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Linking Medical Errors, Nurses' 12-Hour Shifts



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. Senior leadership should embrace these creative staffing and scheduling options to increase nurse satisfaction and improve efficiency.



40 comments on "Linking Medical Errors, Nurses' 12-Hour Shifts"
Mark Stanley (11/7/2014 at 4:38 PM)

If someone cannot handle 12 hour shifts, then they shouldn't be working them. as far as the comments about feeling bad for patients who have nurses working 12 hour shifts, you are completely ignorant. try working 5 days in a row in a hospital and tell me by day 3 your not done for the week. 12 hour shifts give a nurse more time off and more time with family. Do not post if you are not a nurse please, you don't have a clue.
Sandra Sumers (10/28/2013 at 6:36 PM)

All I can say is, when my daughter tells me she fell asleep driving on the way home from her 7PM to 7AM shift, I'm suing somebody if she gets in an accident. She has no time with her kids. She has to sleep the day before she works and recover the next day. That's a full 48 hours she has no time with her family since their hours are different than hers. There is a two year waiting list to get on the day shift, but because she is new in the field, she must work nights. This is in Houston, at a major hospital in the medical center. I'm thrilled that she is able to realize her dream of becoming a nurse, but in my opinion the hours are reprehensible.
John Smith (4/15/2013 at 10:25 AM)

My daughter like the 12 hrs. shift but I'm concern about the number of nurses accidents driving back home after the third 12 hrs. shift on top of the possible medical errors.
EMR Saves Lives (10/23/2010 at 9:34 AM)

This is common sense. Scheduling problems are notorious in hospitals and nursing homes. I feel bad for the patients and the nurses.
Kit (10/20/2010 at 2:42 PM)

The comments I have read are very interesting. Let's consider some of the science behind safety . 1-Cognitive load (CL) counts ( When RN's note: There is " too much input to cope with") This load is defined by the total patient numbers/acuity. Regular measurement of this load is recommended by laudable nursing researchers like Dr. Aiken. This load is further defined by the National Nurses United (NNU). Their nurse attorneys, scientists & 150,000 members recognize the CL challenge. The NNU also recommends system based solutions like those used in the airline industry. Moreover the NNU mandates consistent external reporting to reduce CL. <*Documenting assignment that are at risk for high CL> 2- Compassion fatigue counts ( When RN's note: There is " too much sadness to cope with") Recent data finds many fatigued staff work with patients demonstrating low Years of Productive Life Left <YPLL> . Examples of high risk units with low YPLL include ICU, palliative care, heme-onc , gero-psych & emergency departments. Staff fatigue that occurs after coping with low YPLL patients, eventually results in compassion challenges. Those challenges may be most evident towards the patients who frequently don't show medical improvement. This can compound errors in a high risk cohort. This concern for compassion fatigue extends into refugee care as well. That is, some care is too "hot" to do over an extended period. Compassion fatigue can occur readily in nursing/refugee partnerships unless there are system based approaches to reduce it. As a result, fatigue researchers would concur with previous postings. That is, they may question whether RNs can manage a high care burden five out of seven days per week. They would likely counter that the care demand in five days straight is too excessive. That would seem logical since many hospitalized populations are simply very vulnerable and needy. The likely result is that the patients and their caregivers become dysphoric regularly. In addition, this inherent compassion fatigue risk is already managed with spacing interventions within the respite care movement. The NHPCO, or the lead hospice oversight group, has noted the challenge there as well. For instance, the prevalence of major depressive disorder in hospice caregivers approaches 40%. Hospital nurses are impacted; therefore, by both the dysphoria of the patient & their caregivers. As a consequence, finding optimal hours to have good nurses care for this population is important. It is equally important to schedule respite into any safe system that patients and RNs interface with. 3- Social velocity counts ( When RN's note : There are "too many voices to hear") If you regularly add overtime, have a heavy unit or many anxious families, your RNs are likely to be fatigued. The total number of calls & 24/7 open visitation also adds to this fatigue. If the RN must manage a unit or pick up for a late desk clerk, the risks go up for the patients again. This cumulative social velocity adds to the potential for judgment errors. It is also one of the reasons that quiet rooms are being considered again for medicine distribution. Nurses need to think and they need quiet at some part of the day to do that or systemic errors will occur. 4- Environmental challenges count (When RN's note: There is "too much background distraction to focus") Recent med-surg data shows these units are above OSHA recommendations for noise. This may be exacerbated as the elders require greater numbers of telemetry, C-PAP and fall monitors. In addition, a recent Institute for Safe Med Practices (ISMP) report noted that 17,000 RNs refuted the practical nature of the CMS med administration guidelines. While the CMS guidelines were initiated with the best intentions , they added to the stress for the RN team. Human factors, like the practicality for an RN team, must always be calculated into health care standards. My summation from this research is that an RN can't provide safe direct care five days a week. It would be possible; however, to have an RN work 36 hours week one + 32 hours week two or 68 hours per pay period. That direct care aggregate should be an FTE. (Benefits eligible). In addition, this schedule would allow for some 8 & 12 hour options. Unlike employees who deal with retrospective data, the RN must use iterative judgment and act expeditiously under stress. As a consequence, I argue that additional time beyond 68 hours should be used towards passive duties. These RN projects could still benefit the patient if they included meetings, precept development & oversight for novice MDs. ============================== The central challenge is we need to keep a nursing body. An additional challenge is that nurses & American patients in aggregate are aging. As a result, we need to keep pace with new safety data. I ask my colleagues to offer other suggestions for improving the total nursing representation in that care number. From my perspective, a few cost sensitive safety strategies could be considered to help the already burdened teams: a- The hospitals should consider LPN training to improve chronic care. b- EMTs should be allowed to help RNs on acute units. c- RRTs should be mandated to assist with challenging interventions d- Nursing ratios be mandated with outlier hospitals surveyed more frequently. Thanks in advance for reading & wishing you all the best, kit, FNP-c MPH
lorayne Embretson (10/15/2010 at 3:12 PM)

