Effects of Shift Length on Quality of Patient Care and Health Provider Outcomes Systematic Review

BACKGROUND

Traditionally, shift work was organized past dividing the day into three 8-hour shifts. This pattern was the norm in nursing for many years. In mutual with other industries, there is now a trend for some wellness care employers to adopt longer shifts, typically 2 shifts per solar day each lasting 12–13 hours. Employees work fewer shifts each calendar week.¹ Changes are driven past perceived efficiencies for the employer, and improved piece of work life remainder for employees considering they work fewer days per calendar week.^1–three However, persistent concerns have been raised about negative impacts on the quality of care associated with working longer hours.

From an employer'due south perspective, a move from 3 to 2 shifts per day reduces periods of shift overlap and the number of handovers, thus reducing costs by reducing total workforce requirements.^iv Considering handovers and overlaps between shifts are regarded as unproductive, the aim is to improve efficiency with no detrimental issue on quality. Indeed a reduced number of handovers might have beneficial effects as handovers are associated with discontinuity and errors.^five,vi From an employee perspective, there are reports that many nurses adopt the compressed working week that results from working fewer shifts.^7–x

Nonetheless, the introduction of 12-hour shifts has raised concerns. Long working hours are correlated with fatigue and decreased levels of alacrity, potentially resulting in more adverse events.^11,12 However, the point at which longer shifts adversely bear upon operation is likely to be manufacture, context, and task specific,¹ and studies in health intendance have given mixed results.¹³ A recent study based on a survey of 22,275 registered nurses (RN) in four US states found that nurses who worked shifts of ≥12 hours were significantly more probable to report poor quality of intendance and poor patient safety when compared with nurses working eight- to nine-hour shifts.¹⁴ Patients in hospitals where a college proportion of nurses worked longer shifts also reported lower satisfaction.¹⁰ All the same, the odds of adverse reports of quality and safety were greater for nurses working 10–11 hours than for those working ≥12, which is inconsistent with a elementary outcome from longer hours worked on the shift. Assay of a subsample of 3710 pediatric nurses found that reports of poor quality and safety were substantially elevated only among nurses working >13 hours.¹⁵

Several issues remain to be clarified. Hospitals in many countries worldwide are implementing 12-60 minutes shifts,^7–10 but the extent to which employers are adopting this shift pattern is unclear. Surveys of Us RNs indicated that 65% worked shifts of 12–13 hours.¹⁴ A survey in eleven European countries indicated variation in shift patterns between countries but did non report specifically on shift length.¹⁶ Studies from outside the United States accept more often than not focused on nurse chore satisfaction and take not quantified associations with care quality (eg, Richardson and colleagues^8,17). It is unclear whether findings relating to quality of care from the The states will be replicated in a European context, where typical weekly working hours are shorter and annual leave allowances more generous¹⁸ with the EU working time directive setting limits to both the total working week and continuous hours worked for many countries.

In the by, research in this area has lacked a clear theoretical framework.¹⁹ Recently, a simple model has been proposed, whereby increased fatigue during the shift mediates the effect of shift length on performance leading to errors, omissions, and lower efficiency.²⁰ Even so, previous research has tended to conflate overtime working (working beyond contracted hours) with long shifts. Overtime working has too been associated with adverse quality because of cumulative fatigue, lack of rest, and adverse working environments.^21,22 To more fully understand the result of shift length and make research more useful to guide hospitals in developing their staffing policy information technology is therefore important to also consider both overtime working and full hours worked.

In this written report, we describe the shift patterns worked by nurses on medical and surgical wards in European hospitals and explore associations between hours worked, working across contracted hours on a shift, and reports of quality and safety of care while controlling for total hours of work.

METHODS

We undertook a cross-sectional survey of RNs in medical and surgical wards of astute hospitals every bit part of the RN4CAST study.²³ Data were collected in 12 European countries: Belgium, England, Germany, Finland, Hellenic republic, Republic of ireland, The Netherlands, Norway, Poland, Spain, Sweden, and Switzerland. Depending on national legislation, the study was approved by either fundamental (eg, national, regional) or local (eg, hospitals) ethical committees.

