fatigue, 12-hour shifts, nurse outcomes, nursing, patient safety, sleep deprivation



  1. Kupperschmidt, Betty


ABSTRACT: Concern is reported about the negative outcomes of 12-hour shifts for nurses, including sleep-deprived fatigue, negative neurobehavioral outcomes, and patient safety. However, 12-hour shifts remain the prevailing staffing method. When should the concern for nurses' health and well-being be factored into staffing decisions? If the 12-hour model was used more wisely, that is, nurses were not working too much and/or too long, would there be a need for change? Will nurses and researchers pursue ways to address the negative outcomes of 12-hour shifts?


Article Content

In their seminal report, To Err Is Human (2000), the Institute of Medicine asserted that nurses' long work hours are one of the most serious threats to patient safety. The Joint Commission (Lockley, et al., 2007) issued a warning that evidence strongly suggests extended-duration work shifts (greater than 8 hours) significantly increase nurse fatigue and impair performance. As early as 1935, a compelling article from the American Journal of Nursing addressed nursing shift lengths, and was highlighted by Gardner and Dubeck (2016). Gilbreth (1935) noted that nurses' jobs make great physical and emotional demands upon them; therefore, nurses "should have a shorter work day" (p. 28).

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Twelve-hour shifts were devised by Baylor University Medical Center, Dallas, Texas, to attract registered nurses (RNs) to hospital nursing and address turnover. In the Baylor Plan, staff nurses worked three 12-hour shifts and were paid a standard work week of 40 hours per week. Initially, the Baylor Plan allowed nurses to work full time with 4 days off work per week (Garner & Bufton, 2001). However, nurses may work as many as five or six 12-hour shifts weekly (Trinkoff, Geiger-Brown, Brady, Lipscomb, & Muntaner, 2006). Increasingly, researchers report negative outcomes for nurses who work long or extended shifts and consecutive long shifts.


One literature review dating from 1975 to 2008 categorized studies as those finding positive outcomes from 12-hour shifts for nurses, patients, and organizations; studies noting conflicting evidence; and studies linking 12-hour shifts to increased risk of medical errors and health hazards for nursing staff (Lorenz, 2008). More recently, 12-hour shift research is predominantly divided into two categories-studies reporting negative patient care outcomes and studies reporting negative nurse outcomes.


This article reviews studies that address the negative impact of 12-hour shifts on nurses' health and well-being. The hope is that nurses and organizations who may be unwisely using the 12-hour staffing model will consider the potential health risks. Negative outcomes of 12-hour shifts for nurses are discussed and summarized in Table 1; a Glossary defines terms from work literature.

TABLE 1: Commonly Re... - Click to enlarge in new windowTABLE 1: Commonly Reported Negative Outcomes of 12-Hour Shifts


Trinkoff et al. (2006) used data from the Nurses Worklife and Health Study of 2,273 RNs to study work schedules. They concluded nurses were working too long, too much, and without adequate rest between shifts. Some RNs reported working shifts of 12 or more hours, working more than one job comprised of 12-hour shifts, working more than 50 hours per week, and getting inadequate sleep and rest between consecutive shifts. The researchers stressed that collective action was needed to address and improve scheduling. Ten years later, despite increasing research noting real, potential, current, and future health risks for nurses who work 12-hour shifts, this staffing method continues.


In the same year, Stone et al. (2006) examined 805 surveys from 99 nursing units, comparing outcomes from nurses working 8-hour shifts with outcomes reported by those working 12-hour shifts. Compared with nurses who worked 8-hour shifts, nurses who worked 12-hour shifts were on average more satisfied with their jobs. This study found no differences in patient outcomes. Nurses working the 12-hour shifts reported being less emotionally exhausted, and units with 12-hour shifts had lower vacancy rates.


Caruso and Hitchcock (2010) expressed concern for nurses' cognitive decline when working 12-hour night shifts (7 p.m. to 7 a.m.). Night-shift nurses sleep at irregular times and out of sync with their normal circadian rhythm. Cognitive declines associated with sleep-deprived fatigue include microsleeps (short episodes of sleep lasting a few seconds during which the brain is not processing information); errors of omission and commission; impaired information processing and learning; short-term recall and working memory decline; decreased awareness of one's environment; and decreased communication skills. Sleep deprived nurses cannot control and may even be unaware of the occurrence of microsleeps. Sleep deprivation leads to inferior ability to assess risks and increases the risk of drowsy driving. Caruso and Hitchcock note that evidence does not support the thought that the effects of sleep deprivation can be overcome through motivation, professionalism, training, or experience.

