent-shift nurses. “Every floor has to decide how to best use these nurses so that they can be as effective as possible,” she says.

Managers need to take the lead

While options like the Cleveland Clinic’s parent shifts are helpful, Witkoski Stimpfel does not see 12-hour nursing shifts going away, and she doesn’t recommend that. However, she is hopeful that education about this issue will help both managers and individual nurses move toward sensible scheduling solutions. For example, she notes that nursing administrators can take steps to limit the number of 12-hour shifts that are clustered together, using more of a mix of 12-hour and 8-hour shifts. Another alternative would be to offer some type of hybrid schedule in which nurses provide direct patient care for eight hours and then do committee work or administrative tasks for the remaining four hours of a 12-hour shift, adds Witkoski Stimpfel.

When people are really fatigued, performance suffers, adds Witkoski Stimpfel. “Our brain kind of tricks us. We feel OK, but we don’t realize how impaired we might be,” she says. “By scheduling smarter, we can avoid some of that because it is really hard to tell when you are at the point when you might be unsafe in practice.”

It is going to take time to change a culture in which it is expected for nurses to work these longer shifts, adds Witkoski Stimpfel. This is why managers need to take the lead on providing education around this issue and providing support for a healthier balance in scheduling, she says.

Reference

  1. Witkoski Stimpfel A, Sloane D, Aiken L. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs 2012;31:2501-2509.

Sources

  • Nancy Albert, PhD, RN, CCNS, NE-BC-FAHA, FCCM, Senior Director, Nursing Research and Innovation, Cleveland Clinic Health System, Cleveland, OH. E-mail: albertn@ccf.org.
  • James Bryant, RN, MSN, CEN, CCRN, NEA-BC, Associate Chief Nursing Officer, Emergency Services, Cleveland Clinic Health System, Cleveland, OH. E-mail: bryantj2@ccf.org.
  • Amy Witkoski Stimpfel, PhD, RN, Post-Doctoral Fellow, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA. E-mail: amywit@nursing.upenn.edu.