Authors

  1. Keys, Yolanda DHA, MSN, RN, NEA-BC, EDAC

Abstract

OBJECTIVE: The purpose of this study was to explore perspectives of nurse leaders regarding strategies to mitigate the job demands of 12-hour shift work and learn their views regarding the role of breaks in offsetting the cognitive and physical demands of acute care nurses working 12-hour shifts.

 

BACKGROUND: The strain of long shifts can result in adverse outcomes for nurses, organizations, and patients.

 

METHODS: A modified, 3-round, e-Delphi solicited input from nurse leaders. First, qualitative information about support and resources to mitigate the adverse effects of 12-hour shifts was collected, and then 2 subsequent rounds used consensus identification and item ranking to develop recommendations.

 

RESULTS: Findings reinforce that job demands of 12-hour shifts can be mitigated via staffing practices, quiet break spaces, and the opportunity to work with familiar patients.

 

CONCLUSIONS: Recommendations from this work may enhance patient safety, positive organizational outcomes, and a resilient and sustainable nursing workforce.

 

Article Content

The 12-hour shift has become ubiquitous in acute care nursing, but it has not always been so. Shifting from three 8-hour shifts to two 12-hour shifts began as a way to address a national nursing shortage in the 1970s.1 Since then, both nurses and nurse leaders have become accustomed to 12-hours shifts for scheduling convenience; however, the effects of 12-hour shifts on nurse, patient, and organizational outcomes are inconsistent.2,3

 

Review of Literature

Nurses working shifts greater than or equal to 12 hours are at a greater risk for missing care interventions,3 making errors,4 work-related injury,5,6 and poor sleep patterns.7 The perceived benefits of 12-hour shifts for nurses include flexibility of work hours and more time with family,4 but when the strain of long shifts leads to burnout, it can cost the organization upward of $25 000 per nurse.8 One of the purported benefits of 12-hour shifts is the ability for nurses to have more days off in a row, but this means they often work multiple, consecutive, 12-hour shifts. The cumulative effects of multiple 12-hour shifts place nurses at a greater risk for physical injury2,9 and workplace stress,10 both of which can lead to burnout.9,11

 

In addition, shifts of 12 hours or greater have been shown to adversely impact patient outcomes. Patients of nurses who work 12-hour shifts can experience increased levels of dissatisfaction,12 a greater risk of missed treatments,3 and higher-than-expected mortality.9 Higher proportions of nurses working 12-hour shifts are associated with increased levels of patient dissatisfaction internationally3 and nationally per the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.12 Decreased HCAHPS scores can result in reduced Medicare reimbursement.12

 

When the job demands of 12-hour shifts result in turnover, organizations incur costs related to replacing experienced nurses with newer nurses, part-time or temporary staff, increased adverse events, lack of care continuity, and declines in staff productivity.8 Nurses report being more satisfied with their jobs when they work 12-hour shifts but also report higher levels of burnout and injury risk as shift length increases.5,12 For example, older nurses who find it difficult to keep up with the physical demands of a 12-hour shift may leave the profession prematurely, depriving the organization of their intellectual capital.1,13

 

Few studies focus on organizational strategies to mitigate the negative effects of 12-hour shift work in acute care nurses. The American Nurses Association called for RNs and employers in all care settings to collaborate on evidence-based strategies to reduce the risks of shift work and long hours,14 and because there is no indication 12-hour staffing patterns are being eliminated, it is incumbent on nurse leaders to use evidence-based strategies to support a healthy workforce within that framework.

 

One commonly recommended strategy to offset the demands of nursing work is the use of breaks. Previous studies underscore the importance of breaks15,16 and break spaces,17,18 but none has specifically considered the nuances of breaks to improve the job performance of nurses who work 12-hour shifts. Although the importance of work environment and organizational policies influence break practices, only 1 study addressing supervisor support of breaks was noted.19

 

The purpose of this Delphi study was to explore the perspectives of nurse leaders regarding strategies to mitigate the job demands of 12-hour shift work and to learn their views regarding the role of breaks in offsetting the cognitive and physical demands of nurses who work 12-hour shifts.