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Geiger-Brown and Trinkoff (2010a) reviewed 12-hour shift studies, finding that when nurses worked 12 or more hours, fatigue-related changes in nursing vigilance, increased needlestick injuries, and an increase in musculoskeletal disorders (especially neck, shoulders, and back) were reported. Other health consequences included hypertension, diabetes, and impaired glucose tolerance. Nurses reported failing to achieve adequate sleep between 12-hour shifts to recover physically and cognitively. Sleep deprivation consequences showed a linear increase in impaired neurobehavioral responses, such as reaction time and lapses of attention, as staff became more fatigued with consecutive 12-hour shifts and increased sleep deficit.


Geiger-Brown and Trinkoff stressed that research demonstrated that "much more than a few full nights of sleep for study participants to return to full neurobehavioral functioning" was required (2010b, p. 10). They queried why, given the problems, the alarm had not sounded among nurse administrators to pull the plug on 12-hour shifts. One year later in a follow-up study, researchers found that nurses working 12-hour shifts reported difficulty disengaging from work demands and failed to achieve restorative sleep. In addition, nurses evidenced a general lack of self-awareness of performance deficits concurrent with being sleep deprived (Geiger-Brown, Trinkoff, & Rogers, 2011). Geiger-Brown and Trinkoff shared what they termed harm reduction strategies to address 12-hour shifts. They urged leaders to use commercially available risk-management software, develop policies that respect nurses' days off, and provide completely relieved breaks and naps. Nurses also must willingly admit when they are exhausted and be allowed to call in ill when fatigued.



Nurse researcher Linda Aiken, joined by colleagues (Griffiths et al., 2014), conducted a cross-sectional survey of 31,627 nurses in 12 European countries. A relationship was found between shifts greater than 12 hours and nurses' reports of lower quality of care, care not completed, and poorer concern for patient safety. Chen, Davis, Daraiseh, Pan, and Davis (2014) expressed concern about the fatigue level (acute and chronic), intershift recovery, and unhealthy fatigue-recovery process reported by nurses working 12-hour shifts. They collected survey data from 130 RNs working 12-hour day shifts, finding that some nurses experienced high levels of acute fatigue (too tired after previous work schedule to engage in normal nonwork activities), and moderate levels of chronic fatigue and poor intershift recovery. The researchers urged nurses and nurse leaders to collaborate to establish fatigue intervention programs.


Although survey data from 22,275 RNs in four states showed that respondents were satisfied with staffing schedules, as nurses worked shifts longer than 13 hours, burnout and patient dissatisfaction with care increased (Stimpfel, Sloane, & Aiken, 2012). In another study, Stimpfel and Aiken (2013) joined the voices calling for regulating nurses' work hours similar to work hours set for resident physicians. Researchers also recommended developing cultures where nurses' time off and right to refuse overtime were respected, and nurses were educated about the importance of taking breaks. These authors stressed that sleep-deprived nurses have little awareness of their neurobehavioral deficits. Thus, relying on nurses to self-regulate their work hours should take a back seat to nurse administrators ensuring well-rested staff.


Stimpfel, Lake, Barton, Gorman, and Aiken (2013) found that pediatric nurses who worked more than 13 hours reported poorer job outcomes and lower quality and concern for patient safety compared with nurses who worked 8-hour shifts. In Griffiths et al.'s (2014) large European study of 12-hour day-shift nurses, nurses also reported lower quality patient care, less attention to safety concerns, and more care left undone. Researchers also began studying consequences of 12-hour shift work: biological rhythms.


The American Academy of Sleep Medicine (Wickwire, Geiger-Brown, Scharf, & Drake, 2017) identifies a disorder common to employees who work when other people are sleeping, and at a time when they would likely be sleeping if they were not on the job. Shift Work Sleep Disorder aptly fits nurses working 7 p.m. to 7 a.m. Working the night shift causes problems with the body's 24-hour internal clock or circadian rhythm. Results of this disorder include negative impact upon the immune system and increased susceptibility to colds and flu.


Geiger-Brown et al. (2012) shared research findings describing patterns of sleep, sleepiness, occupational fatigue, and neurobehavioral performance of hospital staff nurses over three consecutive shifts. Neurobehavioral changes included frequent episodes of inattention to essential tasks, and reduced vigilance, commonly referred to as surveillance. Nurses working successive 12-hour shifts achieved inadequate sleep to recover physically or cognitively, regardless of whether they worked day or night shifts. Thus, these nurses experience disruption of their circadian rhythm resulting in poorer sleep quality, shorter sleep periods, sleep deficit, and intershift and intrashift fatigue. Serious health and safety consequences included an increase in needlestick injuries, musculoskeletal disorders, insulin resistance, and drowsy driving. An alarming finding was that some nurses were unable to effectively judge their personal level of sleepiness. These authors were among the first to indicate a compelling need to develop methods to better assess potentially sleep impaired nurses' fitness for duty.



