Critical Appraisal of Research

Full APA formatted citation of selected article.

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Banakhar, M. (2017). The impact of 12-hour shifts on nurses’ health, wellbeing, and job satisfaction: A systematic review. Journal of Nursing Education and Practice, 7(11), 69-83.

Dall'Ora, C., Griffiths, P., Ball, J., Simon, M., & Aiken, L. H. (2015). Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ open, 5(9).

Emmanuel, T., Dall'Ora, C., Ewings, S., & Griffiths, P. (2020). Are long shifts, overtime and staffing levels associated with nurses’ opportunity for educational activities, communication and continuity of care assignments? A cross-sectional study. International Journal of Nursing Studies Advances, 100002.

Son, Y. J., Lee, E. K., & Ko, Y. (2019). Association of working hours and patient safety competencies with adverse nurse outcomes: a cross-sectional study. International journal of environmental research and public health, 16(21), 4083.

Evidence Level *

(I, II, or III)

Level I

Level I

Level I

Level I

Conceptual Framework

Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).**

This research paper is rooted on the theory that when nurses are exposed to 12-hour shifts as opposed to 8-hour shifts, a variance is recorded with respect to their general health and well-being, as well as, their job satisfaction. Essentially, nurses who are exposed to 8-hour shifts are more likely to have better health wellbeing and higher job satisfaction as compared to those who are exposed to 12-hour shifts.

This paper is grounded on the theory that when nurses are exposed to long shifts, their wellbeing becomes adversely affected and they record an increased rate of job dissatisfaction, as well as, intention to leave their job. The study being conducted by the authors is, therefore, meant to draw a correlation between working long shifts (such as 12-hour shifts); and experiencing burnouts, job dissatisfaction, “dissatisfaction with work schedule flexibility and intention to leave current job among hospital nurses” (Dall'Ora, et al, 2015).

This paper is grounded on the theory that when nurses are exposed to long working shifts their ability to complete important “ancillary” work is hampered. The authors sought to draw a correlation between working ≥12-hour shifts/overtime/lower staffing levels and inability to effectively complete ancillary work.

This study is grounded on the theory that working overtime can effectively lead to adverse nurse outcomes and work-related hazards. The authors engaged in a cross-sectional descriptive study to determine the extent to which exposure to long working hours would lead to adverse nurse outcomes and work-related hazards.

Design/Method

Describe the design and how the study was carried out (In detail, including inclusion/exclusion criteria).

Online databases such as CINHALE, MEDLINE, PsycINFO, Web of Science, EMBASE, and SCOPUS were searched and the information that was gathered related to the time from1980 to 2017. This means that any information that existed prior to 1980 was excluded. Further, the studies which were specifically included were those that related to nurses who were working for 12-hour shifts vis-à-vis those who were working for 8-hour shifts within hospital settings. Studies that did not fall within the aforementioned parameter were excluded. This selection was based on observation and survey analysis.

A cross-sectional survey was conducted in relation to European registered nurses. The total number of participants/ nurses that were involved was 31,627. The participants of the study hailed from 12 European countries including; Belgium, Finland, England, Germany, Ireland, Greece, Netherlands, Poland, Norway, Spain, Sweden, and Switzerland.

Within each of the countries, a minimum of 30 hospitals were included in the study and within every hospital, at least two surgical/medical nursing units were included (Dall'Ora, et al, 2015). The units that were excluded were those associated with specialized nursing since it is highly likely that there is a distinctive variance therein with regard to shift patterns and staffing. Within each of the specified units that were involved in sampling, all registered nurses that were involved in the provision of direct care to patients were requested to participate. No inclusion criteria were placed with respect to minimum working hours so as to protect the authenticity of the research. The participants received the survey either by mail or directly.

2990 registered nurses were involved in a cross-sectional survey in 48 hospitals within England. The study specifically included registered nurses who were working in acute general hospitals. Those who did not fall in this category were, therefore, excluded.

The nurses were required to specifically make a report on; the number of hours they worked; whether they were working as full time or part time care providers; the length of the length of their shift; and whether during their last shift they worked overtime. This information was used to calculate the nurse staffing levels.

In order to evaluate the rate of completion of ancillary work, four survey items were used to analyze; participation in continuous professional development; discussion of patient care between the nurses; observation of patient care assignments that lead to continuity of care; and loss of patient care information in the course of shift changes.

The authors engaged in a cross-sectional descriptive study. Registered nurses who worked in all levels of the acute care hospital setting were involved. Participants who engaged in the survey were recruited through the process of convenience sampling. The chosen nurses were specifically working at three tertiary care hospitals that were affiliated to Soonchunhyang University in South Korea (Son, Lee, & Ko, 2019). Another inclusion criteria that was used was that; the nurses had to at least have one year of experience at one of the hospitals; and to work 3-8 hour shifts at any of the inpatient settings. Nurses who did not fall within this category were, therefore, excluded. The total number of participants was 364.