I have worked 12-hour shifts for 15 years or more and love it. I worked 12's in ED for the same amount of time and would never go back to 8's. Recently I went from 12 hours/day in a busy unit as an RN to a temporary desk computer job w/ 8-hour days/ 5 days/wk. I hated it! I went to four 10's and am doing that now but still prefer my 12-hour shifts. The article stated, "Twelve-hour shifts are a relatively new invention, however, and nurses used to be just fine working eight-hour shifts." What an antiquated view of nursing and how disrespectful to say it was "just fine." It wasn't just fine. Nurses want the choice to have extended time away from the stressful situations and fast paced work environment. Just because hospitals now feel a need to change the shift hours, nurses are once again asked to change. We changed to 12's due to hospitals inability to staff up and most of us like and do well with it. Not everyone has the stamina to do 12's but that is a situation that could be solved with flexibility; however we know that hospitals are not known for their willingness to change for the benefit of nurses unless they are forced to do so. I would like to see studies on 12 hour shifts when the staffing is appropriate, there is no overtime asked of nurses for a year or more, adequate equipment & supplies & pharmacy and housekeeping needs without running, calling and begging for it and Drs. that are respectful and work as a team. Maybe some of these factors should be addressed first, before you start hacking away, once again, at something the nurses have.
Tara (10/11/2010 at 7:16 PM)

I think another point to bring up is that most RNs who work 12 hour shifts have a second job or do constant overtime. So they are not only working a typical 36 or so hour work week and then enjoying their time off, they are taking on more work. But aside from fatigue caused long hours, short staffing in my opinion is by far the biggest cause fatigue. Pushing nurses to their absolute limit for their entire shift is shortsighted, unhealthy and can be dangerous for all.
Bongajum Anastasia (10/11/2010 at 2:47 PM)

In my opinion the issue of the duration of the shift is just looking at half of the problem.In our African context the number of patients under the care of a single nurse is a serious issue.For example in my country cameroon there are settings with the twelve shifts for two days and two days off.And in each twelve shift you are entitled to 15 patients amongst which you have seven who are critically ill and need an hourly monitoring.you do the vital sign checks,you plan administer and chart treatments of each patients.at the same time you receive and set All Iv lines for incoming patients,give nursing education bedside care etc.all this don by a single nurse as she has been programmed to run the shift alone.and by the time she ends the day she is already like vegetable.This consequently is a cause of nurse's errors. Please would want to know what is the nurse- patient ratio and how hospital nursing task are to be distributed.Thanks
Bongajum Anastasia (10/11/2010 at 2:39 PM)