The Joint Commission (TJC, 2011) issued a compelling sentinel event alert in which they listed the negative impact of sleep-induced fatigue on nurses. These factors comprise lapses in attention and inability to stay focused, compromised problem solving, memory lapses, diminished reaction time, and impaired information processing and judgment. Organizational strategies to help mitigate fatigue and protect staff nurses are listed in Table 2.

TABLE 2: Organizatio... - Click to enlarge in new windowTABLE 2: Organizational Actions to Mitigate Fatigue Risks

The Occupational Safety Healthcare Administration (OSHA) also issued recommendations related to nurses' work schedules, including strong emphasis upon fatigue management and safety risk strategies. OSHA stressed that working shifts longer than 8 hours resulted in reduced productivity and alertness. OSHA called for managers and staff to work together to address the negative impact of 12-hour work schedules (Centers for Disease Control and Prevention, 2015).


The National Association of Neonatal Nurses' (NANN) position statement (Samra & Smith, 2015) recognized that preventing work-related fatigue requires a multifaceted approach. NANN's recommendations include limiting the number of consecutive 12-hour shifts to three shifts per week with at least 2 rest days after the three consecutive 12-hour shifts. NANN charges nurses to monitor their personal fatigue level to recognize factors that influence work-related fatigue, and to assume personal responsibility to modify these factors. NANN stressed the accountability of nurses to understand the role of rest and sleep and the significant impact that 12-hour shifts and accompanying sleep deficit has on personal health and welfare.


Concurrent with studies addressing nurses' work schedules, attention is directed to the complexity of the work environment. The demands of nurses' work and the complexity of work environments are well documented. Nurses' work environments have been described using the acronym VACU: Volatile, Uncertain, Complex, and Ambiguous.


Krichbaum et al. (2007) were concerned about the increasing performance demands made on nurses within the context of compressed time frames and system changes. They titled the phenomenon complexity compression, "what nurses experience when expected to assume additional, unplanned responsibilities, while simultaneously conducting their multiple responsibilities in a condensed time frame" (p. 88). During focus groups, subjects expressed feelings of impotence because of the rapidity and nearly continuous environmental changes that add to the physical toll of their work, where 40% of work is not direct patient care. Rather, work is related to the ever-increasing demands of the healthcare system, including new technology, increased and changing documentation requirements, orienting new staff and working with students, and delivering care to increasingly diverse patient groups. The complexity went beyond what nurses expected and for which they were prepared.



According to the National Sleep Foundation (Hirshkowitz et al., 2015), experts can't pinpoint the exact amount of sleep adults need in a 24-hour period. However, the rule of thumb is that adults age 26 and older need approximately 7 to 9 hours of sleep daily. Williamson and Feyer (2000) compared the relative effects of sleep deprivation and one's blood alcohol level. They found that after 17 to19 hours without sleep, performance on some tests was equivalent or worse than a blood alcohol of 0.05%. Response times and accuracy measures were significantly poorer.


Johnson et al. (2014) studied the impact of 12-hour night-shift nurses' sleep deprivation on patient care errors. They found that 56% of the nurses reported being sleep deprived, and making more patient care errors when sleep deprived. Hanlon et al. (2016) found that insufficient sleep is associated with a 33% increase in the hormones that control hunger. Sleeping less than the recommended hours is a risk factor for obesity. In their study, participants who had less sleep were more likely to report hunger and eat snack foods.


In her acclaimed book Lean In, Sheryl Sandberg (2013), the first female to serve Facebook(R) as Chief Operating Officer, discussed the new normal of not enough hours in an 8-hour workday. To heighten her effectiveness, she skimped on sleep. However, she discovered that sleeping 4 or 5 hours a night induced mental impairment equivalent to a blood alcohol level above the legal driving limit. Sandberg shared that if she could do things differently, she would force herself to get more sleep (p. 131).


The American Nurses Association (2015) asserts that nurses have the ethical duty to address workplace fatigue. Provision 5 in the Code of Ethics augments the importance of adequate rest, indicating that nurses have a moral duty to take care of their personal health and safety. Nurses should model the same health maintenance and health promotion measures they teach, avoid taking unnecessary risks to personal health, get sufficient rest, and strive to balance achievement of recreational and spiritual needs. The Code also states that nurse leaders share the responsibility to assist staff nurses to achieve this balance.