 

The central questions guiding this inquiry of nurse leaders included the following:

 

* What do you believe might help offset the cognitive and physical demands of nurses who work 12-hour shifts?

 

* How might mandated breaks offset the cognitive and physical demands of nurses who work 12-hour shifts?

 

* How might the architectural design of breakrooms or respite rooms offset the cognitive and physical demands of nurses who work 12-hour shifts?

 

* What alternative strategies or other elements of the work environment might help offset the cognitive and physical demands of nurses who work 12-hour shifts?

 

 

Conceptual Model

The conceptual model for this study is the Job Demands-Resources (JD-R) model.20 The JD-R model is based on the assumption that every occupation has both job demands associated with cognitive or physical stress and job resources that can help alleviate or mitigate the cognitive or physical stress associated with job demands.20 Shifts greater than or equal to 12 hours are characterized as a nursing job demand because of the physical and cognitive toll experienced by the nurse.3-6 The JD-R model has been used to understand the demands of working understaffed,21 but no research has used it to understand job demands on nurses who work 12-hour shifts or job resources that might offset the demands of 12-hour shift work in nurses.

 

Methods

The study used a modified e-Delphi methodology as described by Hasson and Kenney (2011) to solicit input from a diverse group of nurse leaders. There were 3 rounds of online data collection. Each round informed the next.

 

Setting and Sample

Nurse leaders were recruited from the American Organization of Nurse Leaders' (AONL) membership through newsletter platforms and from the principal investigator's (PI's) professional network. Inclusion criteria were posted on the 1st page of the online survey to ensure participants were at least 18 years old; had at least 3 years of experience directly supervising acute care, bedside nurses who work shifts greater than or equal to 12 hours; and were willing to participate in at least 1 round. Participants who indicated they met the inclusion criteria were taken to the 1st survey question, and those who did not meet inclusion criteria were taken to a "thank you" screen that ended the survey. All participants were invited to share the invitation associated with each round in snowball recruitment style.

 

Human Subjects

This study was approved by the Texas A&M University-Corpus Christi Institutional Review Board. Study details outlining the purpose, procedure, risks, benefits, alternatives, and confidentiality measures were included in the recruitment information sent to potential participants. Information about the study was available on the opening survey screen for each round along with a reminder that participants could withdraw from the study at any time without penalty. Completion of the online survey served as implied consent.

 

Measures

The 1st Delphi round gathered qualitative information about support and resources to mitigate the adverse effects of 12-hour shifts, and 2 subsequent rounds synthesized collected data using consensus identification and priority ranking of recommendations.22 Validity was established through member checking inherent in the 3-round Delphi design and through the assistance of 2 external auditors to review not only the specific analysis of each Delphi round but also the entire study.23

 

Round 1

The modified approach used for this study presented participants with issues preselected from a literature review to provide context.24 Questions for round 1 are listed in Table 1. Topics guiding round 1 included the cognitive and physical demands of 12-hour shifts,20,21,25 work breaks,15,16,19,26 breakrooms,17,18,27 respite rooms versus breakrooms,17,18 relaxation strategies,28,29 and a final, open question about ways the work environment might offset job demands.

  
Table 1 - Click to enlarge in new windowTable 1 Questions Used in Delphi Round 1

Analysis

NVivo (v12) qualitative software was used for content analysis of the 27 completed round 1 surveys. Responses were imported into the software, reviewed, and coded to identify themes. Themes were reviewed, consolidated, and then formulated into questions for round 2 (Table 2).

