The 12 Hour Shift - Will We Keep Ignoring the Evidence?

By Rose O. Sherman, EdD, RN, FAAN

“Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.” John Adams

In a blog last year on the dilemma with the 12 hour shift, I talked about how in politics, the term third rail is a metaphor for any issue so controversial that it is considered to be highly”charged” and “untouchable”. Social Security in the United States is an example of a political third rail. Anyone who dares to discuss these third rail topics will receive enormous push back. The 12 hour tour is nursing’s third rail. Nursing leaders have concerns about the widespread use of 12-hour tours and their impact on patient safety. Today’s nursing workforce grew up with the work-life balance freedoms that the 12-hour tour provides. In my discussion with students under the age of 40, they can’t imagine not working a 12 hour tour, because it is all they have ever known. Any discussion of their elimination or reduction evokes passionate arguments on both sides of the issue. Yet the evidence about the downsides of the 12 hour tour continues to grow.

Recent Research

In the November 2012 issue of Health Affairs, a research team led by Dr. Linda Aiken at Center for Health Outcomes and Policy Research published a study that looked at the length of a nurse’s shift, level of nurse burnout, nurse satisfaction and patient dissatisfaction. The study sample included 22, 275 nurses working in 577 hospitals in four states. Sixty five percent (65%) of the study sample worked 12-13 hour shifts, 26% 8-9 hour shifts and the remaining nurses worked either 10-11 hour shifts or more than 13 hours.

In this article, it is pointed out that although many nurses work 12 hour tours, these tours frequently extend to 13+ hours because of the unpredictability in patient care needs. In addition, many nurses work on their days off to supplement their family income. There are currently no national work-hour policies for registered nurses as there are in other industries where safety is a major concern.

Their major findings included the following:

The majority of nurses (80%) were satisfied with scheduling practices at their hospitals.
Increases in shift length were significantly (2 1/2 times more likely when the tour exceeded 9 hours) associated with increased burnout, job dissatisfaction and intent to leave.
When nurses shift length was compared to HCAHP scores – having higher proportions of nurses working 8-9 or 10-11 hour tours resulted in fewer reports of patient dissatisfaction with care.
When nurses worked beyond 13 hours on a tour burnout, job satisfaction, intent to leave and patient satisfaction were significantly impacted in a negative direction.

Where do we go from here?

A recurring dilemma in evidence-based nursing leadership is what to do if we have compelling evidence to support a practice but choose not to implement it because of staff values or preferences. We know from other research that nurses who work 12 hour tours average only 5.5 hours of sleep between tours, and are 3X more likely to make errors as opposed to those on 8 hour tours. We also have evidence that the mortality of patients with selected conditions like pneumonia is increased in units/hospitals with 12 or more hour shifts. Patient safety is clearly being compromised but nursing staff prefer the 12 hour tour. Nurse leaders ,while aware of the evidence, want to avoid the conflict that a change would bring. Nurses themselves acknowledge that there are issues with the 12-hour shift but are reluctant to change their lifestyle. So the dilemma is where do we go from here. This can’t be nursing’s third rail. It is really up to nurse leaders to talk with staff about the issues involved with 12-hour tours which include nurse fatigue, patient safety, staff burnout and now patient satisfaction. With Medicare reimbursement now tied to HCAHP scores, there is also now a strong business case that needs to be considered. There may no perfect solutions to this dilemma but the conversation needs to begin.

Read to Lead

Geiger-Brown, J. & Trinkoff, M. (2010). Is it time to pull the plug on 12-hour tours: Part 1. The evidence. Journal of Nursing Administration, 40 (3) 100-102.

Montgomery, K.L. & Geiger-Brown, J. (2010). Is it time to pull the plug on 12 hour tours: Barriers to change and effective leadership strategies. Journal of Nursing Administration. 4(40), 147-149.

Stimpfel, A.W., Sloane, D.M. & Aiken, L.H. (2012). The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs, 31(11), 2501-2509.