Sample

The survey was mailed or directly distributed to RNs in acute general hospitals between June 2009 and June 2010. The target sample was 30 hospitals in each country. In Ireland, Kingdom of norway and Sweden all eligible hospitals were included. In Belgium, England, Germany, Kingdom of the netherlands, Switzerland, and Spain, hospital selection was random with stratification for geographical location, type, and size. In Finland, Poland, and Greece, hospitals were sampled purposively to exist geographically representative. A minimum of ii (mean, 5.1) adult medical/surgical wards were randomly selected from each hospital. In Sweden, nurses were approached by the professional clan which organizes over 70% of nurses and so all wards were potentially sampled. Specialized nursing units (eg, intensive care, high dependency, long-term care) were excluded because staffing and shift patterns in these can differ substantially. In each ward, all RNs delivering direct care to patients were asked to consummate and return a written questionnaire. In total 54,140 questionnaires were distributed. Responses were obtained from 33,659 (62%) RNs in 488 hospitals (Table ane). Fuller details take been published elsewhere.^23,24

TABLE ane:

Hospital/Nurse Sample by State

Measurements

The survey was based on the validated International Hospital Outcomes Study questionnaire.²⁵ The English language survey was translated into Dutch, German, Greek, French, Italian, Finnish, Norwegian, Smooth, Swedish, and Spanish using the translation-back translation method. Content validity and translation quality indices for all items used in this study were classified equally "good" or better (content validity alphabetize>0.six).²⁶

Nurses were asked to written report the number of hours worked, the menstruum of the day, and whether they had worked across their contracted hours on the last shift they worked. Shifts were dichotomized into twenty-four hours (including afternoon/evening shifts) and night shifts. Shift length was grouped into 5 categories: ≤8, 8.1–10, 10.ane–11.9, 12–xiii, >13 hours. Where nurses had identified a shift length that was ≥eighteen hours, we treated data as missing. Absolute numbers of these were very low (<ane%). In most cases information technology appeared that these nurses had given the number of hours worked weekly. Nurses also reported on the number of patients on the ward and the numbers of nursing staff working on that shift. From this we calculated patient to nurse ratios.

Nurses were asked to evaluate the quality of nursing care on their ward as fair or poor as opposed to practiced or splendid. This measure out has been validated past associations with hospital-level mortality, patient satisfaction, and care processes.²⁷ For analysis, "poor" and "fair" responses were grouped to reflect negative evaluations of quality. Patient safety was rated equally poor, failing, acceptable, very good, or fantabulous with "poor" and "failing" ratings combined to reverberate negative evaluations. Nurses were asked to identify whether whatsoever necessary activities from a list of thirteen cadre nursing duties were left undone on their last shift worked considering of lack of time. Items were derived from the BERNCA musical instrument, which has validated associations between intendance left undone, patient experience, and outcomes.²⁸ A charge per unit of care left undone was derived past summing the number of activities ticked per person, resulting in a score indicating the number of areas of care left undone (range from 0 to xiii) (run into Fig. ane for details of specific questions used).

FIGURE 1:

Survey items about shift piece of work and quality.

Assay

Intraclass correlation coefficients (ICC 1) were computed from unconditional random intercept models to depict inside-land, within-hospital, and within-unit of measurement variation for shift length. The ICC one measures the caste of similarity between individuals inside a cluster.²⁹ It also indicates the proportion of variance in the outcome that tin can exist attributed to variation betwixt groups (wards, hospitals, countries) equally opposed to between individuals.^xxx

The association of shift length and overtime with the result measures was estimated through a binomial generalized linear mixed model. The association of shift length and overtime with care left undone was estimated past a generalized mixed model with a Poisson distribution. Considering of the small-scale sample size of the >13 hours category (n=260, 0.08%), we grouped the >xiii hours category with the 12–13 hours into a ≥12 hours category for analysis. The multilevel construction allowed nurses to be nested into units, hospitals, and countries. We controlled for potential misreckoning variables, including variables chosen because they take been shown elsewhere to have contained relationships with the quality of intendance in hospitals^31,32 or the ability to cope with shift work.³³ Control variables were shift type (day/night), ward blazon, nurse staffing levels (quantified by the ratio of patients per nurse), nurses' historic period, full fourth dimension versus part fourth dimension working, hospital size (<250, 250–500, >500 beds), loftier-technology hospitals (those that performed major organ transplant surgery and/or open heart surgery), and educational activity status (hospitals that provide training to undergraduate medical students). The variance inflation factor (VIF) was assessed for all model predictors to place multicollinearity, with VIF<5 indicating no multicollinearity.³⁴ Analysis was conducted using RStudio version 0.96.330³⁵ and lme4 package.³⁶

RESULTS

Data from 31,627 respondents working on adult medical/surgical wards was bachelor for analysis. The mean historic period of respondents was 38. Ninety-2 percent were female. Sixty-five percentage of nurses worked full time (n=20,513). Sixty-vii per centum worked in high-technology hospitals and 68% in teaching hospitals. Fifty-seven percent worked in medical units or mixed medical/surgical units, with the remaining 43% in surgical units. The majority (76%) of nurses reported on day shifts (Table 2).

Table 2:

Characteristics of Final Shift Worked and Hours Worked

Shift Length

The most common shift length was≤8 hours (50%, n=fifteen,930). Thirty-two percent worked from eight.1 to 10 hours (n=9963) and xiv% (n=4314) worked 12 to 13 hours. Only 260 nurses (1%) worked >13 hours on their last shift.