In my opinion the issue of the duration of the shift is just looking at half of the problem.In our African context the number of patients under the care of a single nurse is a serious issue.For example in my country cameroon there are settings with the twelve shifts for two days and two days off.And in each twelve shift you are entitled to 15 patients amongst which you have seven who are critically ill and need an hourly monitoring.you do the vital sign checks,you plan administer and chart treatments of each patients.at the same time you receive and set All Iv lines for incoming patients,give nursing education bedside care etc.all this don by a single nurse as she has been programmed to run the shift alone.and by the time she ends the day she is already like vegetable.This consequently is a cause of nurse's errors. Please would want to know what is the nurse- patient ratio and how hospital nursing task are to be distributed.Thanks
zuriel (10/11/2010 at 12:29 AM)

Let nurses in the trenches make this decision.studies show what studies want.With the 7.5H SHIFT and short staff i have seen nurses work constantly for 3-4 days at a time for AS LONG AS 12h to complete there work. I have seen RNs work overtime on a consistent bases and are still CONSISTENTLY the best RNs I know.Did this study take into account all factors .I AM A GOOD NURSE IF I DO 7.5 OR 12.5H SHIFT I AM DEDICATED I LOVE WHAT I DO.MAYBE its not the hours but the pressure on RNs these days to obtain higher education mixed with family life and the threat of a poor economy.Question is what next ? a cap ,all white and apron.I AM FOR THE 12H SHIFT History has shown flowed studies in the past.Question why did the 12h shift stared again?
Tim (10/9/2010 at 8:53 AM)

"the reasons to change to 12 hour shifts were, 1-continuity of care," Ronnie, I don't see how there IS better continuity of care. For 8-hour shifts, a patient will see nurses stay with him or her over a greater number of days, who will have had more opportunity to follow their story. On 12s, a pt can get a whole new set of nurses every few days. Nurses on 12s typically work 36 hrs, but on 8s, 40 hrs; which means over the course of a week a pt will see 11% fewer nurses if they are on 8 hr shifts than if they are on 12s.
Tim (10/8/2010 at 3:48 PM)

Continuity of care is a fiction. Over the course of a week, a patient still has the same number of nurses. They have each one for a longer stretch during any given day with the 12 1/2 plus hour shift, but switch nurses from day to day more often. In fact, the 8-hour based system (40 hr/wk) ensures 11% more time with each nurse in the course of a week than does a 12 hour system (36 hr/wk).
ronnie mitchell (10/8/2010 at 2:00 PM)

i have been in the health care proffesion since 1981 when i started as a cna. i remember when most shifts were 8 hour, which changed to 10 hour shifts. the reasons to change to 12 hour shifts were, 1-continuity of care, and 2-being able to have more than 2-3 days off in a row to relax and recreate. i am 59 years old, i spent over ten years as a lpn/lvn on an ortho/neuro; and a combined 17 years,in the e.r., and i.c.u. when i was younger it seemed that i had a lot more energy. now i have more knowledge, but just not able to physically, and emotionally work, do my best, and actually feel content,relaxed with working 12+ hours. i agree that i would like 8 hour shifts, just to be able to return to emergency medicine. i now do 12 hour shifts in a home setting.
Tim (10/8/2010 at 1:44 PM)

"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." Regardless of "generation", everyone seeks a happy balance between work and personal life. There is no 12 hour shift, but rather a 12 1/2 hour plus one. Flexibility is always good, but I agree with CV Compton Shaw, the second commenter, that there are natural limits to what we can do. Inadequate sleep is inevitable when working consecutive 12 1/2 hour plus days. Just one night of 4-hour sleep, or consecutive nights of 5 or 6 hours, in healthy people raises insulin resistance the following day. Poor sleep messes with other hormones, too, such as the adrenal hormones. Jammming the workweek into 3 long days with 2 short nights in between amplifies the high stress of nursing. Then, at least where I work, most RNs working 12 1/2 + days buy the cafeteria lunch, which damages their health further, along with the toxic edibles that people share or buy for themselves as rewards and treats. We have little sense about how to care for ourselves. The wisdom of taking time to de-stress, getting a good night's sleep, and eating wholesome food is obvious and timeless. It escapes most of us, however, which means we need to set some limits that will support us, and not undercut us, in this work. Night shift is also difficult on most people, since it's so out of sync with the diurnal rhythms of nearly everyone. What I would like to see is for the day shift to work slightly (1/2 hour to 1 hour) longer and the night shift slightly shorter for the same daily pay. Instead of giving the night people a higher total amount, give them a shorter workshift. Higher pay for night work doesn't get them less stress or more sleep.
Holly L. Sherlock RN PhD (10/8/2010 at 10:56 AM)

