Practice Tip of the Week | Reconsidering the 12-Hour Work Shift

By Bethany Fijan, MSN, RN, CMSRN

In the United States, the majority of inpatient bedside nurses work 12-hour long shifts to cover the 24/7 needs of patients in acute care settings. Historically, this was not always the case—this shift length was introduced as a perk to attract nurses in a time of nursing shortage. With expanding research on the impact of fatigue on patient safety and quality metrics, current high levels of nurse burnout, and the present need for organizations to retain inpatient bedside nurses amidst another shortage, it is important to re-examine the effect of long working hours such as the standard 12-hour shift in comparison to the more traditional eight-hour shift for nurses.

History

12-hour shifts have not always been the norm. In 1938, the Fair Labor Standards Act established the eight-hour workday, or 44-hour work week, for all shift-workers. This applied to nursing as well.

Fifty years later, the transition from eight-hour shifts to 12-hour shifts for nurses occurred gradually as hospitals looked for ways to attract new nurses and increase staff retention during nursing shortages, by offering full-time benefits to nurses despite nurses working fewer than the general full-time 40-hour per week requirements. The 12-hour shift has since become a common scheduling practice in many healthcare settings, despite the move to 12-hour shifts being controversial since its inception. Though generally accepted, several voices have raised concerns about the potential negative effects of longer shifts on nurse safety and patient care over the years.

The Data

Nearly twenty years ago, Rogers et al (2004) measured the working hours of nurses and their errors or near-errors during work. 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 (Rogers et al., 2004). Ten years ago, a study of 22,275 hospital staff RNs from 577 non-federal acute care hospitals in four states (California, New Jersey, Pennsylvania, and Florida) showed that nurses working shifts of 10 hours or longer were associated with worse reports of patient care quality and overall safety grade compared with nurses working eight to nine hours (Stimpfel & Aiken, 2013). Since this study, the body of research on patient safety and quality of care related to nursing work hours has grown, with a recent systematic literature review showing a conclusive relationship between excessive nurse work hours and adverse patient outcomes (Bae, 2021).

Nurses themselves are unsure how they feel about working 12-hour shifts in comparison to eight-hour shifts. According to the most recent nationwide survey of 12,694 nurses, when asked about shift length preferences, 40% prefer eight-hour shifts and 37% prefer 12-hour shifts (American Nurses Foundation, 2022). This is a surprisingly similar percentage, and shockingly different than what employers offer, as another study of 22,275 hospital staff RNs showed that 65-85% of staff nurses work 12-hour shifts (Stimpfel & Aiken, 2013). Undoubtedly the mismatch between what nurses want and what employers offer is associated with nurse burnout, dissatisfaction and retention. This conclusion is supported by a large survey of 31,627 RNs working in 2,170 general medical or surgical units within 488 hospitals across 12 European countries, which found that nurses who work 12-hour shifts have a higher job dissatisfaction and burnout rate compared to nurses who work eight-hour shifts (Dall’Ora et al, 2015).

The Benefits of the Eight-Hour Shift

A return to the eight-hour work shift for nurses would increase return-to-work time from approximately 11 hours between shifts to approximately 15 hours between shifts. Dahlgren et al (2016) found that increased frequency of quick returns (<11 hours between shifts) was a significant predictor of poor sleep quality, short sleeps, unwinding, exhaustion, satisfaction with work hours and work-to-family interference. Their study of 1,459 nurses over three years found quick returns more problematic in those areas than night shift work (Dahlgren et al, 2016).

Of the 14% of actively licensed RNs in the United States that are currently sitting out of the workforce, approximately half of them reported caring for family and home as the reason for unemployment (Smiley et al., 2023). It is reasonable to argue that working an eight-hour shift length would allow more opportunities to balance home care, childcare, and adult care, bringing some of these 14% of RNs who are not actively employed back into the workforce.

Eight-hour shifts with approximately 15 hours between shifts would allow nurses more time for physical, mental, and emotional recovery between shifts. A systematic review of coping strategies for burnout in healthcare workers found that social and emotional support, physical activity, physical self-care, emotional and physical distancing from work were the most effective (Maresca et al, 2022). Having more time between shifts for self-care, hobbies, and supportive relationships would reduce nurse burnout and fatigue. Reduced fatigue would lead to greater patient safety and reduced errors, as fatigue related to long shifts is a known contributor to adverse events and near misses (Bell et al, 2023).

With the current state of the nursing shortage crisis, it is time to reconsider the norm of the 12-hour shift length. Adopting a greater number of eight-hour shift lengths for nurses would lead to better patient safety outcomes, increased nurse retention and nurse satisfaction due to greater work-life balance and reduced burnout.

REFERENCES 

American Nurses Foundation. (2022). Pulse on the Nation’s Nurses Survey Series: COVID-19 Two-Year Impact Assessment Survey. Retrieved April 21, 2023, from https://www.nursingworld.org/~492857/contentassets/872ebb13c63f44f6b11a1bd0c74907c9/covid-19-two-year-impact-assessment-written-report-final.pdf .

Bell, T., Sprajcer, M., Flenady, T. (2023). Fatigue in nurses and medication administration errors: a scoping review. Journal of Clinical Nursing 32(17-18):5445-5460. https://doi.org/10.1111/jocn.16620

Bae, S. H. (2021). Relationships between comprehensive characteristics of nurse work schedules and Adverse Patient Outcomes: A systematic literature review. Journal of Clinical Nursing, 30(15-16), 2202–2221. https://doi.org/10.1111/jocn.15728

Dahlgren, A., Tucker, P., Gustavsson, P., & Rudman, A. (2016). Quick returns and night work as predictors of sleep quality, fatigue, work-family balance and satisfaction with work hours. Chronobiology international, 33(6), 759–767. https://doi.org/10.3109/07420528.2016.1167725

Dall’Ora, C., Griffiths, P., Ball, J., Simon, M., & Aiken, L. H. (2015). Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave. Findings from a cross-sectional study of 12 European countries. BMJ Open, 5(9). doi:10.1136/ bmjopen-2015-008331

Maresca, G., Corallo, F., Catanese, G., Formica, C., & Lo Buono, V. (2022). Coping Strategies of Healthcare Professionals with Burnout Syndrome: A Systematic Review. Medicina (Kaunas, Lithuania), 58(2), 327. https://doi.org/10.3390/medicina58020327

Rogers, A. E., Hwang, W.-T., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The working hours of hospital staff nurses and Patient Safety. Health Affairs, 23(4), 202–212. doi:10.1377/hlthaff.23.4.202

Smiley, R. A., Allgeyer, R. L., Shobo, Y., Lyons, K. C., Letourneau, R., Zhong, E., Kaminski-Ozturk, N., & Alexander, M. (2023). The 2022 National Nursing Workforce Survey. Journal of Nursing Regulation, 14(1). doi: 10.1016/s2155-8256(23)00047-9

Stimpfel, A. W., & Aiken, L. H. (2013). Hospital staff nurses' shift length associated with safety and quality of care. Journal of Nursing Care Quality, 28(2), 122–129. doi: 10.1097/ncq.0b013e3182725f09