Extended Nurse Work Hours and Patient Safety: Effects and Solutions

While most healthcare organizations have eight-hour shifts, many hospitals have relied on 12-hour shifts since the 1970s. Working three 12-hour shifts is highly appealing to nurses who seek additional days off to spend with family or on other interests. But the effect of long nurse work hours on patient safety is an area of concern.

Despite the perks of a 12-hour workday, the impacts of 12-hour vs. eight-hour nursing shifts on patient outcomes can be significant. According to recent research, longer shifts for hospital nurses lead to increased errors, burnout, patient dissatisfaction, and can potentially affect nurse well-being.

Nurses worked even longer days during the COVID-19 pandemic, and some still do because of ongoing staff shortages. What is the long-term impact of extended nurse hours on patient safety, and how can hospitals ensure they’re protecting the health and well-being of both patients and staff?

Are eight-hour shifts better than 12-hour nursing shifts?

The early 2000’s watershed To Err is Human report — which found that upwards of 98,000 people died in U.S. hospitals every year due to preventable medical errors — caused many to question how long work hours correlate to patient safety. Many have since debated the topic, with a growing body of evidence suggesting that longer days may put nurses and their patients at risk.

There are distinct advantages and disadvantages associated with both eight- and 12-hour shifts, and healthcare administrators have yet to come to a consensus on whether one is inherently better than the other. In most cases, it depends on the team and workplace culture.

Benefits of eight-hour nursing shifts

When implemented effectively, an eight-hour workday can help:

• Minimize nurse fatigue — Nursing is a rewarding yet physically and emotionally demanding profession. Even eight hours on the job can be tiring compared to 12, especially when 12 hours turn into 13 or 14. In fact, studies show that nurses accrue a considerable sleep debt while working successive 12-hour shifts, leading to higher levels of fatigue that may cause mistakes in patient care.
• Prevent nurse burnout — Burnout — a state of physical, emotional, and mental exhaustion caused by prolonged stress — is a major issue in nursing. According to research, nurses working longer shifts are more likely to experience burnout and job dissatisfaction, leading to high turnover rates. With a projected shortfall of over 200,000 nurses by 2030, hospitals can’t afford to lose staff members.
• Reduce medical errors — In a systematic review of 19 studies, researchers found that the risk of making an error increased when nurses suffered from excessive fatigue and sleep deprivation. They concluded that fatigue was a significant factor in the occurrence of hospital medication errors, which greatly compromise patient safety, since medication administration accounts for up to 40% of nursing clinical activity in hospitals.
• Improve nurse well-being — Long hours and high stress levels in nursing can lead to poor health behaviors, which in turn can lead to illness and injuries for workers and even their families.

Benefits of 12-hour nursing shifts

Despite the disadvantages associated with 12-hour shifts, there are several advantages. When implemented effectively, a 12-hour workday can help:

• Increase patient satisfaction — For most patients, a stay in the hospital causes fear and uncertainty. The last thing they want during this time is to have to switch frequently from nurse to nurse, hindering their ability to form meaningful connections with the people in charge of their care. Longer shifts decrease patient handoffs — instead of three or more nurses attending to a patient during a single day, a patient may only need two nurses. Fewer handoffs translate to higher patient satisfaction ratings and fewer opportunities for miscommunication and error.
• Expedite nurse scheduling — From an administrative perspective, longer shifts can make scheduling significantly easier. Rather than scheduling three eight -hour shifts to cover 24 hours, managers can schedule two 12-hour shifts. Fewer shifts help minimize scheduling conflicts and allow managers to spend less time producing a schedule and more time on other pressing priorities.
• Improve work-life balance — For many nurses, a 12-hour workday offers more flexibility than a standard eight -hour day. While 12-hour shifts leave very little free time on workdays, they provide nurses with four full days off each week. They reduce the amount of time nurses spend commuting and provide them with more freedom for other pursuits, like raising a family, furthering their education, or even working a second job.
• Boost nurse morale — In many cases, the flexibility that accompanies longer shifts can help boost morale among nurses. But while longer shifts can boost morale and even improve retention for some hospitals, they can also lead to burnout. Hospital administrators must always pay close attention to their staff and monitor employee engagement to determine if longer shifts are helping or hindering their teams.

Do nurses prefer 12-hour shifts?

Many nurses believe that longer shifts allow them to provide better care by increasing the amount of time they spend with each patient. The more involved a nurse is with a patient during their shift, the better equipped they are to notice the nuances of the patient’s condition and side effects. These small details often help nurses provide more effective pain management and pinpoint sudden changes.

