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Linking medical errors, nurses’ 12-hour shifts


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Rebecca Hendren, for HealthLeaders Media, October 5, 2010

It's well known that caregiver fatigue is a huge cause of errors, whether the caregiver involved is a new resident coming off a marathon week or an overworked nurse pulling back-to-back shifts.

A few months ago, the Accreditation Council for Graduate Medical Education placed new restrictions on the hours residents can work and the supervision they receive. This follows years of research into new physicians' training and the effect long hours and tiredness play in performance and contribute to poor quality care. A 2004 study found that first-year residents working all night were responsible for more than half of preventable adverse events.

Nurses don't have the same extraordinarily-long work requirements as residents—and they clearly perform very different tasks—but like residents, they work long shifts and suffer from fatigue. Studies have linked nurse fatigue with medical errors, poor quality care, stress, and burnout.

There are many reasons for nurse fatigue, but one stands out as pretty easy to fix: shift length. It's no wonder that nurses are fatigued when 12-hour shifts are the norm. Despite the fact the Institute of Medicine has recommended limiting use of 12-hour shifts, it's standard practice throughout the profession. Nurses routinely work back-to-back-to-back 12-hour shifts.

At the recent Nursing Management Congress in Grapevine, TX, held September 23-25, I attended a presentation by Cole Edmonson, CNO/vice president of patient care services at Texas Health Presbyterian Hospital in Dallas. Edmonson noted that research is helping us understand the dangers nurse fatigue presents to patients and to nurses themselves. He called 12-hours shifts a dead idea whose time has passed and suggested they may cause more problems than they solve. He asked attendees whether it is time to declare the end of 12-hour shifts.

I can't imagine working a 12-hour day as a nurse. Nursing is a professional job, requiring college education and high-level thinking. But it's also manual labor. Nurses are on their feet all day, running everywhere, lifting patients, changing dressings, inserting IVs, and all the other direct patient care responsibilities.

It's no wonder that nurses are fatigued. Shifts include mountains of paperwork, difficult patients and families, and hundreds of tasks. Somewhere in all this nurses make time to connect with their patients, expressing compassion and empathy. Let's not forget that 12-hour shifts also frequently run into overtime, when the nightmare shift means they have to stay late to complete their charting.

Over the next few years, more studies will be published that show the danger of nurse fatigue. What if hospitals preempted the public outcry and started reducing 12-hour shifts now? Let's focus on shifts that are best for patients, nurses, and hospitals alike. This means ending rigidity and allowing greater flexibility. 

Senior leadership can embrace creative staffing and scheduling options that increase satisfaction for nurses and improve efficiency.

For example:

  • Staggered shifts–Nurses who want to be full time but not work more than two 12-hours shifts in a row could take two 12-hour shifts and two eight hour shifts, which gives them three days off (and five evenings) to be with family and friends each week
  • Group sharing–A group of nurses bands together and signs up for eight-hour shifts, but they match each other to ensure the entire 24 hours are covered
  • Peak-time shifts–Eight-hour, four-hour, two-hour-shifts—or any combination—make a huge difference on units during busy hours
  • Multi-task shifts–Combine roles within a regular shift, such as four-hours patient care, two hours precepting and mentoring new nurses, and two hours in committee work
  • Job sharing–Two or more nurses split a full-time schedule


Of course, one of the biggest barriers may be nurses themselves. Many like being able to work a full time job in only three days and have a long period of time off, which is especially attractive to young generation Y nurses who place high value on having a work-life balance. Twelve-hour shifts are a relatively new invention, however, and nurses used to be just fine working eight-hour shifts.

If we accept the fact that nurse fatigue is a serious issue, then eliminating 12-hour shifts seem like an obvious place to start.

Source: HealthLeaders Media