JONAVolume 40, Number 9, pp 357-359Copyright B 2010 Wolters Kluwer Health |Lippincott Williams & Wilkins

Is It Time to Pull the Plug on12-Hour Shifts?Part 3. Harm Reduction Strategies if Keeping12-Hour Shifts

Jeanne Geiger-Brown, PhD, RNAlison M. Trinkoff, ScD, RN, FAAN

This article is part 3 of the seriesBPulling the Plug on 12-HourShifts.[ In part 1 (March 2010),the authors provided an update onrecent evidence that challenges thecurrent scheduling paradigm andsupports the lack of safety of longwork hours. Part 2 (April 2010)described the barriers to changeand challenges for the nurse exec-utive in moving away from thepractice of 12-hour shifts. Thisarticle presents strategies for miti-gating the effects of 12-hour shiftsfor nurses who continue to work12-hour shifts despite the potentialrisks to their health and to patientsafety.

In our previous articles in thisBPull the Plug[ series, we pre-sented evidence showing that12-hour shifts increase the risk

for adverse outcomes for bothnurses and patients. However, be-cause some nurses are highly sat-isfied with this schedule, manynurse executives are reluctant tochange back to shifts of shorterduration. Although we do notagree with this position, we pre-sent some harm reduction strat-egies that may be used to protectnurses. These include finessing theschedule, reducing fatigue duringwork hours, adding protectionsfor night shift nurses, and makingpolicy changes.

Finessing the ScheduleWork schedules are a key elementin a nurses intent to remain in aposition, and the negotiation of anurses schedule involves a delicatebalance as unit staffing needs arematched to the nurses desiredschedule. Fatigue is common in12-hour shift nurses. There is awell-developed science of schedul-ing to reduce fatigue risk, alongwith commercially available fa-tigue risk-management software.This software is being used suc-cessfully in other safety-sensitiveindustries to identify the most ex-treme fatigueYproducing sched-ules and avoid them (eg, too

many consecutive 12-hour shifts,risky patterns of shift rotation, toomany early start times). Extracaution must be exercised to en-sure that nurses at increased riskfor harm are not given schedulesthat overtax their abilities. Theseinclude nurses with chronic medi-cal conditions, nurses taking medi-cations that vary in effectiveness bytime of day, older workers, preg-nant nurses, or nurses who havelong commutes.

Respect for days off is essen-tial because lack of time awayhas been shown to be related tonurse injuries.1 There need to bepolicies that prevent nurses frombeing called in on days off orvacation days. Although someadministrators discount this, say-ing that nurses are allowed to sayno, when nurses are repeatedlycalled and asked to come back in,it sends an unhealthy messagethat if you are dedicated, you willignore your physiologic needs forsleep and rest and place the jobahead of these needs. Employeeswho readily volunteer for addi-tional shifts are often exhaustedand sleep deprived despite theirwillingness to do extra work. Wehave heard from 12-hour shiftnurses who have grave concerns

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Authors Affiliation: Associate Profes-sor (Dr Geiger-Brown), Professor (DrTrinkoff), Work and Health ResearchCenter, Department of Family and Com-munity Health, University of MarylandSchool of Nursing, Baltimore.

Corresponding author: Dr Geiger-Brown, University of Maryland Schoolof Nursing, 655 W Lombard St, Suite575C, Baltimore, MD 21201 (jgeiger@son.umaryland.edu).

DOI: 10.1097/NNA.0b013e3181ee4295

Copyright @ 20 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.10

about their overall quality of lifeand health. These nurses describebeing socially isolated and lack-ing family time and adequate sleepopportunity. At a talk wherein wepresented about work hours at anursing specialty conference, somenurse attendees reported that theywere unable to get the day offto attend and were therefore go-ing to be working 12 hours afterfinishing the day at the conference.This constitutes a 20-hour day andshould not be considered somethingthat nurses just have to endure.Because nursing is a safety-sensitiveposition, it is incumbent upon nurseexecutives and managers to pro-mote healthy work limits. We havethe public trust and respect, andpart of keeping that is promotingsafe practice.

When nurses are working12-hour shifts, they should be leav-ing work on time 100% of thetime. Shift overruns are one reasonwhy nurses like 12-hour shiftsVthey have to extricate themselvesonly 2 to 3 times per week insteadof 4 to 5 times. Leaving on timemust become a guarantee ratherthan an unlikely occurrence. Facili-ties need to collect data by unit tosee when nurses actually leave andrectify problems causing late de-partures. Remedies may includereducing handoff and end-of-shiftsign-out tasks, moving activitiesoccurring at shift change to othertimes of day, and others. Staffmeetings should never be held at7:30 AM, asking night shift nursesto extend their duty time; this isextremely unsafe. Human factorsengineers can assist organizationsto tailor their work schedules tothe production needs of unitswhile reducing risk for workers; aconsultation would be money wellspent.

Reducing Fatigue DuringWork HoursFatigue prevention during 12-hourshifts is a challenge because ex-tended hours strain the limits ofconcentration and physical endur-ance for many nurses. However,fatigue countermeasures such astaking breaks are important forproductivity and to relieve stress.Because these breaks are mandatedby the Occupational Safety andHealth Administration, it is rea-sonable and humane to ensurethat nurses are able to take them.Workplaces need to make it apart of the cultural norm to takecompletely relieved breaks, whichwe define as a time when the nurseturns over responsibility for her/hispatients for the duration of thebreak. However, many facilitieshave limited or no coverage to al-low their staff to take their requi-site meal and other breaks duringthe workday.