  
Table 2 - Click to enlarge in new windowTable 2 Questions Used for Delphi Round 2

Results

Round 1 participants represented 10 different states with 11 participants from Texas; 6 from California; 2 from Michigan; 2 from Wisconsin; 1 each from Louisiana, Maine, Missouri, and Washington; and 1 who indicated they worked nationally. Round 1 themes were grouped into 2 categories: recommendations to mitigate job demands of 12-hour shifts and suggestions regarding breakrooms. Questions resulting from identified themes were reviewed with 2 independent researchers before distribution of the round 2 survey.

 

Round 2

Round 2 questions were written so participants could rank elements according to level of importance along a 7-item Likert-type scale (1, not at all important; 2, low importance; 3, slightly important; 4, neutral; 5, moderately important; 6, very important; 7, extremely important). Updates to the AONL recruitment advertisement were requested, and emails were again distributed to the PI's professional network and to those participants who shared their emails in round 1.

 

Analysis

The Statistical Product and Service Solutions (v26; San Francisco, California) was used to analyze frequencies and descriptive statistics for the 23 round 2 responses submitted. If participants had 70% or greater agreement that an item was important (rated as either 5, 6, or 7), then the item was included in the round 3 survey.

 

Results

Round 2 participants represented 9 different states with 10 participants from Texas and 1 each from Arizona, Iowa, Louisiana, Michigan, Missouri, New York, Washington, and Wisconsin. One participant was from Canada. Topics retained for round 3 included unit culture, adequate staffing to cover breaks, the ability to leave the unit during a break, fatigue education, self-care education, reduced walking distances, having the same patients for multiple sequential shifts, good teamwork, on-time report, respite rooms, quiet breakrooms, pleasing esthetics of the breakroom, a window in the breakroom, comfortable furniture, and breakroom proximity to the unit. Three topics were deemed important by all participants: adequate staffing to cover breaks, good teamwork, and on-time report. As with round 1, questions resulting from round 2 analysis were reviewed with 2 independent researchers before distribution of the round 3 survey.

 

Round 3

Round 3 questions were written so participants could rank-order related elements that may be more important than others in alleviating the negative effects of 12-hour shifts (Table 3). Participants were asked to assign a value to a cluster of elements derived from round 2 data (1, most important; 2, secondary importance; 3, tertiary importance; etc). Updates to the AONL recruitment advertisement were requested, and emails were distributed for a 3rd and final time to the PI's professional network and to those participants who shared their emails in rounds 1 and 2.

  
Table 3 - Click to enlarge in new windowTable 3 Questions Used in Delphi Round 3

Analysis

The Statistical Product and Service Solutions (v26; San Francisco, California) was used to assess frequency rankings to determine priority areas, and results are presented in Table 4 with elements ranked most important highlighted. Question 1 asked participants to rank elements related to breaks, and 18 respondents indicated uninterrupted breaks to be of upmost importance when compared with the ability to leave the unit or access to the outdoors. Question 2 focused on elements related to unit operations, and 14 respondents indicated adequate staffing so nurses could take uninterrupted breaks was most important compared with good unit teamwork and on-time change-of-shift report. Question 3 asked participants to rank different elements of education that might mitigate the impact of 12-hour shifts, and a majority of 15 indicated education for nurses on self-care practices was most important compared with education on fatigue or organizational break policies. Question 4 asked about walking distances and patient assignments, and 13 respondents indicated having the same patient assignments over multiple shifts in a row was most important when compared with a unit layout or patient assignments that limited walking distances. Question 5 asked respondents to consider a separate breakroom compared with 2 aspects of food availability. Whereas a majority of 11 respondents indicated a designated room in which to rest (distinct from a traditional breakroom) was most important, 9 respondents indicated the opportunity to purchase food quickly and not spend valuable break time in cafeteria lines was also important. Question 6 asked respondents to rank breakroom characteristics substantiated in earlier rounds of this study. Quiet was the breakroom characteristic ranked most important, with a window to look outdoors and close proximity to the patient care unit not far behind. A final question asked participants to rank the topics from the previous questions to assess which topic was most important in alleviating the negative effects of 12-hour shifts. A clear consensus among participants indicated adequate staffing so nurses could enjoy uninterrupted breaks was essential.

