Posted 29 May 2023 - 11:00
Posted 29 May 2023 - 11:00
Analysis
Why are so many nurses still on 12-hour shifts, despite the risks?
Fewer but longer shifts have become the only practical, cost-effective way of working, say some nurses, but they may risk safety and cost services more
Fewer but longer shifts have become the only practical, cost-effective way of working, say some nurses, but they may risk safety and cost services more
- Increased costs related to travel and parking charges are among the reasons why many nurses opt for 12-hour shifts over fewer days
- Longer shifts are associated with higher rates of sickness and nursing instances of missed care
- Ensuring work-life balance, safety and the required staff cover may come down to doing 12-hour shifts better, rather than reverting to eight-hour rotas, some suggest
Some nurses like 12-hour shifts as they mean fewer days spent at work, while others find them too long and tiring, but amid staff shortages and
Fewer but longer shifts have become the only practical, cost-effective way of working, say some nurses, but they may risk safety and cost services more
- Increased costs related to travel and parking charges are among the reasons why many nurses opt for 12-hour shifts over fewer days
- Longer shifts are associated with higher rates of sickness and nursing instances of missed care
- Ensuring work-life balance, safety and the required staff cover may come down to doing 12-hour shifts better, rather than reverting to eight-hour rotas, some suggest
Some nurses like 12-hour shifts as they mean fewer days spent at work, while others find them too long and tiring, but amid staff shortages and financial struggles these shifts are becoming more common.
The evidence suggests that longer shifts could be less safe and more costly for health services than the traditional eight-hour workday.
The work patterns that managers and nurses prefer
Yet despite ward and hospital managers saying they want to switch back to the old pattern of eight-hour shifts, many nurses prefer not to have to attend work for five days a week. For some, the cost of living crisis and ever-increasing travel and parking charges mean that fewer but longer shifts are a more practical and cost-effective way of working.
University of Southampton lecturer and research fellow Chiara Dall’Ora, who co-wrote a discussion paper on the value of 12-hour shifts in 2022, says: ‘A lot of the managers I have spoken with say, “I would definitely consider eight hours,” but their nurses can’t afford the costs of coming into work for more days.’
‘With the cost of living crisis, nurses say they use days off to do extra shifts. Other nurses like having fewer days at work. Long shifts also make childcare arrangements easier’
Chiara Dall’Ora, University of Southampton lecturer and research fellow
Use of 12-hour shift patterns began in the US in the 1970s. Dr Dall’Ora says they were adopted in UK healthcare in the late 1990s, becoming popular with some nurses, albeit for practical reasons.
But according to her research, 12-hour shifts may be putting financial strain on health services.
It has been assumed that the long shifts save money. Two nurses are needed to cover 24 hours in a 12-hour shift pattern, whereas three are required over the same period if using an eight-hour rota, and the longer shift pattern can reduce overlap time between shifts (see box below).
12-hour shifts: why do managers think they are cost-effective?
A 2015 report by the National Nursing Research Unit found many UK hospitals use 12-hour shifts because managers believe they are more cost effective over a 24-hour period.
When wards operate a three eight-hour shifts system, there are overlaps of between one and three hours between shifts, and three handovers in a 24-hour period, explains recent research by University of Southampton lecturer and research fellow Chiara Dall’Ora.
This adds up to between 26 and 30 hours of staffing, with 14% of paid time covering handovers.
With a 12-hour shifts system, there are only two handovers in 24 hours, meaning staffing is more likely to add up to 25 hours in total.
While there are no economic benefits for nurses, who would work the same weekly hours and receive the same salary under either shift system, reorganising a 24-hour working day into two shifts could lead to financial savings for healthcare systems, in theory.
Higher rates of sickness and nursing errors
Dr Dall’Ora says: ‘In theory, implementing 12-hour shifts should have reduced staffing hours and staffing costs, because fewer staff are required to cover a 24-hour period. But on wards where a higher proportion of 12-hour shifts are deployed, there is no reduction in nursing hours worked and actually there is no reduction in staffing costs.’
She says although there are no robust economic evaluations showing financial gains or losses connected with 12-hour shifts, they are associated with higher rates of sickness and nursing errors. ‘This increases the bill. If sickness absence and patient incidents are higher, it will cost the healthcare system more money, not less.’
Higher rates of missed nursing care are also reported on 12-hour shifts, including incidents such as not administering medication at the right time and not taking vital signs when required, according to Dr Dall’Ora’s discussion paper. Units that employ 12-hour shift patterns have lower nurse vacancy rates but they also find that turnover among staff is more rapid, it found.
