The price of fatigue: How shift work schedules can make or break quality care

More healthcare employees are suffering from burnout, and long hours play a key role in this epidemic, especially among nurses. In fact, 75 percent of nurses work 12-hour shifts. Working 12-hour shifts for days on end means nurses are at special risk of fatigue and high stress levels.

"Nurses are very often shift workers in this environment, working irregular hours and working around the clock," said Susan M. Reese, chief nurse executive at Kronos Incorporated "Twelve-hour shifts are not necessarily in everyone's best interest. Nonetheless, there are many environmental factors that have us still contending with 12-hour shifts."

Although longer shift lengths are attractive to nurses because they enable individuals to have shorter work weeks, they present significant consequences in the form of fatigue. Dr. Reese investigated the effect of shift work schedules on nurse engagement during a Kronos-sponsored webinar, presented by Becker's Hospital Review March 21.

Fixed versus variable scheduling
Shift work schedules come in a variety of formats. Scheduling may revolve around the time of day, in which an employee is permanently scheduled to work a day or night shift, or it may rotate shifts forward or backward (morning to night, night to morning). Another shift work schedule may focus on days of the week, which could be fixed or an inconsistent variable distribution. On-call coverage is also a factor to consider.

Fixed schedules follow patterns. The most popular are the Metropolitan or Continental plans for eight-hour shifts and the Dupont, Pittman and Panama plans for 12-hour shifts.

"[Fixed schedules] are most successful in units with defined volumes or appointment-setting units where patterns lend themselves to consistency," said Dr. Reese.

Organizations opting for variable scheduling can build employee schedules in the following ways.

  • Manually build: This tactic involves an employer starting from scratch with a blank sheet of paper or Excel spreadsheet to fill in shifts.
  • Auto-generate with manual intervention: This technique leverages a rules-based software solution but requires manual intervention to ensure the schedule is reasonable and full.
  • Self-schedule: This approach is gaining popularity, as it offers a plethora of benefits, including nurse empowerment, work/life balance support, lessened administrative burden on managers and communication improvement.

Although variable scheduling presents many advantages, there are several potential problems, including opportunities for human error, fairness issues and infringement on work/life balance. These shortcomings can have an outsize effect on employee mental wellness, particularly when shift work schedules interfere with healthy sleep behaviors.

"There definitely is a price to pay when work schedules are poorly constructed," Dr. Reese warned.

The price of fatigue
Poorly constructed work schedules wreak havoc on nurses' sleep cycles. In fact, nurses cited shift work schedules as a leading cause of nurses feeling tired, stressed and fatigued. This is because shift work schedules can disrupt sleep patterns and circadian rhythms.

"What happens when we are unable to obtain the appropriate restorative sleep between shifts is accumulating sleep debt," Dr. Reese said. Sleep debt is the amount of sleep you should be getting minus the amount of sleep you are actually getting. Consecutive shifts, whether it's day or night shifts, will incur significant sleep debt. Commute times also contribute to sleep debt; a 2014 study found every minute of commute time translates to 0.84 minute of sleep loss.

Sleep debt is an official disorder under the International Classification of Diseases version 10, called the Circadian Rhythm Sleep Disorder, Shift Work Type. Employees on permanent night shift schedules or schedules with a night shift rotation face the greatest risk of developing this disorder. A 2012 study found 37.6 percent of 5,000-plus nurses fulfilled the criteria for this disorder.

"That [statistic] really took me back when I realized how pervasive this problem is," Dr. Reese said. The National Sleep Foundation reports sleep debt hurts nurses' performance.

Dr. Reese conducted research in 2016 leveraging the Fatigue Index Score Calculator from the Health & Safety Executive. The tool finds the probability of fatigue on a daily basis for a shift work schedule.

She evaluated 379 12-hour shifts occurring in an acute care hospital in the Southeast over a four-week period. For the day shift, the highest registered probability of fatigue was 20.7 percent during an employee's fourth consecutive 12-hour shift.

"This tells me that working day shift is fatiguing, but probably not overwhelmingly fatiguing," Dr. Reese said.

In contrast, the lowest probability of fatigue for a night shift worker was 42.3 percent during the first shift after two rest days. The highest score was 59.8 percent during the fifth consecutive 12-hour night shift.

"Many things fatigue our staff, but rarely have we considered the fact that the way I'm scheduling them is actually adding to the likelihood of fatigue for the staff," said Dr. Reese.

Work schedule-induced fatigue yields nurse disengagement in three key ways: exhaustion, depersonalization and reduced personal accomplishment. Absenteeism, turnover and performance decrements will likely result from disengaged nurses.

Fatigue and sleep debt can cause a nurse to experience burnout, which ultimately leads to poor care delivery, including the following quality concerns.

  • Performance decrements and decision regret
  • Increased patient mortality: A 2011 study found pneumonia-related deaths were higher when nurses said they'd worked long hours and hasn't spent much time away from work.
  • Greater readmissions: Fatigue resulting from overtime work correlated with increased readmission rates, according to a 2011 study. "Not only is that not good for the patient, but it's certainly not good for the organization with the financial impacts that type of behavior can have," adds Dr. Reese.

8 ways to curb fatigue and boost engagement
What can organizations do to fight fatigue and sleep debt incurred in nurse scheduling?

"There is no magic bullet here, but we certainly need to tune into the impact that the work schedule has on behaviors in the workplace," Dr. Reese said.

She recommends eight strategies to reduce fatigue and boost engagement.

  1. Lay out rules for scheduling.
  2. Do not schedule a nurse for more than four consecutive 12-hour day shifts.
  3. Do not schedule a nurse for more than three consecutive 12-hour night shifts.
  4. Foster a culture of openness in discussing burnout and promoting reporting of excessive fatigue.
  5. Monitor night shift nurses for signs of fatigue.
  6. Take nurses' commute times into account when scheduling.
  7. Find out if your nurses have second jobs.
  8. Find out if your nurses are working overtime in other units.

"Shift work schedule creation is where quality care giving begins," concludes Dr. Reese.


Listen to the webinar recording here and view the webinar slides here.

To learn more about Kronos, click here.



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