In politics, the term third rail is a metaphor for any issue so controversial that it is considered to be highly”charged” and “untouchable”. Social Security in the United States is an example of a political third rail. Anyone who dares to discuss these third rail topics will receive enormous push back. I believe that 12-hour nursing tours is a third rail issue in nursing today. Nursing leaders have concerns about the widespread use of 12-hour tours and their impact on patient safety. Today’s nursing workforce grew up with the work-life balance freedoms that the 12-hour tour provides. Any discussion of their elimination or reduction evokes passionate arguments on both sides of the issue.
The Beginning of the 12 Hour Tour in Nursing
Nurses did not always work 12-hour tours. They were introduced in the 1980s during a serious nursing shortage as a strategy for improving working conditions for nurses. Initially, they were used only in specialty units such as critical care and the ER. Over time, use of 12-hour tours spread to most units in acute care facilities. Schedules shifted from 5 days per week to 3 days per week followed by two to five days off. Nurses quickly came to appreciate having more time off and the reduction in their commuting expenses. Nurses were able to increase their income by working overtime or Per Diem on their days off. Today in hospitals, 12-hour tour scheduling is the most common staffing pattern in use. In some settings, there is no other option. A significant percentage of the nursing workforce has never worked a schedule other than a 12-hour tour.
A troubling picture is emerging from the research on 12-hour tours that is becoming difficult to ignore. Twelve-hour tours may be great for nurses, but it appears that they may not be in the best interest of patient care and outcomes.
The Evidence about 12-Hour Tours
The research question that drives most studies looking at 12-hours is whether nurses can work more consecutive hours without any adverse impact on productivity, quality and safety. Geiger-Brown & Trinkoff (2010) are two faculty members at the University of Maryland who closely study these issues. They have determined from their research and a review of the evidence globally that the answer is no. Surprisingly, they found that nurses who worked 12-hour tours averaged only 5.5 hours of sleep between shifts and that sleep was fragmented. They contend that there is research to support that the likelihood of a nurse making a mistake is 3 times greater for nurses who work 12 hour tours versus 8 hours. Their recent research indicates that mortality for selected conditions like pneumonia were higher in hospitals where nurses reported longer shifts.
The complexity of acute care environments has significantly increased over the past decade resulting in ever increasing demands on direct care nurses. On blogs where nurses discuss 12-hour shifts, many are acknowledging their fatigue and mental exhaustion during these shifts. With an aging nursing workforce, these are important concerns. Nurse leaders have expressed concern for years that the increased issues with communication and fragmentation of care in acute care environments are partially attributable to 12-hour tours. Although their are fewer hand-offs on these tours, nurses rarely work with the same team members and often don’t take care of the same patients. Nurse managers struggle to keep staff who work only a few days a week updated about changes in policies and procedures.
For the 12th year in a row, nurses have been voted as the most trusted profession in Gallup’s ranking of professional groups on their honesty and ethical standard. Patient’s and their families depend on nurses during life crises to care for them. If a piece of medical equipment or a nursing procedure was known to endanger patient safety – we would quickly work to fix the problem. The evidence is mounting that 12-hour tours need to be reconsidered or modified. Nurse leaders have hesitated to act because of concerns about retention of staff and possible nurse staffing shortages from nurses who have second jobs on their days off. Nurses themselves acknowledge that there are issues with the 12-hour shift but are reluctant to change their lifestyle. So the dilemma is where do we go from here. This can’t be nursing’s third rail. It is really up to nurse leaders to talk with staff about the issues involved with 12-hour tours, nurse fatigue and patient safety. There may no perfect solutions to this dilemma but the conversation needs to begin.