Does Evidence Based Practice Concerning Nurses' Schedules Matter?

[Eschell2971]

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.

[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.

[Jedrnurse, BSN, RN]

Can we please stop using the phrase "12 hour shift"? They are never just 12 hours...

[OncoRN84]

I've asked many nurse's on schedule preference and it usually- "I want to do my 3 days and be done." I have a few that wanted to transfer but decided going back to 5 dasys a week just isn't worth it. However, i have consistently brought up the problems with asking workers to stay over for extended meetings. Especially after night shift, a three hour meeting is not only torturous but dangerous as we still must drive home. I think safety needs to be more thoroughly studied regarding nights but I think it would be a hard sell for inpatient RNs.

[gypsyd8]

This person has 2 years of experience. Nurses need ratios, not a reduction in hours worked. If I was forced to work 5 days a week without overtime I wouldn't be at the bedside.

[CKPM2RN, ASN, EMT-P]

12 hour shifts work well for some but not others, we all have our own circadian rhythm, our own bodies that react differently to different situations. Having forced 12 hour shifts is ridiculous. But it really comes down to being chronically understaffed in my opinion. 6:1 in a busy ED, 8 or 10:1 on a floor, 30 or 40:1 in a facility? These are not reasonable and safe numbers. And I think the nurse can safely work a longer shift if he or she doesn't have an overburdened workload.

We all do what we can to make it work the best for our patients while admin tells us to do more with less, gets rid of our flexible hours and punishes us for poor Press-Ganey scores.

[CKPM2RN, ASN, EMT-P]

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.

Overlapping 10's make all the sense in the world! Great patient hand-off, time to chart uninterrupted! One can dream.

[NurseSpeedy, ADN, LPN, RN]

Can we please stop using the phrase "12 hour shift"? They are never just 12 hours...

I would love this post if I could. I miss my "8's", because I knew that they usually would not be 12's, and even in the unlikely chance that they were, I NEVER had to worry about the 12 that turned into a 14, that had a 1 hour drive home...now should I shower, eat dinner, and sleep...or skip dinner to get some sleep?...this is especially true when scheduled three days straight. Think about it. How many people who work in other fields would agree to this craziness? My husband will sometimes work 10 hours, plop down on the couch and say he's wiped. I ask if he wants to add 2-4 hours and do it two additional days in a row...he's no longer upset I'm not in a talking mode when I get home.

[NuGuyNurse2b]

i've never heard of overlapping 10's. How does that actually work? I think there needs to be some overlap. Every day I come in, get my assignment, and then the prior shift is trying to go home, so I get report without really knowing the facts (and what wasn't done...). If I'm lucky I may not even have someone who needs me right away for something and I can actually look at the orders and plan my shift. But most days, I'm just getting to my orders and REALLY know what i'm doing a full 2 hrs later into my shift.

[Chisca, RN]

What about 18 hours? Is that unsafe? Nephrology nurses are frequently required to work long hours without relief. I think we can all agree that hospital management should be the last authority on what is safe and what isn't.

[Cvepo]

I would leave bedside if they took away 12s. I could not imagine doing 5 8-hour night shifts a week. With 3 12-hour shifts, it's so easy to group your shifts, have 3-4 nights off to have a life, then do it all over again.

[Everline]

As a hospital floor nurse I did and would chose to work three 12 hour shifts. I'll be honest that this is mostly because I did not like what I was doing and wanted to spend as few days as possible doing it. I can't imagine working at the bedside in a hospital or SNF five days a week. That being said, outside of bedside nursing, I find myself having no problem with 8 hour shifts. Even better, 8 hour shifts that don't include weekends, nights or holidays. This is my current schedule and I love it, despite the fact that I've said in the past I would never want to work five days a week as a nurse. I find that it very much depends on where I am working, the necessity (or lack thereof) of staying after a shift is supposed to finish, and how I feel about my job. I have to admit, EBP has nothing to do with it and probably would not factor into my preference even if there had been adequate study of which schedule is better.

[Jeniele, ADN, RN]

The real issue with nurse burnout and exhaustion isn't the length of the shift in my opinion, but the staffing ratios and acuity of the patients. Add in the "pamper policies", customer service expectation, and downright mean and rude patients and you have a recipe for disaster.

Everyone will have a shift length that works best for them at their current time of life, and thankfully nursing can typically offer some type of employment that will fit that need.

Patients in acute care are very sick and it boggles my mind that the hour before the patient was "sick enough" to be 2:1 in ICU but is now "well enough" to be 5:1 on the floor I work. I get that improvement can happen rapidly and that is very good for the patient. Most of the time we run out of ICU beds and we play the patient shuffle. So unfortunately what happens is that an acutely ill patient that may not necessarily need intensive care is sent down to a nurse that is now 5:1 and that's when bad things can happen. It's not fair to the patients, and it's not fair to staff. I'm usually a second set of eyes on that patient to be on the lookout for any changes (despite having a patient load of 10 myself) while the poor nurse tries to catch up on their med pass (that's already an hour late), after which they try and figure out what the plan is for this new patient. Somewhere in this mix we both try to deal with the total care patient, the "needy" patient who calls every 15 min, and the high fall risk with injury confused patient who attempts to get out of bed every 10 minutes "to go to work". We have 2 patients that the physician said will go home today during their rounds who are on their lights wanting to know when that will happen, though no orders are in yet for discharge and the charge want's to know who we will have ready first because ED is calling up with a new admit. The total care patient is a "feeder" and it's 12:30 and family wants to know why no one has been in yet to feed their family member and I haven't had a chance to sit, pee, or eat and I've been there since 0630.

This is why nurses are exhausted and that's not even what I would call a horrid day. We need legislation to dictate safe patient ratios based on acuity, until then I don't think any admin or management will listen. Because when something bad does happen, it will be the nurse's fault not theirs.