Since Nursing Review published this shift work article earlier this year, New Zealand researchers have released a major literature review of the error rates of nurses working 12-hour shifts.
Condensing your working week into three days has definite appeal to some nurses. Working three 12-hour shifts instead of five eight-hour shifts may mean more time for the kids or garden and less time commuting and arranging childcare.
But are 12-hour shifts safe for patients and nurses? New Zealand research published this year in the International Journal of Nursing Studies by Dr Jill Clendon and Dr Veronique Gibbons indicates that they are not.
The pair’s systematic review examined the research evidence on the error rate for nurses working 12-hour shifts or longer, compared with nurses working shifts of less than 12 hours. The search through thousands of research abstracts was narrowed down to 13 quality studies: six studies reported higher error rates for nurses working more than 12 hours on a single shift; four reported higher rates of error on shifts of up to eight hours, and three reported no difference.
Clendon, a New Zealand Nurses Organisation researcher, said the six studies showing higher error rates for shifts going beyond 12 hours included the RN4CAST research that involved 31,000 nurses across 15 European countries. In total, the six studies highlighting concerns with 12-hour shifts involved 60,780 nurses – or 89 per cent of the review’s total sample size of just under 68,000 nurses. “You are talking about big numbers with robust data and robust methodology,” says Clendon.
Two of the studies found the likelihood of making an error after 12 hours or more was between double to three times above that for those working shorter shifts. Another study found nurses were significantly more likely to suffer a needlestick injury when working 12-hour shifts; another that nurses working more than 13 hours were more likely to report frequent central line-associated bloodstream infections; and another that the longer nurses worked over 12 hours the less likely that a patient’s pain was controlled.
“Hospitals and units currently operating 12-hour shift systems should review this scheduling practice due to the potential negative impact on patient outcomes,” is the conclusion reached by Clendon and Gibbons. They added that further research is also needed into mitigating the risk of errors in situations where 12-hour shift schedules cannot be changed.
The most recent NZNO employment survey indicated that around 10 per cent of registered nurses work 12-hour shifts. The greatest concentration of 12-hour rosters are in public hospitals in Auckland and Wellington; and the most likely services to use 12-hour shifts are intensive or high dependency care units, child health, emergency departments and maternity.
Evidence should prompt rethink
Clendon is convinced the evidence is now strong enough for hospitals to start reviewing the use of 12-hour shifts. She says it is not new news that NZNO as an organisation doesn’t support 12-hour shifts and the collective agreement with the 20 DHBs has for some time spelled out that eight-hour shifts are preferred. “Ten and 12-hour shifts are not recommended as a standard rostering pattern and shall occur only where clear clinical/service rationale supports this practice,” says the MECA (Multi-Employer Collective Agreement), which also states 12-hour rosters should “not compromise” those nurses who elect to work 8-hour shifts.
But while the organisation may not support 12-hour shifts, it does support its members and Clendon is aware that many nurses quite like or prefer 12-hour shifts as it suits their family needs and lifestyle. She is also well aware that apart from the evidence of increased risk to patients there are organisational and fiscal factors encouraging employers to consider shifting away from 12-hour shifts. One of these is the accrual of annual leave by nurses who can have four days off in every seven.
The Clendon research has featured in an article in NZNO journal Kai Tiaki, and been presented to nurse executives group NENZ, but Clendon says there is no active agenda by NZNO to push organisations to reschedule rosters.
Capital & Coast DHB contemplating shift
One region that is actively considering revisiting 12-hour shifts is Capital & Coast District Health Board.
Director of nursing and midwifery Andrea McCance says it is reviewing 12-hour shift rosters in some areas and staff consultation is already underway in midwifery.
At present the board has predominantly eight-hour shifts in its general medical and surgical wards and a mix of eight, 10 and 12-hour shifts in critical care areas (like intensive care, emergency department and neonatal intensive care), neuroscience, oncology and midwifery. It also has a mix of shift lengths in its mental health, addiction and intellectual disability services.
McCance says it is looking at revisiting 12-hour shifts in some of these areas, due to a combination of factors including clinical safety, and rostering complexities through having a mix of eight and 12-hour shifts that can cause issues like four-hour gaps and duplication of handovers. She also says there are increased annual leave and sick leave costs for staff on 12-hour shifts. The Clendon and Gibbons research and other studies are informing the consultation process currently underway involving the two midwifery unions NZNO and MERAS.
McCance says some staff are welcoming the change, including some of the older workforce who say 12-hour shifts are too tiring and unsafe. They have been joined by some of the new graduates citing similar concerns about 12-hour shifts, particularly with increasing throughput and the patient complexity and acuity.
The board will next year introduce the Care Capacity Demand Management (CCDM) safe staffing tools and McCance says at the same time it will be looking “at all sorts of shift patterns, including roster re-engineering in consultation with the unions to ensure we have the right staff at the right place at the right time”.
UPDATE: Nursing shift work and fatigue research
Karyn O’Keeffe said in early November that the Massey Sleep/Wake Research Centre again has its fingers “tightly crossed” as it makes its second attempt to gain Health Research Council funding for an extensive survey of nurses about shift work and fatigue. She said the application has made it through to the full application round and the centre has also been seeking smaller grants for related research work.