Countries varied in their typical shift length (Table 3). For Belgium, Germany, Greece, The Netherlands, Norway, and Sweden <five% of nurses reported working shifts of ≥12 hours. In all these countries the majority of day shifts were ≤8 hours. Shifts of ≥12 hours were also rare in Republic of finland, Spain, and Switzerland. For Ireland and Poland, shifts of 12 hours were the norm (≥73% of all shifts). England presented a mixed picture, with 32% of day shifts and 37% of night shifts lasting ≥12 hours. Nigh variation in shift length was between units, with individuals within units disposed to piece of work similar shifts (ICC=0.63). Individuals in the same infirmary and country also tended to work similar shifts (ICC=0.58, 0.49) with substantial variation between hospitals and countries.

Tabular array three:

Day and Nighttime Shift Length by Country

Overall, 8606 nurses (27%) reported that they had worked overtime (across their contracted hours) on their final shift (Table 2). Most reports of overtime work were made by nurses who reported working 8.1–10 hours (49%, 4175/8606). A bulk of nurses who reported working shifts of >thirteen hours worked overtime on that shift (60%, 156/260). In that location was wide variation between hospitals, with a range from 0% to 80% of nurses working overtime. There was also variation between countries ranging from fifty% (England) to 12% (Poland) (Table iii).

Associations With Quality, Safety, and Care Left Undone

Xx-5 percent (n=7815) of nurses reported poor/fair quality of care and vii% (2736) reported "poor" or "failing" patient safety. Distributions of quality and condom statements by country are reported elsewhere.²⁴ Nurses reported on average 3 activities left undone on their last shift. Just 3934 nurses (12%) did non written report leaving any care undone.

Longer shifts and working overtime were significantly associated with quality of care, patient condom reports, and care left undone (<0.05). Compared with nurses working ≤8 hours, nurses working ≥12 hours on their last shift were more than likely to rate the quality of nursing intendance in their unit equally "poor" or "off-white" (OR=1.30; 95% CI, i.10–ane.53) and more likely to written report "failing" or "poor" patient rubber in their units (OR=1.41; 95% CI, 1.13–1.76). Although not statistically significant, odds of adverse quality and safety were raised for all shift lengths >8 hours although simply marginally for shifts of 8.1–ten hours. Nurses working ≥12 hours reported college rates of intendance left undone than did nurses working ≤eight hours (RR=1.13; 95% CI, i.09–1.sixteen). All shifts >eight hours were associated with statistically significant increases in the rate of intendance left undone (P<0.05) (Table 4).

TABLE 4:

Results of Multilevel Regression Models: Associations Betwixt the Model Predictors, and Quality of Care, Patient Rubber, and Intendance Left Undone

Nurses working overtime on their terminal shift were more than likely to study poor/off-white quality of nursing intendance (OR=1.32; 95% CI, 1.23–1.42), poor/failing patient safety (OR=1.67; 95% CI, 1.51–ane.86), and higher rates of care left undone (RR=1.29; 95% CI, 1.27–1.31) (Table 4).

There were meaning associations between reports of quality, prophylactic, or missed care for several command variables including night shifts (fewer negative evaluations), patient to nurse ratio (more negative evaluations with more than patients per nurse), and function time work (fewer negative evaluations) (Table four).

We tested for interaction between shift length and overtime (model non shown—available from authors); yet, the relationship was not meaning. To appraise the impact of our determination to collapse the 12–13 hours and >thirteen-60 minutes categories, we analyzed the information with the 12–13 hours and >thirteen-hour categories separately. To ensure conclusions were not biased by mail hoc nomenclature of safety ratings, nosotros analyzed the data with "acceptable" safety ratings grouped with "poor" and "failing." These changes did not alter results significantly.

Give-and-take

To our knowledge, this is the offset study in Europe to demonstrate a relationship betwixt longer shifts worked by hospital nurses and bug in the quality and condom of care. Shifts of ≥12 hours and working overtime (beyond contracted hours) on a shift were independently associated with nurses' reports of lower quality of intendance, poorer patient prophylactic, and increasing rates of care left undone. All shifts >8 hours were associated with increasing rates of care left undone. Our results show substantial variation in typical shift patterns between European countries. Although overall merely 15% of nurses reported working ≥12 hours on their last shift, long shifts were common in England, Ireland, and Poland. The reason for the variation is unclear. Of countries where 12-hour shifts were common, only England was reported as experiencing nursing shortages at the time of the study,³⁷ although the pattern may accept been established in Poland and Ireland during historical periods of shortage. Twenty-seven percent of all nurses reported working overtime on their last shift.