Sample/Setting

The number and characteristics of

patients, attrition rate, etc.

In the course of the research, a total of 12 studies were gathered. The matters that were addressed in the studies regarded the extent to which the different shifts impacted the health wellbeing of the nurses; whether either shifts led to increased fatigue and decreased critical thinking; and whether either shifts led to increased job satisfaction.

The total number of participants/ nurses that were involved was 31,627. The participants of the study hailed from 12 European countries including; Belgium, Finland, England, Germany, Ireland, Greece, Netherlands, Poland, Norway, Spain, Sweden, and Switzerland.

Within each of the countries, a minimum of 30 hospitals were included in the study and within every hospital, at least two surgical/medical nursing units were included (Dall'Ora, et al, 2015). Within each of the specified units that were involved in sampling, all registered nurses that were involved in the provision of direct care to patients were requested to participate. 33,659 received the survey and those who participated by responding to the survey were 31,627.

2990 registered nurses participated in the survey. These nurses were working in acute general hospitals. They hailed from 48 hospitals within England.

The total number of participants was 364. They hailed from three hospitals that focused on tertiary care and that had affiliation with Soonchunhyang University in South Korea. The study was conducted in South Korea and the locations included were; Bucheon, Cheonan, and Seoul.

Major Variables Studied

List and define dependent and independent variables

The dependent variable that was being measured in the study was health wellbeing and job satisfaction of the nurses. Health wellbeing relates to the mental and physical wellbeing of the nurses. Job satisfaction relates to the feeling of enjoyment and fulfillment that the nurses derive from their work and this is measured through the self-reporting surveys, as well as, an analysis of the reasons behind the high turnover rates.

The independent variables that were being measured in the study are the 12-hour shifts and the 8-hour shifts. The causal effect of either shifts being implemented would be reflected on the health wellbeing and job satisfaction of the nurses.

The dependent variables that were being measured in the study were the nurses’ experience of job dissatisfaction, burnouts, dissatisfaction in relation to work schedule flexibility and intention to leave the current employ. Job dissatisfaction is related to the extent to which the nurses harbor negative feelings with respect to their workplace. Work schedule flexibility speaks to the extent to which the employees are given the liberty to formulate their own schedules so that they can be able to achieve a work-life balance. The issue of burnouts speaks to the extent too which the employees are exposed to physical, mental and emotional exhaustion due to prolonged stress.

The independent variable in the study is working long shifts (such as a 12-hour shift).

The dependent variable that was being measured in the study was quality of involvement in ‘ancillary’ work. Ancillary work included continuous professional development programs, engagement in discussions regarding care information between nurses; and the promotion of continuity of care in the course of shift changes.

The independent variables that were being measured included; exposure to ≥12-hour shifts; lower staffing levels; and exposure to overtime. These three variables may be seen as being interrelated or synonymous to each other since, for instance, one of the factors that lead to exposure to ≥12-hour shifts and overtime is low staffing levels.

The dependent variable that was being measured in the study was occurrence of adverse nurse outcomes and work-related hazards. This is inclusive of matters such as occurrence of accidents and avoidable poor patient outcomes.

The independent variable was exposure to long working hours. This includes exposure to more than 8 hour shifts.

Measurement

Identify primary statistics used to answer clinical questions (You need to list the actual tests done).

Of the 12 studies yielded, all of them talked about the extent to which a 12-hour shift had an effect on the health and wellbeing of the nurses.

4 out of 12 of the studies which were yielded talked about whether a 12-hour shift led to increased fatigue and decreased rates of critical thinking as compared to an 8-hour shift.

9 out of 12 of the studies measured job satisfaction with respect to both shifts.

The survey that was sent to the participants had a total of 118 questions. The questions were organized in five different sections namely; ‘About your job’, burnout and job satisfaction, investigating work environment, ‘quality and safety’, ‘About your most recent shift at work in this hospital’ (Dall'Ora, et al, 2015).

In order to understand the shift length of the nurses, an inquiry was made with respect to the number of hours worked in every shift. An inquiry was also made with respect to they worked overtime during their last shift.

With respect to the issue of burnouts, an assessment was conducted through reference to the Maslach Burnout Inventory (MBI). The three dimensions of burnouts were measured using three different subscales. The three scores were not combined into one since they needed to be examined separately.

The variable of job satisfaction was measured using one survey question: ‘How satisfied are you with your job?’ (Dall'Ora, et al, 2015, p. 2). A report on the same was measured on a scale of 1 to 4.

Satisfaction with the work schedule flexibility was also assessed so as to determine whether a 12-hour shift is indeed associated with this flexibility.

