Posted 03 December 2019 - 00:01
Posted 03 December 2019 - 00:01
Analysis
12-hour shifts: they may offer nurses work-life balance, but are they worth the risk to safety?
Many nurses see long shifts as helpful to their home life, but there are dangers – for staff as well as patients
- More than 2,000 nurses tell Nursing Standard what 12-hour shifts mean to their lives
- Researchers reveal what they have discovered about the impact of longer shifts on nursing staff and patient care
- Check you know your rights – and how to harness simple habits to help you cope with long hours
Nurses are divided on the impact of 12-hour shifts on patient safety and their own well-being, according to a Nursing Standard survey.
Many NHS employers see the shift pattern as a cost-effective way of providing 24-hour care, with lower costs and greater continuity of staff, according to a 2015 report by the National Nursing Research Unit.
Survey on long shifts shows divided opinion among nurses
But of the 2,243 UK nurses who responded to our well-being at work survey, 40% were against 12-hour shifts, 35% were for them and 25% were undecided.
Some nurses said longer days with fewer shifts gave them greater flexibility and more time away from work.
Yet others voiced concerns 12-hour shifts left them and their colleagues ‘exhausted’, burned out and in fear of making errors due to fatigue.
The case against 12-hour shifts: ‘When I was an inpatient I witnessed nurses tire’
‘I think they are dangerous,’ said one nurse responding to our survey. ‘How can you concentrate after 12 hours on a busy ward?’
Another said: ‘They are too long, especially when you factor in the travel time that staff have before and after shifts. It's simply not good for staff or patients.’
One respondent opposed 12-hour shifts on the grounds that nursing is physically and emotionally draining, and cited patient safety as a concern.
‘I was an inpatient and witnessed the nurses tire as their long shifts progressed,’ the respondent said. ‘Nurses may say they prefer them, but that is just so they can get longer days off; but is that best for patients?’
Prevalence of 12-hour shifts among healthcare employers
Individual employers are responsible for their nurse staffing levels and shift patterns.
No central data exist for how many NHS organisations or independent care home operators use 12-hour shift patterns.
‘I constantly work over my hours. I would rather do 12-hour shifts, have an extra day off and be paid for staying later’
Nursing Standard survey participant
‘How can you concentrate after 12 hours on a busy ward? It’s dangerous’
Nursing Standard survey participant
However the 2015 National Nursing Research Unit report highlighted a substantial increase in the proportion of staff nurses in NHS hospitals working 12-hour or even longer shifts between 2005-09, increasing from 31% to 52% in that period.
The case for 12-hour shifts: They’re better for our work-life balance
The National Nursing Research Unit report found nurses working 12-hour shifts were as or more satisfied with their working hours than those working shorter shifts.
Nursing Standard survey respondents who favoured longer shifts said it cut down on travel costs and afforded them a better work-life balance, especially those with caring responsibilities at home.
Significantly, longer shifts were seen by some as reducing the likelihood of unpaid overtime.
‘I constantly work over my hours anyway,’ said one nurse. ‘I would rather do 12-hour shifts, have an extra day off and be paid for staying later at work than staying later all the time and not getting paid or getting time back for it.’
Another said: ‘More days off, better work-life balance. Opportunity to pick up an extra shift per week, as it’s needed on nurse wages.’
What the evidence says about safety and job satisfaction
While long shifts prove popular with some, there is a growing body of research evidence in the UK suggesting 12-hour shifts are having an adverse effect.
Chiara Dall’Ora is a research fellow in nursing workforce at the University of Southampton. She conducted a study in 2015 that concluded working 12-hour shifts was associated with more nurses intending to leave the profession.
‘Employers assume 12-hour shifts will save money, but this is not true’
Chiara Dall’Ora, nursing workforce researcher, University of Southampton
The study, involving more than 30,000 nurses in 12 European countries, showed those working shifts of 12 hours or longer were more likely to report job dissatisfaction and intention to leave their job and experience burnout.
‘We don’t yet have any real evidence of actual turnover related to this, but still we have indication that working 12-hours shifts might not be great for the staffing crisis,' she tells Nursing Standard.
Yet many employers still choose to use them – a fact researchers believe represents a false economy.
Dr Dall’Ora adds: ‘There is resistance from employers because there is an assumption 12-hour shifts will save money, but this is not true.’
In a 2018 study, Dr Dall'Ora found that on days when 50-75% of shifts lasted 12 hours, costs were higher than on days when no one worked the long shifts.
‘It is something we are starting to explore more with further research,' she adds.
The hospital trust where long shifts are no longer routine
Using research evidence to make informed decisions on changes to shift length has been a key approach at Gloucestershire Hospitals NHS Foundation Trust.
Some areas such as critical care, intensive care and the emergency department still ran 14.5-hour shifts when the organisation’s director of nursing, Steve Hams, joined two years ago.
He said: ‘It was clear to me 14.5-hour shifts were excessive and, having read some research, I was clear they weren’t going to continue.’