Given the research documenting the negative impact of 12-hour shifts, why has this staffing model remained the industry standard? Lothschuetz Montgomery and Geiger-Brown (2010) stress the evidence supporting a need to change staffing models is compelling, and the mandate for change is clear. What are the barriers to change?



The greatest barriers to changing this staffing model are staff nurses and nurse leaders. Staff nurses reportedly like, demand, and have become accustomed to the 12-hour model, currently the norm in many organizations. Staff nurses like the increased income potential and perceive they have more time off. Nurse leaders resist the major organizational culture revolution they perceive would be required for change. In addition, the 7 p.m. to 7 a.m. shift facilitates staffing the 3 p.m. to 11 p.m. shift, a slot reportedly most difficult to staff.


Poignant questions must be asked and answered, such as: When should the concern for nurses' health and well-being be factored into staffing decisions? If this staffing model was used more wisely, that is, if nurses were not working too much and/or too long, would there be a need to address changing the model? Rather than address the potential greater good to be obtained with a safer staffing model, will nurse leaders and researchers anticipate no change and pursue other ways to address the negative outcomes of 12-hour shifts?


Rather than proposing work schedules that address the most serious and/or the most frequently cited evidence-based negative outcomes of 12-hour shift work, authors are focusing on the fatigue factor. As early as 2010, Scott, Hofmeister, Rogness, and Rogers discussed implementation of a fatigue countermeasure program (FCMP). The FCMP comprised organizational-level fatigue management strategies, including assuring adequate staffing to allow staff nurses to experience completely relieved breaks, including meal breaks, and providing for strategic naps at work. The nurses learned strategies to help improve sleep quality, to enhance vigilance at work, to incorporate naps into their daily routine, and judicious use of caffeine. Challenges to implementing the FCMP included changing work group culture and letting go of sacred cows, geography of the units, and emotional response to change. Nurse managers cited limited resources, out-of-date policies, and nurses' resistance to completely relieved breaks (when nurses shut off personal cell phones and similar devices). Scott noted that to successfully establish FCMPs, nurses must appreciate the significant impact of sleep deficit on their personal health and welfare (Scott et al.).


A multilevel organizational fatigue risk management system (FRMS) was proposed at one large academic medical center (Steege & Pinekenstein, 2016). The FRMS includes evidence-based decision making at the organizational nurse leader level. Unit nurse leaders monitor adherence to breaks and adopt and use software scheduling systems. Staff nurses must learn strategies to monitor sleep quality, quantity, and practice of self-care.


Development of a comprehensive fatigue management program was discussed in a two-part article. In Part 1 (Blouin, Smith-Miller, Harden, & Li, 2016), authors differentiated fatigue (body's response to sleep loss) and sleepiness (tendency to fall asleep). They found that younger nurses reported a higher incidence of acute fatigue, and all staff reported less than ideal intershift recovery. The authors urged nurse leaders to "consider nursing staff as a limited resource, one that requires rest and respite to work and adequate recuperation time" (p. 334).


In Part 2, authors describe fatigue reduction interventions. The interventions were comprised of duty-free breaks, limiting shift duration to 12.5 hours under normal circumstances, and limiting consecutive shifts (no more than 60 hours in a 7-day period). Two factors that hampered duty-free breaks include nurses' reluctance to let float nurses cover their patients, and fluctuating patient census. Recommendations include educating staff about the negative impact of fatigue, instituting duty-free breaks, and standardizing scheduling policies requiring 48 hours of recuperation between a night and day shift. The authors note that "despite the preponderance of evidence, most nurses did not conceptualize work-related fatigue as a patient safety issue" (Smith-Miller, Harden, Seaman, Li, & Blouin, 2016, p. 415).


Perhaps a more provocative thought might be why nurse leaders hesitate to use the evidence supporting the negative impact of 12-hour shifts and push for safer staffing models. An important question was asked a decade ago (Lorenz, 2008): Given the research documenting negative staff nurse outcomes, are 12-hour shifts an ethical scheduling option for nurse leaders?


