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Effects of Extended Work Shifts and Shift Work On Patient Safety, Productivity, and Employee Health
Effects of Extended Work Shifts and Shift Work On Patient Safety, Productivity, and Employee Health
Effects of Extended Work Shifts and Shift Work On Patient Safety, Productivity, and Employee Health
ABSTRACT
It is estimated 1.3 million health care errors occur each year and of those errors 48,000 to 98,000 result in the deaths of
patients (Barger et aI., 2006). Errors occur for a variety of reasons, including the effects of extended work hours and shift
work. The need for around-the-clock staff coverage has resulted in creative ways to maintain quality patient care, keep
health care errors or adverse events to a minimum, and still meet the needs of the organization. One way organizations
have attempted to alleviate staff shortages is to create extended work shifts. Instead of the standard 8-hour shift, workers
are now working 10, 12, 16, or more hours to provide continuous patient care. Although literature does support these
staffing patterns, it cannot be denied that shifts beyond the traditional 8 hours increase staff fatigue, health care errors,
and adverse events and outcomes and decrease alertness and productivity. This article includes a review of current
literature on shift work, the definition of shift work, error rates and adverse outcomes related to shift work, health effects
on shift workers, shift work effects on older workers, recommended optimal shift length, positive and negative effects of
shift work on the shift worker, hazards associated with driving after extended shifts, and implications for occupational
health nurses.
he current shortage of nurses in the United States in their support of the U.S. Fair Labor Standards Act,
498 AAOHNJOURNAL
Yokoyama, & Uchiyama, 2005), and the grounding of the majority of the staff (64%). The minimum number
the oil tanker Exxon Valdez off the coast of Alaska (Wad- of 24-hour periods off after a night shift before returning
sworth et al.). The concept of fatigue is difficult to quanti- to work should be two and the minimum number of 24-
fy because fatigue is a subjective and personal experience hour periods off after a day shift before returning to work
(Richardson et al., 2007). Symptoms of fatigue can in- should be one.
clude muscle weakness, lethargy, inability to think clearly
or concentrate, listlessness, decreased cognitive function, NEGATIVE ASPECTS OF EXTENDED SHIFT
anxiety, and exhaustion. Working extended hours for long WORK
periods can increase damage to workers' health and well- Many negative aspects are associated with working
being commensurate with the hours worked (i.e., total ex- extended shifts and shift work, including an increase in
posure to workload) (Raediker et al., 2006). accidents while on the job, reduced duration and qual-
ity of sleep, and sleepiness, fatigue, and less alertness
SHIFT WORK AND THE OLDER WORKER while performing duties (Smith et al., 1998; van der
Extended work hours and shift work more profoundly Hulst, 2003). The worker may experience decreased re-
affect older shift workers. In the author's experience,older action times and poorer work performance (Scott, Rog-
workers are less capable of working longer shifts because ers, Hwang, & Zhang, 2006). The worker will have more
of the normal physiological changes that occur naturally days off but may feel ill many of those days and experi-
with aging. They tend to have less stamina, are more prone ence long-term adverse health effects. Night shift work-
to chronic illnesses, and may have a complicated home ers may have fewer opportunities to communicate with
environment that interferes with rest between shifts (i.e., upper management. Managers often cannot find cover-
care of older parents, grandchildren, or ill spouses). Aging age for extended shifts when a worker is ill or injured
decreases the speed of circadian adaptation to night work, (Knauth, 2007). If workers are in an environment with
increases the risk of sleep disorders and negative health ef- toxic exposures, they experience more time exposed dur-
fects, and threatens safety in work environments designed ing extended shifts (Knauth).
for younger employees (Letvak, 2005). Workers may also experience difficulties at home
One study suggested that older workers working 12- with spouses and children because they are away for
hour shifts had a higher incidence of absence, sickness, long periods. Also, these workers are more prone to au-
and intoxication (Smith et al., 1998). Younger workers are tomobile accidents after extended shifts. Nurses working
naturally fatigued at the end of a long workday. However, extended shifts experience the following: the need to re-
they are more capable of rebounding after the shift and orient after returning from several days away, short time
tend to enjoy this work schedule because it rewards them between shifts, lack of continuity of patient care, reduc-
with more days for social activities. One study found that tion in quality of patient care, and stress associated with
satisfaction with working hours and free time increased caring for demanding patients and families for more than
(Josten et al., 2003) when working 12-hour shifts. Al- 8 hours (Richardson et al., 2007).
though older workers may enjoy more days away from
work, they tend to prefer shorter shifts when given the POSITIVE ASPECTS OF EXTENDED SHIFT
choice of the two shifts. WORK
The positive effects of working extended shifts include
WHAT IS THE OPTIMAL SHIFT LENGTH? the ability to work a second job, more days away from
Both types of work patterns have positive and nega- work, and more free time with family and friends. Nurses
tive aspects. The 8-hour shift is safer than longer shifts have more time for leisure and social activities, more time
(Mitchell & Williamson, 2000; Raediker et al., 2006). In for domestic duties, fewer shift "hangovers," and less travel
one study, a significant relationship was found between time to and from work. Organizations favor extended shifts
duration of shift and total performance scores; working because managers have to provide staffing for only two
a shift of 8 hours or less resulted in higher total perfor- shifts instead of three, experience less staff turnover, and
mance scores than when working 12- to 12.5-hour shifts have less overtime. Nurses have less pressure to complete
(Fitzpatrick et al., 1999). assignments in an 8-hour day and better continuity of care
Richardson et al. (2007) found that working extended (Knauth, 2007; Richardson et al., 2007).