Before making a decision on what shift lengths to introduce, Mr Hams invited University of Southampton researchers Peter Griffiths and Dr Dall'Ora to present their research on the impact of long shifts to staff and union representatives.
‘Some trusts have gone to 12-hour shifts because of the perception this saves money. I have followed the evidence, which is very clear.
‘I was able to have clear and articulate conversations with the chief executive and the board to say this is something we shouldn’t support. There are other ways to deliver efficiencies and save money.’
The traditional early, late and night three-shift pattern continues to be the preferred organisational pattern, with decisions made on a 'case-by-case' basis for nurses who really want to do long shifts.
What older nurses think about working longer shifts
According to the RCN’s 2018 UK nursing labour market review, 35% of nurses and midwives are aged 50 or over, up from 32% in 2013.
RCN national officer for health and safety/working environment Kim Sunley feels there is growing resistance to 12-hour shifts as the workforce ages.
She says: ‘Speaking anecdotally, my feeling is that, as we are a workforce that is ageing, there is a little more resistance to [12-hour shifts].'
Her belief is echoed in some of our survey responses.
One nurse said: ‘12-hour shifts are too long, especially when one is working up to 66 years of age.’
‘Most people recognise 12-hour shifts have more associated risks, but those risks can be managed with good staffing and management’
Professor Jane Ball, nurse staffing and workforce policy expert
Another said: ‘I am mid-50s and would like the option of some shorter shifts.’
One respondent said: ‘Great when young and fit, yet when older or [with] long-term health conditions, not appropriate.’
Unison’s submission to the NHS Working Longer Review Group in 2013 cited evidence that in a simulated 12-hour shift rotation, ‘performance for the older workers was consistently lower than for the younger subjects’.
Shift work: what are your rights?
According to the UK Working Time Regulations (1998), most workers should not work more than 48 hours a week. There should be 11 hours' rest between shifts, and breaks are mandatory.
The regulations stipulate:
- All staff are entitled to take a break of at least 20 minutes where the working day is longer than six hours
- Rest breaks should be taken during the period of work, and not at the start or the end of a shift
- Employees should be able to take this rest break away from their work station
Unison national officer Alan Lofthouse says staff often do not take breaks ‘because the health service is staffed by altruistic people who care for patients, have a great sense of team work and feel guilty’.
But, he points out, if nurses are regularly doing an hour’s unpaid work, this soon adds up to a free shift, which in turn, hides staffing problems.
‘The management system should ensure people are taking adequate breaks,' he insists.
‘If people are working through their breaks, we would say raise the issue through your union and bring it to the attention of the management system to say this is unsafe practice.’
How employers implement long shifts can influence how they manage risks
Nurse staffing and workforce policy expert Jane Ball says the way employers implement long shifts is critical.
Professor Ball says: ‘Most people do recognise 12-hour shifts have more risks associated with them than eight-hour shifts, but those risks can be managed with good staffing and management.’
It is when rosters are not managed well and staff are not getting enough rest between shifts, or breaks during shifts, that safety is compromised – both for nurses and patients, she argues.
Employers’ duty of care to nurses working long shifts
The RCN's Kim Sunley agrees that employers have a duty to ensure shifts are managed well.
‘It is about recovery time – how many days off are you getting and how long does it take you to get home, unwind and sleep?
‘The problem is when services use 12-hour shifts and still understaff areas and/or have no flexibility to cope with peaks in workload’
Nursing Standard survey participant
‘We would like to see employers offering flexibility around shift patterns and length.’
Ms Sunley says there are some practical steps nurses can take to help them cope with the rigours of longer shifts. These include taking rest breaks, staying hydrated and eating nutritious food.
She also points nurses to a new series of mindfulness based videos that have been created by the RCN for nursing staff.
One video advises nurses to establish a ritual before leaving work to help them avoid ‘auto-pilot’, and suggests breathing exercises to help them unwind.
Do you work 12-hour shifts? Top tips on how to look after yourself
Faculty of Occupational Health Nursing membership director, and nurse specialist practitioner in occupational health, Lyndsey Marchant advises:
- Tired feet make a 12-hour shift harder Comfortable footwear with a cushioned sole and arch support is key
- Prepare everything in advance Have your uniform ready and packed lunch organised, so you don’t need to get up earlier
- Take plenty of snacks and your meal This should include complex carbohydrates to give you sustained energy
- Take a drinking bottle This will help you monitor your fluid intake when busy. Staying hydrated helps with concentration and fatigue
- Sleep well Make sure that you go to bed at a reasonable time and aim to have at least seven hours of sleep prior to your shift
Why this is an issue of national importance
A number of survey respondents said 12-hour shifts would be more appealing if proper breaks were factored in.
‘The problem is when services use 12-hour shifts and still understaff areas and/or have no flexibility in their systems to cope with peaks in workload,’ pointed out one nurse.
Professor Ball believes that the debate on the place of 12-hour shifts in healthcare is one of national importance.
'Individual employers are responsible for their nurse staffing levels and patterns, but there is a responsibility and a need for more national oversight and guidance on this issue.’
Further information
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