Toni, toni
i want the article attached to be summarize
viewpoint
How do 12-hour
shifts affect
ICU nurses?
A review of the literature shows mixed results from nurses work
ing 12-hour shifts. However, many nurses report improved patient
care, greater job satisfaction and better safety from working these
extended shifts.
By David Aveyard
Twelve-hour shifts for hospital-based nurses have been used in New Zealand since the 1990s to enhance staff retention and
recruitment, and provide greater fle xib ility
for rostering. Recently, some district health
boards have removed 12-hour nursing shifts
from hospital wards w ith ou t sta ff consultation
and have signalled th a t intensive care units
(ICUs) may be next.
Why is there such a negative attitude
towards 12-hour shifts in nursing? Does i t
relate to the cost of replacing staff for sick
and annual leave, or maybe concerns for staff
and patient safety, and are these views and
concerns based on research?
I work in an ICU where both eight and 12-
hour shifts are worked. Twelve-hour shifts were
introduced to this ICU in the late 1990s, after
consultation with staff, to provide greater
fle x ib ility and staff retention. Staff view
them very positively. I decided to conduct a
literature review to establish what positive
and negative impacts 12-hour shifts have
on ICU nurses and th e ir patients, and what
evidence there was to ju s tify continuing or
removing 12-hour shifts from the ICU nursing
roster. Only articles th a t were research-based,
published in a peer-reviewed nursing journal
and relating to hospital ICU nursing, patients
and 12-hour shifts were selected.
Nurses are the largest workforce in hospitals
and are monitoring and caring for patients
24 hours a day, seven days a week. Since the
1960s, a nurse’s working week has undergone
numerous changes in response to nursing
shortages, rising health costs and funding cut
backs^ The introduction o f 12-hour shifts and
flexible shifts for nurses was a way of address
ing these issues, and an attem pt to increase
nurse retention and attract new nurses to the
profession.., Some research has identified th a t
accommodating flexible work hours for sh ift
workers benefits the employer by increasing
nurse recruitment and retention.
Shift work’s negative impacts
The negative effect o f s h ift work on employ
ees is well documented in all industries. Shift
work has been described as detrimental to
an individual’s health, causing disruptions to
th e ir circadian rhythms, altered activity-rest
patterns, increased stress levels, and creating
issues w ith social and domestic life.. Humans
are designed to work during daylight hours
and sleep at night, and any work outside
these daylight hours causes disturbance to
the body’s internal clock and affects normal
function. I t is, therefore, d iffic u lt to identify
whether i t is the sh ift length or sh ift work
its e lf which negatively affects workers’ health
and well-being.
Research relating to 12-hour shifts for
nurses has been conducted internationally
since the 1970s, w ith both negative and posi
tive results relating to nursing perceptions
and patient outcomes. During the 1980s, in
the United Kingdom (UK), 12-hour shifts were
forced upon many nurses working in hospitals
w ithin the National Health Service (NHS),
w ith ou t consultation. During this period, UK
research relating to 12-hour shifts was very
negative for both patient outcomes and nurse
perceptions.., However, authors aLso id e n ti
fied th a t, when 12-hour shifts were voluntary,
patient and nursing outcomes were more posi
34 Kai Tiaki Nursing New Zealand * vol 22 no 11 December 2016/January 2017
Twelve-hour shifts not only improved th e function o f th e ICU bu
and other health-care professionals.
tiv e .7g During the same period, international
research was more positive about 12-hour
shifts for both ICU and general ward nurses
and patients. Since 2000, there has been
an increase in research relating to 12-hour
shifts in the ICU and its effect on nurses and
patients.