‘Despite the problems, I understand why managers favour 12-hour shifts,’ says Dr Dall’Ora. ‘There is a nurse shortage and they have staffing gaps to fill. It’s easier to fill shifts with one person rather than two. But it’s time to admit that 12-hour shifts are not the solution everyone thought they would be. They do not reduce costs.’
Nurses opting for longer shifts for practical reasons, not because they like them
A second paper by Dr Dall’Ora, published in May 2023, looks at 12-hour shifts and nurse burnout. The authors asked nurses what control they have over choosing the length of their shift, and what would be ideal for them.
‘We don’t have overwhelming numbers of nurses saying their ideal rota involves 12-hour shifts,’ says Dr Dall'Ora. ‘Nurses say they want to work longer shifts because they fit better with other constraints on their lives. But that’s not the same as liking them.
‘With the cost of living crisis, nurses say they use days off to do extra shifts. Other nurses like having fewer days at work. Long shifts also make childcare arrangements easier.’
‘Exhausting, but a better work-life balance’
On Twitter, some nurses agree that 12-hour shifts have benefits.
One, @pyfon, tweeted: ‘You get parking space in the morning, as it’s early and there is little traffic. If I left at 5pm I’d be in traffic for ages.’
Another, @emz418, added: ‘They can be exhausting, but by the time you’ve done three, they work well for work-life balance.’
A Nursing Standard survey in 2019 that drew responses from 2,243 nurses in the UK about preferred shift lengths showed 40% were against 12-hour shifts, 35% wanted them to remain and 25% were undecided.
There is no central data available detailing which NHS trusts, Health and Social Care (HSC) boards or independent organisations use 12-hour shifts.
Dr Dall’Ora says she is unaware of any acute NHS trust or HSC board that does not heavily rely on them. She estimates that around 80% of inpatient staff working in acute services work 12-hour shifts.
Tips on how to look after yourself during a 12-hour shift
Advice from RCN national officer for health, safety and well-being Kim Sunley:
- Take your break Do not get into a habit of skipping breaks. Everyone has a role to play in encouraging a culture of taking breaks
- Record missed breaks If you cannot take breaks, keep a tally of this and submit it as part of an incident form
- Hydrate Come onto a shift well-hydrated, and drink throughout the shift. If you are not able to access water speak to your line manager or RCN rep
- Eat well Eat something before your shift starts, and bring snacks that do not need to be refrigerated, such as nuts or dried fruit
Childcare, parking and learning opportunities
Barnsley Hospital charge nurse Martin Jackson has worked on a respiratory care unit for 25 years. He works 12-hour shifts but prefers them to his old eight-hour shift pattern. ‘When we worked eight hours, we sometimes did ten or 11 shifts on the trot, which I thought was more tiring than the present situation.
‘If we haven’t turned the clock back to eight-hour shifts for a decade, then it won’t happen during a cost of living crisis’
Jill Maben, professor of health services research and nursing
‘We used to do earlies and lates. Often you’d finish a late shift and have to be back in a few hours later for an early the following day. We also did long night shifts. Eight hours didn’t mess around with your body clock any less than 12-hour shifts.
‘There was the issue of childcare too. If you were on all these different shift times and working more of them, childcare was more difficult to find and more expensive. Parking or commuting for five days a week is also nearly double the cost of three days a week. So switching back to eight-hour shifts is not affordable for many nurses.’
However, on Twitter, @CourtyLaura disagreed, arguing that eight-hour shifts meant better working conditions and more educational opportunities. ‘Short shifts more frequently had better staff and patient continuity, as well as time for learning and development.’
‘A 12-hour shift quickly turns into 16 or 17 hours away from home’
King’s College London professor of health service research Ruth Harris worked eight-hour shifts as a nurse in the 1990s. In 2015, she led a scoping review into the effects of 12-hour shifts on nurses, and says the preferred shift length may depend on various factors.
‘In London and inner cities, nurses can’t afford to live near the hospitals,’ Professor Harris says. ‘They live further out. It takes longer to get home, with transport delays and traffic. It’s not unusual to have a 90-minute commute. You’re also working 13 hours, rather than 12 hours, because of the unpaid break in the middle of the shift. You often leave later than you should.
‘When you add it up, a 12-hour shift can quickly turn into 16 or 17 hours away from home. Then you eat something and have a shower. It doesn’t leave long to sleep, and you might be working again the next day.
‘But a nurse in a different part of the country may be able to afford to live closer to their workplace. Separately, where a nurse works in a team where everyone is permanent staff, the shift might run more smoothly and they’re not doing as much overtime. For that nurse, 12-hour shifts are easier.’
On Twitter, @LobbanMeg suggests staff find longer commutes workable if they have fewer weekly shifts: ‘I liked [12-hour shifts] but lived near the hospital. Some staff had a 40+ minute commute each way, which was bearable doing 12.5-hour shifts. But they would say unbearable doing that on core shifts.’