As 12-hour shift research depicting negative outcomes increases, can nurse executives ethically continue to support 12-hour shifts? Nurse leaders are charged as stewards of their most valuable asset-professional nurses. Boa (2001) writes that work is not a result of the fall (Genesis 3); work is part of God's created order for mankind's good. Work embeds us in a temporal environment in which we can exhibit God's kingdom values. He asserts that "work provides a context in which we can represent demonstrating character...and by doing our work with care and quality" (p. 238). Boa further points out that what may appear to be a secular job becomes a spiritual pursuit, if the focus of the workers' hearts is on God's kingdom (Matthew 6:33). Work can be pleasant and stimulating, whereas work becomes labor when it requires strenuous effort to a point of fatigue.



Within some faith communities, adherents, including nurses, believe that the third person of the Trinity, the Holy Spirit, indwells Christ followers. Our bodies are temples of the Holy Spirit. Consistent with this belief is the expectation that nurses who affirm this are to be good stewards of their bodies (1 Corinthians 3:16; 2 Corinthians 6:19). In Conformed to His Image (2001), Boa notes that when one works too long or too much, the ability to cultivate quality relationships with God and/or family and friends is hindered. He reminds readers of the Sabbath principle: The principle of restoration, achieved by a balanced rhythm of work and rest.


Since Trinkoff et al.'s (2006) study addressing nurses' work shifts, there has been an increasing number of studies depicting negative outcomes on nurses of 12-hour shifts. The initial intent of the Baylor Plan was that nurses would work three shifts, thus they could conceivably have four days off. In reality, many nurses are reportedly working more than three shifts per work week. To date, there is a dearth of literature differentiating the potential impact on nurses working three 12-hour shifts from that of nurses working extended hours and extended numbers of 12-hour shifts. Perhaps, the future emphasis of studies of this staffing model should include that differentiation as a variable.


In the interim, nurses who believe the Holy Spirit resides in them and who work more than four 12-hour shifts in a 7-day work week should ask: Does my current work schedule demonstrate that I am caring for the temple of the Holy Spirit? Does my work schedule show respect for myself? For my patients? Am I self-monitoring my fatigue level and potential cognitive decline in relation to the outcomes I desire for my patients? Am I exhibiting kingdom values?


Glossary of Key Fatigue and Sleep-Related Definitions

Acute fatigue: Inability to engage in normal activities as a result of previous activity.


Chronic fatigue: Sets in when a person can't recover from acute fatigue; characterized by unrelieved physical exhaustion (Chen et al., 2014).


Fatigue: An overwhelming sense of tiredness, lack of energy, and a feeling of exhaustion associated with impaired physical and/or cognitive functioning (Gardner & Dubeck, 2016).


Fatigue recovery process: Process in which one recovers physically and mentally from extended work; staff nurses reportedly sacrifice recovery time to work extra hours.


Intershift fatigue: Sense of being tired; indicative that staff nurse did not recover from fatigue from previous shift(s) work.


Intrashift fatigue: Sense of being tired while working extended shift, usually a result of inadequate rest and restorative sleep between shifts.


Partial sleep deprivation: Occurs in situations in which staff nurses waking (work schedules) are longer than 18 hours, shortening their time for sleep.


Sleep: A biological need for life and health, similar to need for food and water; a naturally recurring state where the brain progresses through alternating cycles of light and deep sleep (sleep stages), allowing the brain and body to physically and cognitively restore itself; characterized by altered consciousness, relatively inhibited sensory activity, inhibition of voluntary muscles, and reduced interactions with surroundings (National Institute of Neurological Disorders and Stroke, n.d.).


Sleep deprivation: Inability to achieve adequate sleep requires to self-evaluate feeling of being wakeful and ready to perform.


* Results from obtaining fewer hours of sleep than required to feel rested (Caruso & Hitchcock, 2010; Johnson et al., 2014).


* The effects of sleep deprivation are not overcome by motivation, professionalism, training, or experience (Caruso & Hitchcock, 2010).


* Impairs information processing and learning (Caruso & Hitchcock, 2010).


* Leads to an inadequate ability to assess risks; risk-taking behaviors may increase (Caruso & Hitchcock, 2010).


* Leads to irritability, anxiety, depression, and impaired communication competencies.



Sleep-deprived fatigue: Caused by/result of sleep deprivation. When wakefulness is extended beyond the usual 16-17 hours, performance is likely impaired. It is unknown what the level of fatigue is when performance becomes problematic (Williamson & Feyer, 2000).


Sleepiness: Results from an alteration of imbalance in sleep/wake cycles (Gardner & Dubeck, 2016); may also result from lack of quantity of restorative sleep.


Sleep inertia: Impairment present immediately on awakening from naps and sleep.


Work-related fatigue: Tiredness from work schedule (to be differentiated from being sleepy); can lead to reduced job performance.


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