Increasing job satisfaction
Job satisfaction is im portant for staff reten
tio n , recruitment and patient care, and there
appears to be a correlation between 12-hour
shifts in the ICU and jo b satisfaction. A study
in to the fatigue of nurses in a surgical respira
tory ICU community hospital in the United
States (US) found a positive correlation be
tween 12-hour shifts and jo b satisfaction^ A
study on a 12-hour s h ift tria l in a regional ICU
in Australia found nurses had a 58 per cent
increase in work satisfaction and 92 per cent
identified th e ir preference for 12-hour shifts.3
Others have noted th a t the way a s h ift change
was introduced and implemented affected the
success of the change.5
In 2000, the UK Department of Health com
municated to NHS hospitals th a t staff with a
good work-life balance would increase perfor
mance and provide improved patient care.10
Research relating to 12-hours shifts in the ICU
reflected very positively on nurses’ o ff duty,
family and sociaL life. Researchers distributed
questionnaires three months after the in tro
duction of 12-hour shifts in an NHS hospital
of respondents spent less time recovering be
tween shifts and 67 per cent fe lt less drained
after a 12-hour s h ift.3 Others identified no
significant difference in feelings of fatigue
between 12-hour and eight-hour shifts – any
possible difference was related to s h ift pat
tern, not s h ift length, with fatigue higher at
the end o f the shift, compared to the begin
ning, for b o th.j Focus groups and question
naires o f critica l care nurses from three ICUs in
the NHS found 12-hour shifts had a negative
impact on motivation and increased tired-
ness.10 One study identified there were more
symptoms o f fatigue and d ifficu lty concentrat
ing with 12-hour shifts, whereas another
found th a t ICU nurses were tired at the end
of a 12-hour shift, but the tiredness did not
relate to the s h ift its e lf but to other factors
outside work.10
Decreased nurse vigilance
im proved com munication and documentation between nurses
ICU with eight beds.n They found these shifts
provided better fle x ib ility and th a t 71 per cent
o f nurses fe lt they enhanced th e ir off-duty
time, compared to eight-hour shifts, w ith 85
per cent wanting to keep 12-hour shifts.
In the Australian study, 92 per cent of
respondents fe lt 12-hour shifts gave greater
fle x ib ility in their personal lives and 83 per
cent fe lt they had more tim e to spend with
th e ir families. A study o f 54 critica l care
nurses in a large NHS hospital examined their
perceptions o f 12-hour shifts. They said 12-
hour shifts improved off-duty time, with more
staff available to cover shifts and overtime.
Fatigue is commonly associated w ith sh ift
. . . authors also id e n tifie d th a t,
when 1 2-h o u r shifts were volun
tary, p a tie n t and nursing
outcomes were more positive.
work and extended working hours. I f fatigue
is prolonged, i t can be irreversible and may no
longer be resolved by the body’s normal coping
mechanisms.6 There appears to be no correla
tio n between 12-hour shifts and nurse fatigue,
nursing performance or critica l thinking.
Fatigue appears to be a problem associated
w ith sh ift work in general, rather than with
12-hour shifts specifically.
One group o f researchers found 58 per cent
In a more recent study, questionnaires on 12-
hour shifts, fatigue and “decision regret” were
sent to members of the American Association
of Critical Care Nurses.13 Twenty-nine per cent
of respondents reported decision regret, an
increase in fatigue, daytime sleepiness, poor
sleep quality and less in te r-s h ift recovery
with 12-hour shifts. 3 In an earlier American
study, log books were mailed to critica l care
nurses asking for inform ation, such as hours
worked, tim e of day worked, overtime, days
off, sleep-wake patterns and errors or near
misses. The study identified a correlation
between s h ift length and an increase in errors,
near misses and decreased nurse vigilance. The
majority o f responders worked 12-hour shifts
but some worked 16-24-hour shifts. Other
researchers identified th a t, due to the lack of
national work hour policies in the US, nurses
often worked overtime and found a correla
tion between sh ift length extension and nurse
burnout.
Due to different employment laws and
the structure o f the US health-care system,
research results relating to 12-hour shifts and
extended shifts may not always be transferable
internationally. Comparisons can, however, be
made between the New Zealand setting and
results from studies conducted in Australia
and UK, due to the sim ilarity of health-care
structure and employment laws.
The study in Australia identified th a t 58
per cent of nurses fe lt they obtained the right
amount o f sleep on 12-hour shifts, compared
to 17 per cent on eight-hour shifts. Another
found there was a decrease in sick leave
taken. In the Australian study, 75 per cent of
participants fe lt there was a decrease in sick
leave taken, with all nurses feeling less tired,
therefore less likely to take sick days. A UK
study found no noticeable difference in sick or
absence rate.