shifts and shift work may not be as significant a concern
as the number of consecutive days worked or number of DRIVING AND EXTENDED WAKING HOURS
hours between shifts when rotating from one time period Concerns also arise when shift workers drive home at
to another. It has been found that many workers agree that the end of their shifts. Studies have shown that the preva-
three consecutive day shifts and four consecutive night lence of sleep-related motor vehicle crashes is higher
shifts should be the maximum number worked before a among individuals who are employed, work more than 60
day off to rest (Richardson et al.). One study found that hours per week, work irregular hours, work at night, and
the majority of staff (66%) reported 24 hours as a safe are sleep deprived (Robb et al., 2008; Scott et al., 2007).
period of time to be off duty after working a day shift and These workers are at more risk of a motor vehicle crash
before starting a night shift. The rest time needed was than the general population. In fact, studies have indicated
longer after working night shifts and before starting day that remaining awake for 19 consecutive hours slows cog-
shifts. A safe period of time was viewed as 48 hours by nitive function and reaction times to a level comparable
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Directions: Circle the letter of the best 6. Research has shown that the
answer on the answer sheet provided. minimum number of 24-hour pe-
This issue of the AAOHN JOURNAL
contains a Continuing Nursing Educa-
(Note: You may submit a photocopy riods off after a night shift before
tion Module on "Effects of Extended for processing .) returning to work should be:
Work Shifts and Shift Work on Patient A. 1.
Safety, Productivity, and Employee 1. According to Lockley et al. B. 2.
Health:' 1.0 contact hour of continuing (2007), physicians-in-training C. 3.
nursing education credit will be awarded working traditional 24-hour shifts D. 4.
by AAOHN upon successful completion
are _% more likely to make
of the posttest and evaluation.
fatigue-related errors that lead to 7. Studies indicate that remaining
A ce rtificate will be awarded and patients' deaths. awake for 24 consecutive hours
the scored test will be returned when A. 100 . slows reaction time to a level
the follow ing requirements are met
B. 200. comparable to a blood alcohol
by the participant: (1) The comp leted
answe r sheet is rece ived at AAOHN C. 300. level of:
on or befo re November 30, 2010; (2) D. 400. A. 0.1%.
A score of 70% (7 correct answers) B. 0.03%.
is achieved by the participant; (3) 2. According to Lockley et al. C. 0.05%.
The answer sheet is accompanied by (2007), nurses working shifts in D. 0.08 %.
a check or money order for $15.00
excess of 8 hours had a decrease
($20.00 non -members) , or purchase
online for $10.0 0 ($15 .00 non-mem-
in productivity during these last 8. Lockley et al. (2007) report that
bers) at www .aaohn.org . Expect up to hours of their shifts: each extended duration work shift
4 weeks for de liver y of the certificate. A. 1. increased the motor vehicle crash
Upon complet ion of this lesson ,
B. 2. rate by _% over baseline.
the occupat ional health nurse will be C. 3. A. 3.4.
able to: D. 4. B. 9.1.
1. Descr ibe extended work shifts!
C. 14.7.
shift work and its history. 3. All of the following are symp- D. 16.2.
2. Discuss the types of errors and toms of fatigue except:
adverse outcomes associated with A. Hyperactive behavior. 9. To alleviate the negative impact
working extended shifts and methods B. Inability to think clearly. of extended duration work shifts,
for decreasing them . C. Decreased cognitive function. the occupational health nurse
3. Describe the health effects com - D. Anxiety. recommends that workers not
monly seen among employees who work more than consecutive
work extended shifts. 4. In the study by Smith et al. night shifts.
4. List the positive and negative (1998), older workers who worked A. 2.
aspe cts of working extended shifts. _-hour shifts had a higher inci- B. 3.
5. Identify the implications for oc- dence of absences, injuries, and C. 4.
cupational health nurses oversee ing illnesses. D. 5.
employees who work extended shifts . A. 8.
AAOHN is accredited as a provider B. 10. 10. By the year 2050, the propor-
of continuing nursing education by C. 12. tion of individuals 60 and older
the Amer ican Nurses Credentialing D. 14. will account for what percentage
Center's Commission on Accreditation . of the total global population?
AAOHN is additionally approved as 5. Recent research indicates that A. 4.
a provider by the Californ ia Board of the safe period of worker rest B. 14.
Registered Nursing (#CEP9283) and time after working night shift and C. 21.
the Louisiana State Board of Nursing D. 26.
before starting day shift is _
(#LSBN3).
hours.
Contact hour credits received for
A. 12.
successful complet ion of the posttest
and evaluation may be used for relicen-
B. 24.
sure, cert ification, or re-certification. C. 30.
doi:l 0.3928/089 10162-20091124-05
D. 48.
1. A B C D 6.A B C D
2. A B C D 7.A B C D
3. A B C D 8.A B C D
4. A B C D 9.A B C D
5. A B C D 10. A B C D
EVALUATION (must be completed to obtain credit)
Please use the scale below to evaluate this continuing education module.
4 - Toa great 3 - Tosome 2 -To little 1 -To no
extent extent extent extent
1. As a result of completing this module, I am able to:
A. Describe extended work shifts/shift work and its history. 4 3 2
B. Discuss the types of errors and adverse outcomes associated with
working extended shifts and methods for decreasing them. 4 3 2
C. Describe the health effects commonly seen among employees who
work extended shifts. 4 3 2
D. List the positive and negative aspects of working extended shifts. 4 3 2
E. Identify the implications for occupational health nurses overseeing
employees who work extended shifts. 4 3 2
2. The objectives were relevant to the overall goal of this independent
study module. 4 3 2
3. The teaching/learning resources were effective for the content. 4 3 2
4. How much time (in minutes) was required to read this module and
take the test? 60 70 80 90
Please print or type: (this information will be used to prepare your certificate of completion for the module).
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