No nurse should ever be forced to work 12h shifts or or have to quit their job. Hospital and nursing leaders need to be on the cutting edge of this new trend. Want to cut back on the nursing shift? Eliminate mandatory 12h shifts and offer flexible work schedules. If people want to do it, fine, but they should never be forced. It has implications in many aspects to do so.
n (10/8/2010 at 2:20 AM)

Employers have to take accountablity and responsibility for the hours of work offered, so they have to review their priorities regarding employee happiness vs customer needs eg safety and continuity of care! In some cases this may be a very difficult debate!
Deb Andelt (10/7/2010 at 12:38 PM)

The range of comments reflect we all have different ways we work at our best, and each person wants a schedule that work for them. This mirrors the results of our recent research on what creates a healing environment for staff. The key finding was the need to shift from primarily caring for others to primarily caring for self in 5 Dimensions of self-caring. One dimension is processes. Shifts and schedules are basically business processes. When self-caring is the keystone of the process strategy, the likely result would be options so that each person can work in a way that works best for them. That's self-caring. Self-caring is what allows us to be present to serve others - whatever our role is. We can't give what we don't have.
D. STEVE (10/7/2010 at 11:32 AM)

I work 8hr shifts currently and I dislike it so much. I think that nurses should be given the option to work 8hr or 12hrs. I personally feel fatigued from working 8hrs due to my units patient care demand. I think everyone has their opinion about this 8-12hr shift discussion but I dont think that it really makes a difference in regards to errors. I say this because you still make errors working 8hr shift you get tired from that as well you're at work 5 out of 7 days. You have other responsiblities you get tired and then you only have 2 days out the week to try to recuperate from working. You still get tired.
Karen D (10/7/2010 at 11:06 AM)

12 hour shifts were around sometime ago and I remember discussing with colleagues in critical care the time it took to recover from their 12 hours to enjoy the other days off. Having worked both- I have been saying for at least 5 years now- not many other professions or professional people get out of college and get to work 12 hour shifts and only 3days a week- most people go to work 5 days a week to do their job. Why should nurses be any different. We promote patient safety yet we are so reluctant to give the 12 hr shift up for safety of both the nurse and the patients. I would like to see more studies on what it does to the nurses' body as well as the toll it takes on families- you don't see your kids before you leave for work and you don't get much of any time with them once you come home when doing a 12 hour shift. Yes we need more flexible staffing. It might even keep more nurses in the work force if they could do say a 4 hour shift 5 days a week or even 6 or fill in with a mix of 10 and 4 hours. People talk about the expense but in the end it could save or at least come out even when you consider the cost of the errors and what we are doing to our health.
JaHall (10/7/2010 at 10:36 AM)

I find it very offensive when those who are not in the trenches would like to dictate a nurses' work hours and flow. Its the hours NIGHT SHIFT and the patient load that accounts for more errors. Rather than try to get rid of a work time that helps the majority of nurses, why don't you work on real issues such as mandatory overtime and dangerously heavy patient loads.
Karen Carano (10/7/2010 at 8:14 AM)

Many nurses have remained in nursing because of the flexibility of the 12 hour shifts. In fact, the shift was created to keep nurses working and to encourage people into the field of nursing during a period of severe nursing shortage. There is not a nurse I know that wants to give up the 12 hour shifts. The leadership should look for other sources of errors, quality, care, and stress. They are numerous in this economy as administrators try to cut corners.
narmin halani (10/7/2010 at 5:00 AM)

