Hospital nurse shift patterns and collaboration — Strategies for improvement

Nurses often work long hours, and the attendant stress and lack of sleep can impede collaboration with other nurses and physicians and threaten patient safety.

In a March 13 webinar hosted by Becker's Hospital Review and sponsored by Kronos, researchers discussed nurse shift patterns, nurse-nurse and nurse-physician collaboration in acute care hospital units, and strategies to improve collaboration and patient safety among managers and frontline staff.

Presenters included:

  • Courtney Green, MSN, RN, regional nurse executive and healthcare clinical strategist with Kronos
  • Amy Witkoski Stimpfel, PhD, RN, assistant professor at New York City-based New York University Rory Meyers College of Nursing
  • Chenjuan Ma, PhD, assistant professor and health services researcher at NYU Rory Meyers College of Nursing

Trends in hospital nurse work patterns

Twelve-hour shifts allow nurses to work three days a week instead of five and are the predominate scheduling model for the frontline providers. Nurses often experience shift overruns due to staffing issues at care facilities. Overruns also occur when nurses must extend shifts to complete additional documentation in the EMR.

Voluntary and mandatory overtime policies vary. Approximately 18 states prohibit mandatory overtime, but not voluntary overtime.. Around-the-clock, 24/7 care requires night shift and rotating shift schedules.

The traditional night shift schedule for a hospital-based nurse is typically two or three consecutive 12-hour shifts from 7:00 p.m. to 7:00 a.m., followed by roughly two to five days off. "I like to think about it this way: this type of work schedule… is equivalent to the jetlag that results from undergoing [a flight from] Tokyo to San Francisco every few days," Dr. Witkoski Stimpfel said. "We know from many years of research that [when] nurses work extended overtime and lots of consecutive shifts, there is a detriment to patient care quality."

The importance of collaboration

"Collaboration among healthcare teams is paramount to any healthcare organization and to their patients," Ms. Green said. Collaboration is a critical component of patient safety and patient-centered care, and when nurses lose sleep due to shift work and overtime, collaboration becomes more difficult due to impaired social, emotional and cognitive processing.
Dr. Witkoski Stimpfel and Dr. Ma examined results from the National Database of Nursing Quality Indicators' (NDNQI) RN Survey to determine the effect of nurse shift patterns on nurses' collaboration with other nurses and physicians in U.S. acute care hospitals. Participants included 24,013 RNs from 957 adult units in 168 hospitals.

The NYU Rory Meyers researchers assessed collaboration by evaluating answers individual survey respondents gave about the quality of collaboration among nurses in their unit, and the quality of collaboration between nurses and physicians in their unit.

Using aggregated nurse responses, Dr. Witkoski Stimpfel and Dr. Ma also assessed the influence of nurse shift length on collaboration by examining the average length of a nurse shift on a unit, the prevalence of overtime on a unit, and the proportion of nurses who perceived an increase in overtime on a unit over the past year. On average, units had an 11.88-hour shift length with 0.37 hours worked overtime.

Overtime was negatively associated with collaboration among nurses. "Shift length was not associated with collaboration, but overtime — regardless of which indicator of overtime we used — was significantly associated with collaboration, especially nurse-nurse collaboration. A one hour increase in overtime was associated with 0.17 decrease in the nurse-nurse collaboration score," Dr. Ma said.

Nurses and nurse managers can take steps to increase nurse well-being and collaboration. According to Dr. Witkoski Stimpfel, strategies to improve collaboration for frontline nursing staff include:

  • Limiting the number of consecutive shifts and voluntary overtime.
  • If rotating shifts, rotating them in a forward pattern.
  • Getting adequate rest before and between shifts (about 7 to 8 hours of sleep a night for most adults).
  • Using caffeine strategically: don’t use throughout the entire shift, but instead use to supplement alertness at the beginning of a shift.
  • Wearing blue light blocking sunglasses on the way home from work and using an app to reduce blue light from electronic devices.
  • Maintaining a healthy sleep environment: the researchers defined this as one that is quiet, dark, between 68 and 72 degrees Fahrenheit, and has no electronics.
  • When trying to find a new position, seek supportive work environments with adequate staffing that allow breaks and limit overtime and excessive consecutive shifts.

Strategies for nurse managers include:

  • Monitoring schedules for excessive numbers of shifts/flips between days/night.
  • Using technology solutions to help manage schedules and staffing.
  • Creating a culture of safety where staff can say "no" to overtime.
  • Providing professional development on sleep hygiene, managing shift work, and shift work sleep disorder.
  • Partnering with physicians to educate staff on effective collaboration.
  • Creating opportunities for continuing education across disciplines on successful collaboration.

Effective collaboration among healthcare providers is a crucial component of patient safety. By leveraging evidence-based best practices, nurses' work environments can be optimized for provider collaboration, and better collaboration means better care for patients.

Click here to access the recording. Click here to acces the webinar slides.

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