Evidence
In general, excessive total hours worked puts nurses and patients at risk. In addition, rotating shifts can also threaten patient safety. Research by Circadian Technologies Incorporated has found that the number of accidents for all shift workers is 1.2 times greater than that for traditional workers and the resulting incremental cost to business is $8.5 billion. (Bureau of National Affairs, 2003)
Following a substantial review of the literature, the Institute of Medicine’s Committee on Work Environment for Nurses and Patient Safety found strong evidence linking prolonged work hours and fatigue and its affect on worker performance (IOM, 2004). This affect includes slowed reaction time, lapses of attention to detail, errors of omission, compromised problem solving, reduced motivation, and decreased energy for successful completion of required tasks. This led to the following recommendation: “To reduce error-producing fatigue, state regulatory bodies should prohibit nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per 7-day period” (IOM, 2004).
Trinkoff, Geiger-Brown, Brady, Lipscomb, & Muntaner (2006) found that 17 percent of staff nurses, 4 percent of managers and 7 percent of advanced practice registered nurses regularly exceeded the IOM’s recommendation.
In 2004, the Institute of Medicine (IOM) report, Keeping Patients Safe: Transforming the Work Environment of Nurses described the central role of nurses in protecting patient safety and achieving better patient outcomes; and it discussed the frequent mismanagement of the nurse’s work environment (eg., failure to refuse additional patients when the unit is already stressed to its maximum capacity) that often threatens these integral contributions. Among those issues highlighted in the report, the IOM focused on institutional support and structures for maintaining nurse staffing at levels sufficient to avoid patient safety issues caused by nurse fatigue. recognized that creating a healthy work environment for registered nurses that is most conducive to patient safety will require fundamental change within a health care organization.
Strong evidence links prolonged work hours (more than 12 hours in a 24-hour span, or more than 60 hours in 7 days), rotating shifts and insufficient breaks to:
- slowed reaction time,
- lapses of attention to detail,
- errors of omission,
- compromised problem solving,
- reduced motivation, and
- decreased energy for successful completion of required tasks. (IOM 2004, p.12).
Findings from a 2004 landmark study, The Working Hours of Hospital Staff Nurses and Patient Safety (Rogers, Hwang, Scott, Aiken & Dinges), clearly demonstrates that the hours a registered nurse works is related to the errors and near misses made by that registered nurse in patient care. This research also found that the likelihood of making an error was three times higher when nurses worked shifts lasting 12.5 hours or more. The authors recognized that long, unpredictable hours suggest a link between poor working conditions and threats to patient safety.
Another study, Extended Work Shifts and the Risk of Motor Vehicle Crashes among Interns (Barger et al., 2005) focused on medical interns and demonstrated the potential of impact of long hours and fatigue on motor vehicle crashes, near-miss incidents, and incidents involving involuntary sleeping. Findings from this report showed that extended-duration work shifts posed a serious and preventable safety hazard for the physicians and other motorists, apart from increasing the risk of failures of attention and serious medical errors.
Findings from the Nurses Work life and Health Study (Trinkoff, et al., 2006), a longitudinal study of 2,273 registered nurse respondents, suggest that of the one-third that worked more than 40 hours per week, 19 percent worked 41 to 49 hours, 8 percent worked 50 to 59 hours, and 6 percent worked 60 or more hours. Looking specifically at those registered nurse respondents with more than one job, the researchers found that these nurses were “more likely to work 12 or more hours per day (37% versus 28% of the total) and 50 or more hours per week (24% versus 14% of the total).” In addition, registered nurses who work more than one job were more likely to work stretches of consecutive days without breaks, work with insufficient rest, and to work during scheduled time off.