I loved 8hr shifts before my unit went to 12hr shifts and I was given the option of work 'em or leave! with 8hr shifts was able to provide extended continuity of patient care! In my simple mind it seems like: 8hr shifts put patients' needs first. 12hr shifts puts the nurse's needs first. have a lovely weekend!
Florencia Trinidad (10/6/2010 at 8:36 PM)

What makes nurses fatigued are patient acuity and the number of patients they have in a given day, not the 12 hour shift.Where I am working, a lot of nurses are satisfied working 12- hour shifts. They work 13 days every 4 weeks instead of 20 hence saving travel time and preparation to go and come home from work,save gas and tolls,and more time for their families,less paperwork since since you are required to write same amount when you work 13 days as when you work 20.If you work overtime without pay, at least you work 13 times for 12 hours as compared to 20 for an 8 hour shift.Nurses gets fatigued if they work 12 hour shift back to back for 3or 4 days.Some nurses also spend the rest or some of their day off working at other hospitals or other places.
susan (10/6/2010 at 7:52 PM)

Unfortunately, some nurses that switched to 3/12 hour shifts also started working per diem at another job on off days...that's why some of them are really tired.
FREDDIEMAC1 (10/6/2010 at 6:32 PM)

Agree with others about more reasonable RN: PT ratios. I have worked both 12 and 8 hour's shifts for over 11 years. I personally like and believe 12 shifts are better for me, and have less fatigue because I then have four days off to recover and get away from the high stress. An excellent manager/director will allow and offer 8 and 12 hour in addition to flex shifts for their staff. Non-progressive Managers only allow 12 or only 8 hour shifts.(because it is harder to cover all of the shifts). I will fight till the end to keep 12 hour shifts!!
Dennis Hawkins (10/6/2010 at 5:05 PM)

I think a better solution would be to mandate fewer patients for nurses with adequate CNA support. Most of the job is paperwork. If it goes to 8 hour shifts, then now you have to get all your paperwork done in 4 hours less time.
Jeremy D (10/6/2010 at 4:39 PM)

I would be fine if our shifts were 8 hours and we were still paid the same as a 12 hour shift! RN's are under paid, that's for sure. Maybe if the hospitals weren't strapped with all of today's regulatory expenses, legal fee's, and Obamacare non-reimbursment, they could raise salary ranges based on merit and bring our shifts down to 12. Also maybe RN's in hospitals should get a % of provider billing, since we are part of the so called "inter-disciplinary team!"
Rachel Daugherty (10/6/2010 at 2:45 PM)

Years ago, I was told by management that due to the nursing shortage, staffing levels would be improved if the shifts went to 12 hours instead of 8 hours. It took more nurses to staff three 8 hours shifts than it did 2 twelve. At the time, I could not tell a difference and yes there were times I still had to stay over to ocmplete the documentation for my shift. Whatever we do let's not go back to the days of 12-20 patients per RN.
Mike Colley (10/6/2010 at 2:01 PM)

Afew key questions to ask. What is wrong with the nurses assigfnment that they need to stay over to complete documentation? What makes you think that this will still not occur with an 8 or 10 hour shift? Regardless of the amount of hours in a shift hospitals need to develop effective means to assure adequate staffing. One of the factors inhibiting flexibility in schedule is having to punch a time clock. Is this the hall mark of a profession punching a time clock.
Anne Creamer (10/6/2010 at 1:44 PM)

I agree with the article. One of the main points the author made was that there should be more fexibility in shift length. When I was younger, I was able to do 12-hour shifts in the ER, but that became harder as the years went on. Fortunately, I was able to choose either 4, 8, or 12 hour shifts (and we had self-scheduling as well) thanks to enlightened management. Mandatory 12-hour shifts have caused many experienced RNs to leave clinical care, which is a great loss to the profession.
Jeremy Engdahl-Johnson (10/6/2010 at 11:56 AM)

Does disclosure of medical errors lead to more lawsuits? http://www.healthcaretownhall.com/?p=3012
TLloyd (10/6/2010 at 11:53 AM)