A later UK study identified there was an
improvement in the quality o f nurse handover
due to an increased knowledge of the patient.
This was because more tim e was spent with
patients, with only two handovers in 24 hours,
and more tim e was given to the handovers.10
In the Australian study, 12-hours shifts not
only improved the function o f the ICU but
also improved communication and documenta
tio n between nurses and other health-care
professionals. This was due to nurses spend
ing more tim e getting to know th e ir patients
during a 12-hour sh ift. A much earlier study
in New Jersey, in the US, found th a t 53 per
cent o f nurses questioned fe lt 12-hour shifts
decreased communication relating to u n it and
hospital business, due to extended tim e o ff
between shifts.
While one study found 12-hour shifts had a
92 per cent positive impact on nurses’ physi
cal and psychological well-being,3 another
found ICU nurses caring for patients who
were in isolation, or seen as difficu lt, experi
enced more challenges when working 12-hour
shifts.1Q The impact o f 12-hour shifts on
education, mentorship and preceptorship was
mixed in the studies reviewed. One found th a t
75 per cent of participants reported they had
more tim e for study,3 whereas others id e n ti
fied lim ited impact on education, mentorship
or preceptorship.10 Nurses in another study
found 12-hour shifts less favourable for nurse
education. Much of the literature showed a
positive correlation between 12-hour shifts
and staff retention. The Australian study
found th a t 75 per cent of participants fe lt
12-hour shifts were beneficial for sta ff reten
tion and 67 per cent fe lt they were good for
recruitm ent^
Improving patient care
The most positive outcome perceived by ICU
nurses working 12-hour shifts was an improve
ment in patient care.12 Other studies have
identified further positive aspects, such as
improvements in nursing performance and skill
level, and communication between health-care
professionals about patient care.3 g 10
ICU nurses fe lt 12-hour shifts increased
continuity of patient care.3 Nurses also fe lt
they had more tim e to plan and prioritise
care, document interventions, and perform
and complete patient cares.10 Twelve-hour
shifts also enabled nurses to provide more
directed and holistic care, and enhanced the
therapeutic relationships w ith the patient
and th e ir family, due to nurses spending more
Kai Tiaki Nursing New Zealand * vol 22 no 11 * December 2016/January 2017 35
viewpoint
time at the bedside.3 Suggested reasons for
this increased quality o f care were th a t nurses
knew th e ir patients better, had extended
opportunities to monitor and provide direct
patient care, and there was better pacing of
care and workload.
Conclusion
During the last 40 years, nursing sh ift patterns
have changed. Some have been voluntary,
whiLe others have been forced upon nurses by
hospital management. These changes often oc
curred due to nursing shortages, rising health
costs and funding cutbacks. Changes such as
12-hour shifts are now seen as the standard
sh ift length in many ICUs around the world,
including New Zealand.
Since the 2000s, studies on 12-hour shifts
in ICUs have increased. However, they have
generally been of a small sample size and
conducted from a nursing perspective. This
review has revealed some negative results, but
positive results relating to patient outcomes
and nursing perceptions have predominated.
The positive results include increased patient
care and continuity of care, improved nurse/
patien t/fam ily relationships, better rostering
and work-life balance, reduced sick leave and
increased jo b satisfaction. Twelve-hour shifts
in ICU also improve staff retention and recruit
ment, increase nurses’ knowledge about their
patients, and improve the quality o f patient
handover, w ith nurses being more likely to
leave work on time.
Negative results include an increase in nurse
fatigue, decreased sta ff communication about
u n it and hospital business, difficu lty in caring
for patients in isolation, and fewer educational
opportunities. These negative findings can
also be attributed to other factors such as the
workplace environment, s h ift patterns, work
load, staffing, and external influences, such as
personal life, which are not always the direct
result o f 12-hour shifts.