Flexible working – what staff are able to request
Both the NHS People Plan, published in 2020, and Section 33 of the NHS Terms and Conditions of Service Handbook, amended in 2021, say staff may request eight-hour shifts as part of flexible working.
Measures designed to make it easier for nurses and other NHS staff to request flexible working arrangements came into force in late 2021.
‘It’s easy to write policies on flexible working,’ says Professor Harris. ‘In reality it is difficult for the ward manager to make it work. You can easily write a roster with everyone on 12-hour shifts. I’m not sure about a rota with some people on eight hours and others on longer.
‘We need to be better at not making promises to nurses that we can’t keep.’
University of Surrey professor of health services research and nursing Jill Maben says the length of preferred shifts may be dictated by low pay rather than what managers know is best for nurses and patients.
She co-wrote the National Nursing Research Unit’s 2015 report on the impact of 12-hour shifts for Dame Ruth May, now England’s chief nursing officer and who at the time of the report was responsible for delivering NHS England’s compassion in practice strategy.
Unrealistic to expect ward managers to solve the problem
Professor Maben says: ‘Managers might know that 12-hour shifts increase fatigue and affect patient care, but they can’t do eight-hour shifts because of the extra financial costs to nurses.
‘If managers suddenly switch to short shifts, half their nursing staff can’t afford that. If pay was better, nurses wouldn’t need to do extra agency shifts, which only work around a 12-hour rota.
‘I’m unsure about a way forward. If we haven’t turned the clock back to eight-hour shifts over the past decade, then it won’t happen during a cost of living crisis.
‘It’s tough for managers, and decisions on shift length shouldn’t be on the heads of individuals. It needs to come from higher up than ward managers and hospital managers. For now, maybe we look at how to improve 12-hour shifts.’
What are nurses’ rights to breaks when working long shifts?
RCN national officer for health, safety and well-being Kim Sunley says the law on breaks during working hours is set out in the Working Time Regulations 1998.
‘They specify that if you work more than six hours you should have a minimum break of 20 minutes away from your immediate workspace. But for a 12-hour shift, 20 minutes is not restorative. Local policies should go higher than that.
‘According to the regulations, when staff are on their feet, the onus is on employers to provide facilities for rest with chairs.
‘We know that a lot of our members can’t get any breaks. If that’s you, then talk to colleagues and raise it as a collective issue. An RCN safety representative can help. It’s about your safety to practise as a registrant, not just patient safety.’
Community nursing – when unsocial hours pay may not apply
Unite national officer for health Colenzo Jarrett-Thorpe says pay on long shifts can be a problem for community nurses.
‘Outside of Agenda for Change contracts, unsocial hours pay can be removed for those on 12-hour shifts,’ he says. ‘It’s particularly a problem with local authority employers. NHS nurses don’t have to deal with this. But some community practitioners and health visitors do 12 hours for flat pay.’
‘Because of the extra financial costs to nurses with eight-hour shifts, perhaps we need to look at making 12-hour shifts easier – although I haven’t seen any evidence for where we go with that’
Colenzo Jarrett-Thorpe, Unite national officer for health
Mr Jarrett-Thorpe, who is on the NHS Staff Council Executive, argues that eight-hour shifts would be preferable for nurses because of the negative health consequences he has witnessed from longer shifts.
‘We have seen nurses with chronic kidney injury due to the lack of fluid, and chronic back pain from a lack of rest. This happens when they’re working straight through for that longer period of time.
‘But because of the extra financial costs to nurses with eight-hour shifts, perhaps we need to look at making 12-hour shifts easier – although I haven’t seen any evidence for where we go with that.’
Ways to make 12-hour shifts work better for nurses and managers
Dr Dall’Ora agrees there is a lack of evidence on how to improve 12-hour shifts. She is now leading a discrete choice experiment – a way of analysing preferences – which presents nurses and managers with different scenarios to determine what they like about different shift systems.
‘The aim is to find one or two possible new things that might work for shift work organisation,’ she says. ‘What will make it easier? We can then trial possibilities in a study and look at effectiveness, and at what happens with sickness and retention.
‘The problem is, it’s not an immediate solution – nothing is. It will be a few years before publication.’
- RELATED: 12-hour shifts: they may offer nurses work-life balance, but are they worth the risk to safety?
NHS Employers director of development and employment Caroline Waterfield says the NHS is a 24-hour service involving shift work and unsociable hours.
‘Twelve-hour shifts are used for a number of different reasons, including the preference by some staff for increased flexibility. For other staff, the opposite applies. Employers continue to look into ways to review and improve working practices.’
Further information