One of the reasons I love being a nurse is the 12 hour shifts. It allows for good work life balance. I like my schedule and I certainly hope a group of adminitrators don't take this away. There are many opportunites to make nursing less tiresome. We should be working smarter not harder. There are many places where nursing can be made more efficent. The problem is the bedside nurse is not invivted to the table to discuss these topics. Typically, these discussions are lead by nurse administrators who have not touched a patient in 20 years. How about "Undercover Boss" - go down in the trenches and see for instance, the double documenting, how long it takes to get a call back from a primary care doctor, how many calls to pharmacy it takes to get a med, and how poorly the floors are organzied for starters. These are the things that make us tired - not the hours.
Susan Casadone (10/6/2010 at 11:29 AM)

I cannot argue that 12 hour shifts are both physically and mentally exhausting but the majority of nurses would oppose any effort to eliminate these shifts. The nurses have built their lives and their family needs around these shifts. Good or bad many use the days off to go to school, tend to family issues and work at a second job. I don't know if shorter shifts, with more frequent turnover of patients is really much safer. Every time a patient is endorsed over to another nurse the chance of important information being omitted or miscommunicated increases.
Joshua BSN,RN (10/6/2010 at 11:16 AM)

Michael, I don't think Mr. Martinez meant to slam nurses with his comment. I am a RN and there are times the work can be monotonous or tedious such as: filling out the same information in multiple areas of a medical record, routine daily tasks such as CBGs and insulins - similar judgement is required but millions of Americans performing this judgement daily at home without a college degree; and more often then not hospitals are attempting to override nursing judgement with policies for everything, or mandated standards instead of allowing nurses to individualize to the patient. I think Mr. Martinez was perhaps trying to say that nurses' work should be changed somewhat to fit our capacity because he said similar to medical residences it's time to look at the entire system because nurses count.
Caroline Tobin, RN (10/6/2010 at 10:59 AM)

On the other hand, working 12 hour shifts means greater continuity of care - the patient only has 2 different nurses in a 24 hour period, and possibly the same 2 the next day. Since, despite our best efforts, miscommunication during handoffs is a major source of errors (or at least of inefficiency), fewer caregivers does help ensure better patient care. I do agree that working multiple back to back 12 hours shifts is unsafe, and the number of hours nurses work both at one time and total during a given period ought to be limited.
Colette Russen (10/6/2010 at 10:58 AM)

I can't imagine having to do my high-stress job (in a busy urban ED) five days a week. With 12-hour shifts, I have time to chart and then plenty of time away from work to take care of personal things. With an 8-hour shift, it would be rare ro get two days off in a row, since we have mandatory weekend shifts. The only time I'd have off with my family would be two weekends a month, since I would probably work an evening shift like I do now.
Kelly (10/6/2010 at 10:54 AM)

I like my 12 hour shifts and will not willingly give it up. I'm sure many other nurses would agree with me. I know what I am capable of and how much time off I need. I do not work 3 days in a row because of how exhausting it is. Granted I don't work a lot of overtime because I know my body. I am sure many people don't listen to their body and keep pulling through. $$$ signs have something to do with that. The hospitals are to blame as well. I once worked at a hospital that would pay their nurses and extra $15.00/hour to pick up extra shifts. This was in addition to the overtime pay. Working 2 or 4 hour shifts if NOT practical with the amount of work we are expected to complete.
Michael Patton (10/6/2010 at 8:16 AM)

Mr. Martinez obviously isn't a nurse. I assure you my work as a critical care nurse in a Level II Trauma ICU is neither monotonous or tedious, and requires a good deal more critical thinking than that of a factory worker.
C.V. Compton Shaw, R.N. (10/6/2010 at 7:36 AM)

Working shifts for health care providers, inclusive of nurses, should be limited, by law, to ten hours per day and fifty hours per week. To do otherwise unreasonably puts the health and well fare of both the health care provider and patient at risk. The vast majority of patients that post on line with regard to this topic favor this common sense approach. The Hippocratic Oath mandates the propositions of first of all "doing no harm" and that the health care provider should have adequate leisure and be in good health. Long working hours and long work weeks, therefore, are inimical to professionalism in health care.
Adrian R. Martinez (10/5/2010 at 5:21 PM)

It´s time to take a look in the entire healthcare team, not only residents, but nurses also count. The works of nurses sometimes could be compared with that of a factory: monotonous and tedious, therefore prone to errors.