Does Evidence Based Practice Concerning Nurses' Schedules Matter?

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    Evidence Based Research on nurse staffing/scheduling & workloads is all, but ignored. Annually, there are millions of medical errors, many of which can be attributed to nurse scheduling/staffing & workload. Nurses and nursing organizations ignore the research at our peril!

    Does Evidence Based Practice Concerning Nurses' Schedules Matter?

    I've been busy lately, as I'm sure many of you have been, as well. I'm also finishing up an online leadership class, and my focus area is staffing/scheduling. I've been interested in this area since nursing school and, sadly, I can't see that much has changed. I'm particularly concerned that in the area of staffing/scheduling/workload, nurses don't take the advice of the much heralded Evidence Based Research we are all so frequently reminded to implement.

    In a nutshell, much of the EBR demonstrates that 12hr shifts are problematic, at best, dangerous, at worst. Yet, since the 1980s, when 12hr shifts went into effect, nurses, nursing organizations, and medical facilities have not budged much on the 12hr shift/schedule. I know the research also shows that for every nurse that doesn't like the 12hr shift, another nurse does, so, nurses themselves are mixed on the decisions. Nursing organizations and governing bodies have largely been silent, or at least, lax, with the exception of California's statutory legislation mandating nurse-patient ratios.

    I believe there is, or has to be a better way. One proposal that I've thought about is in the realm of more nurse autonomy in scheduling, which also flies in direct opposition to management/administration/hospital executive policies and practices. I believe flexible scheduling could achieve cost-cutting goals, patient safety goals, and boost nurse morale, as well.

    I also think that nurses have to decide what they really want! I'm not doubting that nurses want to do right by their patients. I'm not doubting that nurses are professionals and deserve to be treated as the most trusted & honorable profession in the United States. I think many nurses experience intra-personal conflict and don't know how to work out the personal and professional ethical dilemmas going on within some of us.

    On the other hand, I believe management is content with the status quo, as it is in their best financial and personnel costs to leave things as they are, despite the evidence-based research. But, I don't think either of us can have it both ways, at least not forever.

    So, I ask, what do we really want? If we push EBR as the standard, why don't we use the standard when it comes to scheduling/staffing? Or, are millions of annual medical errors totally unrelated to anything having to do with staffing, scheduling, and workload? And, why aren't our membership-based organizations doing more on our behalf in this area?

    And, what about the research that consistently demonstrates the low morale, abbreviated family time, sleep deprivation, high attrition, and other cons of the scheduling/staffing/workload mix? What about the much touted "work-life balance" and "holistic" living for nurses? Do we ignore the parts of EBR that we just don't like?

    Does management ignore the research that demonstrates that nurses want more flexibility, financial incentives, more time off, and more standardized/mandated workloads & nurse to patient ratios? Does management take into account any of the reasons why nurses are leaving the profession or at least leaving the floor, in droves?

    Is either side ready to take a seat at the table and work out the hard spots, always with the idea that there has to be a win-win? Both sides want the best for patients, but, is that same spirit given to both sides in the debate?

    My fear is that things won't change until something devastating happens that will exceed the risk management/liability limits set aside by any medical institution. In other words, when it costs more to pay out medical claims than it does to hire nurses for 12hours shifts, then we will see the need for paradigmatic changes in our profession.
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    30 Comments

  4. by   SaltySarcasticSally
    Honestly, if they took away 12 hr shifts at the hospital, I wouldn't work there. Going to 8s mean two more days of daycare a week and I've done 8s in LTC, you are NEVER there for just 8 hours. More like 10 hrs 5 days a week, extra time you aren't paid for because admin c/o OT so you clock out just to put another 2 hrs in. I suspect the same would happen in acute care since state mandated ratios are a very nice idea that will likely never be implemented. I do think however that night shift workers should be paid for more than a few extra $$/hr because of the toll it can take on your health.
  5. by   MunoRN
    The evidence definitely matters, the bigger question is what the evidence actually is. Shift lengths greater than 13 hours are clearly associated with an increased risk of errors, near errors, and other adverse effects of fatigue, however there isn't conclusive evidence that a 12 hour shift schedule produces more risk and fatigue overall particularly in settings where 24-7 staffing is required. The most cited 'evidence' against 12 hour shifts comes from a Geiger-Brown that supposedly found "3 times" the risk of errors in 12 hour shifts, although a closer reading of the study shows this figured on a "per shift" basis which of course is not an equal opportunity for error, when corrected for an equal amount of time (errors per hour for instance), the risk is actually slightly less for a 12 hour shift schedule.
  6. by   llg
    I agree with MunoRN. More (and better) research is needed. I find it odd that the OP says, "I believe flexible scheduling could achieve cost-cutting goals, patient safety goals, and boost nurse morale, as well," while citing no evidence for this -- or for many other statements in the article. And yet, the author espouses the importance of focusing on and using "the evidence."