Overall, this literature review has shown
th a t 12-hour shifts in the ICU are a very
positive, productive and safe sh ift length for
nurses, patients and hospital management. The
evidence suggests these shifts should continue
and th a t any changes management makes in
sh ift pattern or length w ill only be effective
i f thorough and careful consultation occurs
with all parties. This review has also revealed
a need for larger-scale research relating to
12-hour shifts in the ICU, from both a nursing
and patient perspective. •
David Aveyard, RN, BN, MN, is a staff nurse at
Waikato Hospital’s intensive care unit.
References
1) Fields, W. L., & Loveridge, C. (1988). Critical thinkin g and fatigue: How do nurses on 8- & 12-hour shifts compare? Nursing Economics, 6(4),
189-191.
2) Lorenz, S. (2008). 12-hour shifts: an e th ica l dilemma fo r the nurse executive. The Journal o f Nursing Administration, 38(6), 297-301.
3) Dwyer, T., Jamieson, L., Moxham, L., Austen, D., & Smith, K. (2007). Evaluation o f the 12-hour s h ift tria l in a regional intensive care u nit.
Journal o f Nursing Management, 15(1), 711-720.
4 ) Stone, P. W., Du, Y., Cowell, R., Amsterdam, N., Helfrich, T. A., Linn, R. W., Gladstein, A., Walsh, M., & Mojica, L. A. (2006). Comparison o f
nurse, system and quality patie nt care outcomes in 8-hour and 12-hour shifts. Medical Care, 44(12), 1099-1106.
5) Smith, L., Folkard, S., Tucker, P., & MacDonald, I. (1998). Work s h ift duration: a review comparing e igh t hour and 12 hour s h ift systems.
Occupation and Environmental Medicine, 55, 217-229.
6) Keller, S. M., & Berryman, P. (2009). Effects o f extended work shifts and s h ift work on patie nt safety, productivity, and employee health.
AAOHN Journal, 57(12), 497-502.
7) Todd, C., Reid, N., & Robinson, G. (1989). The quality o f nursing care on wards working e igh t and twelve hour shifts: a repeated measures
study using the MONITOR index o f quality o f care. Inte rn atio n al Journal o f Nursing Studies, 26(A), 359-368.
8) Reid, N., Robinson, G., & Todd, C. (1993). The qua ntity o f nursing care on wards working 8- and 12-hour shifts. In te rn atio n al Journal o f
Nursing Studies, 30(5), 403-413.
9) Ugrovics, A., & Wright, J. (1990). 12-hour shifts: Does fatigue undermine ICU nursing judgments? Nursing Management, 21(1), 64A-64G.
10) Richardson, A., Turnock, C., Harris, L., Finley, A., & Carson, S. (2007). A study examining the im pact o f 12 hour shifts on critica l care
staff. Journal o f Nursing Management, 15(8), 838-846.
11) Richardson, A., Dabner, N., & Curtis, S. (2003). Twelve-hour s h ift on ITU: nursing evaluation. Nursing in Critical Care, 8 (3 ), 103-108.
12) McGettrick, K. S., & O’Neill, M. A. ( 2006). Critical care nurses – perceptions o f 12-hr shifts. Nursing in Critical Care, 11(A), 188-197.
13) Scott, L. D., Arslanian-Engoren, C., & Engoren, M. (2014). Association o f sleep and fatigue w ith decision regret among critica l care nurses.
American Journal o f Critical Care, 23(1), 13-23.
14) Scott, L. D., Rogers, A. E., Hwang, W., & Zhang, Y. (2006). Effects o f critic a l care nurses’ work hours on vigilance and patients’ safety.
American Journal o f Critical Care, 15(1), 30-37.
Evidence mounting against 12-hour shifts – NZN0 reseachers
EVIDENCE IS mounting against 12-hour shifts,
according to NZN0 researchers Leonie Walker
and J ill Clendon.3 In an article published in
Kai Tiaki Nursing New Zealand in 2015, Walker
and Clendon said there was mounting evidence
th a t longer shifts, in addition to many other
factors, might lead to increased risk of error
and harm to patients.