Nurses can be hired for shorterperiods, such as for 4 hour shifts, toprovide coverage for nurses takingbreaks. In addition, this shorterschedule might appeal to motherswith school-aged children. Thesenurses have become disenfran-chised from many nursing work-places because of the exclusive useof 12-hour shifts. By supportingnurses efforts to reduce their fa-tigue, take breaks, and eat properly,workplaces convey that nurses arevalued employees, which also canincrease job satisfaction. This canimprove worker healthVone studyshowed that when fair treatment bysupervisors increased, employeecardiovascular risk decreased sig-nificantly.2 Caring for nurses canaffect their health and longevity asemployees.

The physical environment alsocauses fatigue in nurses. When

nurses are fielding numerous inter-ruptions during tasks that requireconcentration or are having to workin environments with excessive ex-traneous noise, this saps mentalenergy. Nurses can spot ways toorganize supplies and equipment oradjust the layout of the work envi-ronment to reduce the physicalburden of work. Needless to say, ano-lift environment reduces physi-cal fatigue and the risk for injury.

Added Protections for NightShift NursesThe night shift is of special concernbecause it produces fatigue in both8- and 12-hour shift nurses, but atmore dangerous levels in those on12-hour shifts, as their quantity ofsleep between shifts drops to dan-gerously low levels. Both rotatingand permanent night shift work-ers have difficulty remaining alertduring the bodys circadian nadir(2-4 AM), so tasks requiring con-centration should not be scheduledduring that period. If necessary, aBbuddy[ system should be used,with nurses working together tocheck on one another to reduce therisk of errors. Planned napping canbe extremely beneficial and is muchsafer than the unplanned naps thatalready take place during the nightshift. We strongly support this harmreduction strategy. Both laboratoryand workplace studies have con-firmed (by electroencephalogram)that a brief 15- to 20-minute napduring a workshift confers addi-tional alertness, especially forworkers with partial sleep depriva-tion.3 A nap of 20 minutes reducesthe risk for sleep inertia (groggi-ness upon waking). Creatingappropriate conditions for nap-ping will be needed to make thesebreaks effective, including control-ling noise. It is also essential to

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convey to employees that they needto speak up when they are tired someasures such as naps can beimplemented. Nurses must be ableto admit that they are exhaustedwithout being adversely judged, orthey will be reluctant to disclosethis reality. Manipulating light in-tensity levels can increase alertness,although one may need to consult ahuman factors engineer to deter-mine how to dose and time the lightadministration without interruptingpatient care or disturbing patients.

Night nurses also need nutri-tious healthy food options to beavailable as they are for daytimeworkers. Vending machines shouldnot be the primary food sourceduring nighttime hours. In addi-tion, appropriately timed ingestionof caffeine can increase alertness.A ready supply of caffeinated bev-erages should be offered up to11 PM, but none after that (to pre-vent sleep fragmentation duringdaytime sleep).

For nurses new to the nightshift, training must be provided toensure that they learn how toprotect their health during nightshift work. This includes limitingthe number of night shifts workedin a row, modifying the daytimesleep environment to improve thequantity and quality of sleep, usingblue-light blocking sunglasses uponleaving work to prevent triggeringcircadian alerting from daylight,proper timing of caffeine to im-

prove alertness but prevent latersleep disruption, and, in limitedcases, judicious use of medicationsif needed to sustain sleep.

Policy NeedsPolicies and procedures shouldexamine all aspects of schedulingto ensure compliance with Ameri-can Nurses Association guidelineson responsibility of the employerand employee.4,5 Facilities thatoffer 12-hour shifts only shouldconsider offering other schedules,to provide an alternative to and re-duce the number of positions re-quiring 12-hour shifts.

Drowsydriving is a special prob-lem for fatigued nurses, and motorvehicle near misses or collisions arecommon on the way home fromnight shifts. There have been nursefatalities attributable to drivingdrowsy after working shift work.Some hospitals put aside an Bon-call[ room for nurses to nap beforedeparting; however, most nursesjust want to leave at the end of theirshift. We are aware of one hospitalthat maintains a cab voucher pro-gram so that if a staff member is toofatigued to drive home, he/she cantake a cab home and then back towork, no questions asked. Althoughit is not used frequently, it hasprobably saved lives.

There is no doubt that nursesare fatigued when working consec-utive 12-hour shifts, and Bpre-senteeism[ is endemic. Given the

need for vigilance in nursing, call-ing out Bfatigued[ must becomejust as valid as calling out sick. Justas excessive requests for additionalhours must be eliminated, fatiguerisk software can be used to pro-vide scientific support for rationalscheduling decisions. Careful atten-tion to safer schedules for nursesand appropriate strategies to mini-mize fatigue are essential to ensur-ing a healthy nursing workforce.

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relationship of work hours, mandatory

overtime, and on-call to musculoskele-tal problems in nurses. Am J Ind Med.2006;49:964-971.

2. Kivimaki M, Ferrie J, Brunner E, Head

J, Shipley M, Vahtera J, et al. Justice atwork and reduced risk of coronary

heart disease among employees: the

Whitehall II Study. Arch Intern Med.2005;165:2245-2251.

3. Driskell JE, Mullen B. The efficacy of

naps as a fatigue countermeasure: a

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