    Almost everyone ignores the evidence when it says something they don't want to hear. Management ignores the part where nurses say what they want when what nurses want is expensive. Staff ignores the parts that say they should get enough sleep, exercise, eat right, don't work too many hours in a week, etc. when they want the extra pay and/or want to live a lifestyle that is unhealthy. Both sides ignore the inconvenient evidence and only focus on evidence that supports their desires.
  7. by   Nobody00
    Where I work its all 8 hour shifts and self scheduling.

    Weekends and holidays have really nice pay bonuses so people are fighting to work them.
    No one is forced to work nights as again, longer nigh shift (10 hours), good extra pay mean permanent night staff who choose to work nights. Virtually impossible for a new grad to work night shift.

    Yet we have people asking for 12s, to not come to work 5 days a week.
    As a CNA I'd love 12 hour shifts; but here CNAs are only working 0600-1400 + sometimes sitter shifts in afternoon or night.
    It's kinda annoying to start this early 5 days a week.
  8. by   Boomer MS, RN
    Quote from llg
    I agree with MunoRN. More (and better) research is needed. I find it odd that the OP says, "I believe flexible scheduling could achieve cost-cutting goals, patient safety goals, and boost nurse morale, as well," while citing no evidence for this -- or for many other statements in the article. And yet, the author espouses the importance of focusing on and using "the evidence."
    I second this, in particular the need for far more research. I detested 12-hour shifts and didn't start doing them until I was 50. Then went to 10s, which I preferred. But what about SaltySarcastisSally's comment about more days of daycare needed if there are only 8-hour shifts? That's problematic for some. Most younger nurses I've spoken with prefer 12s, which I understand. I've "heard" hospitals prefer 12s b/c it's easier to staff those shifts. From experience I can say it was harder to fill a 12-hour shift when there was a sick call. No easy answers but better research and replicated studies would help.
  9. by   smartassmommy
    I think that when the bottom line is at stake EBR goes out the window. Until the public is made aware of understaffing resulting in negative outcomes, it will continue to be a problem
  10. by   Boomer MS, RN
    Quote from smartassmommy
    I think that when the bottom line is at stake EBR goes out the window. Until the public is made aware of understaffing resulting in negative outcomes, it will continue to be a problem
    Yes, the bottom line, unfortunately, is at stake in the current healthcare climate for various reasons. EBR is the only way to make the public and the PTB aware. No one listens to anecdotal stories. Change will never come without valid research. And even then it may be a long time coming.
  11. by   Ruby Vee
    Quote from Boomer MS, RN
    I second this, in particular the need for far more research. I detested 12-hour shifts and didn't start doing them until I was 50. Then went to 10s, which I preferred. But what about SaltySarcastisSally's comment about more days of daycare needed if there are only 8-hour shifts? That's problematic for some. Most younger nurses I've spoken with prefer 12s, which I understand. I've "heard" hospitals prefer 12s b/c it's easier to staff those shifts. From experience I can say it was harder to fill a 12-hour shift when there was a sick call. No easy answers but better research and replicated studies would help.
    This older nurse will give up 12 hour shifts when they pry them from her cold, dead hands.

    I participated in the struggle to get 12 hour shifts back in the 80s. Compared to 8 hour shifts (which somehow never turn out to be just 8 hours), they're wonderful. Five days of commuting vs. 3? I'll take it! Five days of work means you rarely get two days off in a row, can't go to the shore for a spontaneous d day "weekend" and rarely get to take advantage of a weekday off for errands, doctor's appointments, waiting for the cable guy or to experience the short lift lines at the ski hill, empty camping sites at the state park or early bird tickets at the movies. I get plenty of work/life balance with my 12s.
  12. by   NuGuyNurse2b
    12's are hard, but 8's are harder. With 12's, you might actually leave at 12.5hrs (full charting, everything done) and enjoy what few hours you have to live and then sleep for the next shift. With 8's, you're looking at anywhere from 10-11 hrs once you're done charting and making sure you're not dumping on the next shift. And you basically end up working near-12's for 4-5 days straight, instead of 12's for 3 days.
  13. by   RNperdiem
    Ruby was right about 8 hour shifts rarely being just 8 hours. I worked 7-3, and to get all you need to get done in that time frame is almost impossible. I would almost always stay late to get most of it done.
  14. by   CeciBean
    When 12 hour shifts first came in, I was *told* that I would work them, not asked, and sent to nights from my evening shift. That was my first experience, and it was awful. I eventually ended up on another unit where the manager tried to accommodate everyone's wishes and staff accordingly, 8s and 12s. Following that I worked in a number of places and eventually accustomed myself to 12 hour shifts but have never really liked them. I think overlapping 10s, which I saw in one hospital, would be ideal for everyone, but hospitals seem to be reluctant to try those, as they are reluctant/resistant to any "new" thing.
  15. by   klriggs53
    We preach EBP, however when research reveals something we do not want to hear or it affects the pocket book, convenience, or admin control we turn our heads. Back in the 70's (tellin my age), the common practice was 3 eight hr shifts 5 days a week with 12 on,12 0ff for the weekends. Shift diff incentives for eves and nights. It worked well . . . Naturally, as nurses we adapt. If there is in fact research for better nursing care working 8 hr shifts, we will be hard pressed not to move in that direction and avoid being hypocritical.

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