NZNO’s last employment survey revealed tha t
around 10 per cent of registered nurses worked
12-hour shifts, with d istrict health boards in
Auckland and Wellington using them more
frequently than other DHBs.j
A systematic review of 12-hour shifts and
errors rates among nurses, conducted in 2015,
showed th a t rates of error were higher among
nurses working 12 hours or more on a single
shifts in an acute care h o s p ita l^ .
References
1) Walker, L., & Clendon, J. (2015). 12 hour sh ifts: the debate
continues. Kai Tiaki Nursing New Zealand, 23(5), 18-19.
2) Clendon, J., & Gibbons, V. (2015). Inte rn atio n al Journal o f
Nursing Studies. Retrieved from: h ttp ://d x .d o i.O rg /1 0 .1 0 1 6 /j.
ijnurstu.2015.03.011.
Postgraduate study – to do or not to do? (pl6-17, November 2016 issue) – references
1) Barnhill, D., McKillop, A., & Aspinall, C. (2012). The im pact o f post-graduate education on registered nurses working in acute care, Nursing Praxis in New Zealand. 28(2), 27-36.
2) Manchester, A. (2013). Keeping older nurses working. Kai Tiaki Nursing New Zealand, 19(A), 15.
3) Myer, S.A., & Amendolair, D. (2014) Time is o f the essence: Retain your older nurses. Nursing Management, 45(5) 12-16.
4) Mosely, A., & Patterson, J. (2008). The retention o f the older nursing workforce: A literature review exploring factors th a t influence the retention and turnover o f older nurses. Contemporary Nurse, (3 0 )1,
46-50.
5) Stichler, J. (2013). Healthy work environments fo r the ageing nursing workforce. Journal o f Nursing Management, 21(7), 956-963.
6) Spence, D. (2004). Advancing nursing practice through post-graduate education (p a rt tw o ). Nursing Praxis in New Zealand, 20(3), 21-29.
7) Spence, D. (2004). Advancing nursing practice through post-graduate education (p a rt one). Nursing Praxis in New Zealand, 20(2), 46-55.
8) The Nursing Council. (2015). The New Zealand Nursing Workforce A profile o f Nurse Practitioners, Registered Nurses and Enrolled Nurses. Retrieved from www.nursingcouncil.org.nz/Publications/Reports.
9) Health Workforce New Zealand. (2015). Health Workforce New Zealand: 2015 Postgraduate Nursing Education Programme. Inform ation Booklet. W ellington: Author
10) Bahn, D. (2007. Reasons fo r post registration learning: Im pact o f the learning experience. Nurse Education Today, 27, 715-722.
11) Cooley, M.C. (2008). Nurses’ motivations fo r studying third level post-registration nursing programmes and the effects o f studying on th e ir personal and work lives. Nurse Education Today, 28, 588-594.
12) Austin, W.J. (2011). The incom mensurability o f nursing as a practice and the customer service model: an evolutionary th re a t to the discipline. Nursing Philosophy, 12, 158-166.
13) Toode, K., Routasaio, P., & Suominen, T. (2011). Work m otivation o f nurses: A literature review. Inte rn atio n al Journal o f Nursing Studies, (4 8 ), 246-257.
14) Rodwell, J., Demir, D., & Steane, P. (2013). Psychological and organisational im pact o f bullying over and above negative a ffe ctivity: A survey o f two nursing contexts. Inte rn atio n al Journal o f Nursing
Practice, 19(3), 241-248.
15) Matt, S. (2012). Ethical and legal issues associated w ith bullying in the nursing profession. Journal o f Nursing Law, 15(1), 9-13.
16) Roberts, K. L. (1998). Evidence-based practice: an idea whose tim e has come. Practice Issue, 5(3 ), 24-27.
Co-editors’ note: These references were not published in th e November issue of Kai Tiaki Nursing New Zealand. We apologise for th e error.
36 Kai Tiaki Nursing New Zealand * vol 22 no 11 * December 2016/January 2017
http://dx.doi.Org/10.1016/j
http://www.nursingcouncil.org.nz/Publications/Reports
Copyright of Kai Tiaki Nursing New Zealand is the property of New Zealand Nurses
Organisation and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder’s express written permission. However, users may print,
download, or email articles for individual use.