As data questioning the effectiveness of the 12-hour shift surfaced, many nurses pioneered and participated in a movement to defend their coveted schedule. With the help of nurse unions and hospital management, the movement gained traction in states like California, where legislators enacted a 2015 amendment to the California Labor Code to protect the 12-hour shift.

Though the preference for 12-hour shifts is by no means universal, employee engagement improves when nurses have a say in their schedule. Many nurses want the option of 12-hour shifts, even if they do not take that option. Hospitals hoping to recruit and retain nurses must offer schedules that meet the needs of prospective staff.

How does overtime affect nurses on long shifts?

Many concerns with 12-hour shifts are tied to nurse overtime and patient safety. It is not uncommon for 12-hour shifts to turn into 13-, 14-, 15-, or even 16-hour shifts through voluntary or mandatory overtime. With each added hour, the risk of error and nurse burnout rises.

Nurse overtime typically occurs because of understaffing, meaning that those who work beyond their 12-hour shifts are often already stretched thin. To ensure they accomplish all of their responsibilities within the span of their shift, many nurses avoid engaging their patients in friendly dialogue — a critical component of optimal patient care. Without good rapport, patients can become agitated, try to do too much without the help of their nurse, and potentially experience a fall, for example.

Because any shift, regardless of length, is likely to be accompanied by overtime because of staffing shortages, hospitals must evaluate the dangers of longer shifts. After they address scheduling concerns, administrators can consider addressing how to reduce overtime on a systemic level.

Impacts of extended nursing shifts on patient outcomes

There’s no question about it — extended nursing shifts put patients in jeopardy. According to a sentinel event alert published by the Joint Commission over a decade ago, the fatigue associated with extended shifts can result in:

• Lapses in attention and an inability to stay focused
• Reduced motivation
• Compromised problem solving
• Confusion
• Irritability
• Memory lapses
• Impaired communication
• Slowed or faulty information processing and judgment
• Diminished reaction time
• Indifference and loss of empathy

Each of these effects increases the chance of adverse events, including medical errors and patient injuries, and subsequently, lower patient satisfaction ratings.

But patients aren’t the only ones at risk. Long work hours also lead to an increase in needle sticks and other injuries, in addition to heightened psychological distress. Nurses may underestimate the toll a long shift can take on their mind and body.

Nurses who work longer shifts must spend a significant amount of time during their days off recovering from long, exhausting days at work. The extensive recovery period ultimately detracts from the quality of their time off — especially for nurses who work night shifts. Healthcare professionals working night shifts must change their sleep schedule entirely during their days off to ensure they can spend quality time with family and friends.

A high-stress, difficult work environment also interferes with a healthy, collaborative workplace culture. When nurses convey stress when interacting with colleagues, they can discourage open and honest communication and contribute to an environment that promotes lateral violence.

Improving patient safety through education and culture

As long as nurses continue to advocate for 12-hour shifts, hospitals will need to ensure that these schedules do not harm patients or create a toxic workplace culture. By prioritizing patient safety, hospital administrators can set themselves up for sustained success.

Before making any major changes, healthcare leaders should assess their existing efforts to build a culture of safety. Once they have a strong understanding of their current landscape, they can identify how to best support both nurses and patients. Concrete steps healthcare leaders can take to build a culture of safety include:

• Listening — While taking the time to listen to employees is critical in any profession, it is especially important in a healthcare setting. Leaders should set up a regular, manageable cadence of one-on-one meetings with nurses and other staff members to evaluate their caseloads and identify where they need support. Providing nurses with space to express their concerns and frustrations also encourages communication, increasing employee engagement and patient satisfaction.
• Promoting continuing education — Every nurse enters the workforce with a slightly different level of experience and educational background. By regularly assessing their employees’ skills and taking steps to fill knowledge gaps through quality continuing education, leaders can ensure that their nurses have the skills they need to improve patient safety.
• Reviewing staffing practices — Overtime is one of the leading causes of compromised patient safety. Shifting the culture around overtime should be a top priority for hospitals looking to reduce employee fatigue and protect their patients. Instead of resorting to extended hours to address staffing issues, leaders should strive to create a better balance of permanent and contingent staff, improve float pool management, expand online staffing capacity, implement systems to optimize operations, and adopt technology-enabled forecasting of patient demand and staffing needs.
• Adopting a safety mindset: The most important step that healthcare leaders can take to improve patient safety is adjusting their mindset. Studies show that transforming a hospital culture requires a transformation of priorities. Shifting from a system designed to get the most out of nurses to emphasizing patient safety above all else is critical — even if it costs more to do so.

Build a culture of patient safety

Transforming your hospital culture to encourage patient safety can be challenging. Relias has the tools you need to confidently begin this journey. Our extensive array of resources will help ensure that your entire team is equipped to provide the highest quality care to boost patient satisfaction and employee retention.