  
Table 4 - Click to enlarge in new windowTable 4 Results of Delphi Round 3

Results

Round 3 participants represented 8 different states with 11 participants from Texas, 2 from California, and 1 each from New York, New Jersey, New Mexico, Virginia, and Wisconsin. There was 1 international respondent from Canada and 1 from Saudi Arabia, and 1 participant did not enter a location.

 

Results from round 3 are more complex than those from the previous 2 rounds due to the ranking format used. Participants were asked to assign a value within clusters of elements such that conclusions can only be drawn in the context of the elements included in each respective cluster. In 3 separate clusters (questions 1, 2, and 7), respondents ranked uninterrupted breaks to be most important. In addition, in 2 clusters (questions 5 and 6), participants emphasized the importance of restful environments in that participants prioritized the importance of a room to rest that is distinct from the traditional breakroom and the breakroom characteristic deemed most important was quiet. These findings would indicate a quiet room that is separate from the traditional, busy, nursing breakroom to be a priority among respondents. Finally, it is reasonable to conclude that, if nurses who worked 12-hour shifts were able to take uninterrupted breaks in a room that is quiet and separated from the traditional unit breakroom, they would be able to recharge, participate in self-care practices (question 3), and emerge from their break time renewed to address the demands of their 12-hour shift. A final result of note is participants' preferences for the same patient assignments over multiple successive shifts. This preference is understandable given the cognitive load associated with learning a new patient assignment. When nurses are working multiple successive shifts, the ability to work with familiar patients may help reduce the cognitive demand.

 

Although most study participants were from Texas and then California, the distribution of responses was interesting in that respondents from California (where break guidelines are more stringent) tended to focus more on how to organize mandated breaks whereas nurses from other states, namely, Texas, focused importance on what would support nurses to take breaks. The overall results of this study circle back to the JD-R model20 because, according to the nurse leaders in this study, the job demands of 12-hour shifts can be mitigated by ensuring job resources such as adequate staffing that allows for quiet, uninterrupted breaks.

 

Limitations

Although this study does provide useful information to nurse leaders, 3 specific limitations should be considered. First, the use of round 1 questions based on a literature review may have narrowed the range of responses offered by nurse leaders. Second, the use of a convenience sample may not be representative of all nurse leaders' opinions or all strategies that could be used to mitigate the negative effects of 12-hour shift work. Finally, relatively low response rates (round 1, n = 27; round 2, n = 19; and round 3, n = 22) may not have captured comprehensive perspectives.

 

Practice Implications

Overall responses indicate that, without adequate staffing to allow nurses to take uninterrupted breaks, other design or breakroom elements are for naught. On the basis of findings from this study, it would be optimal for nurses who work 12-hour shifts to have adequate staffing for uninterrupted breaks in a quiet room, distinct from the traditional unit breakroom, so they can recharge, participate in self-care, and emerge renewed to resume the demands of their 12-hour shift. Furthermore, if nurses are working multiple, successive 12-hour shifts, they should have the option to work with familiar patients. These implications may be especially important to manage nursing fatigue during surge capacity situations. Future research might consider differences between staffing models such as whether charge nurses have patient care assignments or whether a unit has a resource nurse to facilitate breaks.

 

Conclusions

Information from this work can inform nurse leaders to create a more supportive work environment. Although 12-hour shifts pose a clear job demand on nurses, there are strategies nurse leaders can leverage as job resources to mitigate the physical and psychological toll. By focusing attention on staffing to ensure nurses can take uninterrupted breaks, quiet spaces, and the opportunity to work with familiar patients, nurse leaders can foster organizational and unit cultures that support job resources to mitigate job demands. By consolidating and confirming the opinions of experienced nurse leaders, this work may be an important next step in support of patient safety, positive organizational outcomes, and a resilient and sustainable nursing workforce.

 

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