In the USA, shifts of ≥12 hours are prevalent^vii,38 and have been associated with poorer quality ratings.^10,15 However, information technology was non clear in these studies whether the agin associations between shift length and quality were the result of the number of hours worked on the shift or working overtime. Associations betwixt overtime and deficits in wellness care quality accept besides been reported previously.^{21,22,39–41} Our report shows working overtime on a shift to be a negative factor contained of the total hours worked on the shift and also clearly indicates that shifts of ≥12 hours are associated with reports of reduced quality, independently of working overtime and the length of the normal working week (full fourth dimension vs. role time).

These findings raise questions for health care organizations, especially in the electric current economical climate, where employers in many countries are aiming to utilise the existing workforce more efficiently, either to reduce expenditure or considering of nursing shortages. Previous research indicates that low nurse staffing levels are associated with worse patient outcomes.^24,42 This finding is supported past our assay. Moving from 3 shorter shifts per solar day to 2 longer ones to maintain current patient to nurse ratios with fewer full staff has been advocated in England and elsewhere, with claimed savings of up to 14% on bacon costs for nurses working shifts.^five However, such a strategy may non accept the desired upshot if nurses perform less effectively and safely.

Overtime working is mutual in nursing. This is reflected by the prevalence seen in the electric current study and in reports from US^43,44 and elsewhere.⁴⁵ In our survey, reported overtime varied betwixt hospitals from 0% to 80% consistent with surveys from the United states of america which too show substantial variation between hospitals.⁴³ Variation of such magnitude suggests that it is unlikely to be a elementary product of variation in workforce supply but may also result from variation in staffing policies. The results of this study suggest that the apparent flexibility for employers, using overtime to meet dynamic staffing requirements, may exist counterproductive because of the negative associations with quality and safety.

Although increased fatigue, loss of alertness, and impaired determination making are plausible mechanisms to explain reduced ratings of quality and safety with longer shifts, this does not fully explain an adverse effect from overtime independent of shift length. Overtime has previously been associated with increased nurse turnover^10,46 and it may be that use of overtime is associated with less favorable working environments for nurses, which are known to exist linked to subjective and objective measures of reduced quality and safety of intendance.^23,47 Overtime can be an private voluntary strategy of "working late" (unpaid) to complete work or an organizational strategy of asking or requiring workers (unpaid or with additional pay or time off in lieu) to extend working hours to come across demand. Although the distinction between these modes of overtime has been questioned,¹⁰ they may be relevant in determining engagement and motivation for those working overtime. For example, overtime that is mandatory may have a negative consequence on psychological well-being related to lack of control.⁴⁸

The caste to which nurses are subsidizing health services through unpaid overtime and the touch of long hours and overtime on burnout have implications for both the costs and the effectiveness of extended shifts, which require further exploration. The paradox whereby longer shifts announced to be preferred by nurses because of the compressed working week,^7–10 and yet deliver poorer evaluations of rubber and quality of care also claim farther investigation.

Our study has some limitations. Our assay of cross-sectional survey data showed associations between shift patterns and quality and safety, but it is non possible to infer causality. Because we did not test for interaction effects between country and shift piece of work, we can but guess the average result across all countries and cannot explore differences betwixt countries related to (for instance) cultural differences. The outcome measures used in this written report were nurses' self-report. The clinical importance of the differences noted is unclear. Although nurses' self-reports of quality and rubber have validated associations with objective measures such equally rates of mortality and failure to rescue,²⁷ further research should include objective measures and consider patients' experiences. Although our sampling strategy was designed to obtain a representative sample of hospitals and nurses in each land, we cannot fully gauge the extent to which this was successful because of lack of data for comparing for nearly countries. Furthermore, the primary purpose of the RN4CAST study was non to assess shift work in particular and then the survey did not ask about the nature of overtime and more specific aspects of shift work, including the number of hours overtime, the nurses usual shift pattern, the possibility of taking breaks during shifts and opportunity to rest between shifts, factors that may be relevant in modeling the effects of shift piece of work on functioning.¹ Although we were able to use full time versus part time status as a proxy for total hours worked, nosotros did not directly measure hours worked.

CONCLUSIONS

European nurses working >12 hours and those working overtime on a shift were more likely to describe the quality of nursing intendance delivered to patients on their unit every bit fair or poor, to appraise patient safe as poor or fair, and to study more care items left undone on their final shift, when compared with nurses working ≤viii hours and no more than their contracted hours. In some countries, long shifts (12 h) seem to be the norm and it is advocated every bit a cost-effective strategy for hospitals in England and elsewhere. Even so, our results propose that a policy of moving to longer shifts to reduce overall workforce requirements may take unintended consequences and reduce the efficiency and effectiveness of the workforce in delivering high quality, safe care. Similarly, the increased flexibility associated with overtime may not deliver the desired goals for employers.

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Keywords:

shift work; quality; condom; nurses; workforce; efficiency; Europe

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