Intention to leave was established through the following question; “If possible, would you leave your current hospital within the next year as a result of job dissatisfaction” (Dall'Ora, et al, 2015, p. 2). Typical answers in this regard were either “yes” or “no.”

The nurses who were involved in the survey were required to specifically make a report on; the number of hours they worked; whether they were working as full time or part time care providers; the length of their shift; and whether during their last shift they worked overtime. This information was used to calculate the nurse staffing levels. It was also used to evaluate the rate of exposure to overtime and ≥12-hour shifts.

In order to evaluate the rate of completion of ancillary work, four survey items were used to analyze; participation in continuous professional development; discussion of patient care between the nurses; observation of patient care assignments that lead to continuity of care; and loss of patient care information in the course of shift changes.

In order to make a determination of the working hours of the employees, reliance was placed on the 4th Korean Working Conditions Survey (KWCS) that was conducted in 2014.

In order to measure the PS competencies of the nurses, the “Health Professional Education in PS Survey” was developed (Son, Lee, & Ko, 2019, p. 3).

In order to measure adverse nurse outcomes, a questionnaire that had been developed by Al-Kandari and Thomas was utilized.

Data was essentially collected for a period of two months through the use of structured questionnaires.

Data Analysis Statistical or

Qualitative findings

(You need to enter the actual numbers determined by the statistical tests or qualitative data).

Out of the 12 studies which addressed the impact of the shifts on the health wellbeing of the nurses, 3 reported that a 12-hour shift had an adverse effect on the nurses leading to consequences such as cognitive anxiety, role stress and sleep disturbance. There was, however, no major difference between the shifts when it came to major illnesses such as cardiovascular disorders and somatic anxiety.

Out of the 4 studies in the second category, 3 showed that nurses working in the 12 hour shifts experienced more fatigue and one did not record a significant variance when it came to fatigue and critical thinking in relation to both shift-lengths.

Out of the 9 studies in the third category, 5 showed that nurses working the 12-hour shifts had a higher rate of job dissatisfaction, while 3 showed that the said nurses had a lower rate of job dissatisfaction.

14 percent of the participants noted that they had worked for 12-13 hours during their last shift while a majority of the participants (50 percent) noted that they had worked for 8 hours or less during their last shift.

27 percent indicated that they had worked overtime during their last shift. England, Ireland, and Poland recorded the highest rates of 12 hour shifts.

27 percent of the participants noted that they experienced a high rate of emotional exhaustion, 10 percent recorded high depersonalization while 17 percent recorded low personal accomplishment.

26 percent noted that they were a little or very dissatisfied with their work schedule flexibility while 33 percent recorded an intention to leave their current job.

The output derived from the fully adjusted models showed that the nurses who work 12 hours and longer experience higher rates of burnouts as compared to those who work for 8 hours or less.

Nurses working 12 hours and longer also experienced increased depersonalization and lower levels of personal accomplishment.

The likelihood of nurses recording high rate of job dissatisfaction increased with nurses who were working shifts longer than 8 hours.

77 percent of the participants reported working as full time care providers. With respect to shift hours, 33 percent worked 8 hours or less; 13.8 percent worked 8.1-10 hours; 19.2 percent worked 10.1-11.9 hours; while 34 percent worked 12 hours or more. The ration of patient-to-nurse was reported as 8.61 while 51 percent noted that they worked overtime.

Nurses who were working overtime or ≥12-hour shifts were most opposed to continuous staff development programs. They were also least concerned with engaging in care assignments that ensure continuity of care. They also recorded the highest level of loss of care information in the course of shift changes.

The average total working hours per week for all the participants was 44.6. the variance with respect to the number of working hours was seen to correlate with the specific units that the participants worked in.

The professionals who were working for 40 hours/week or less had the highest level of PS competencies. The nurses who were working for 50 hours or more had the highest level of adverse nurse outcome score (Son, Lee, & Ko, 2019).

Positive nurse outcomes was seen to be linked with better PS competencies.

Findings and Recommendations

General findings and recommendations of the research

The general findings that were arrived at from the review were that 12-hour shifts resulted in adverse health outcomes on the nurses and it heightened the rate of job dissatisfaction.

A recommendation that was made related to the fact that there was a need to gather more empirical evidence to support the findings.

Nurses who were working 8 hours and longer were more likely to experience job dissatisfaction, burnouts, intention to leave their job, and limited work schedule flexibility.

A distinctive correlation was seen to exist between working ≥12-hour shifts/overtime/lower staffing levels and inability to effectively complete ancillary work

Based on the findings of the research, it is clear that exposure to long working hours would lead to adverse nurse outcomes and work-related hazards.

Appraisal and Study Quality

Describe the general worth of this research to practice.

What are the strengths and limitations of study?

What are the risks associated with implementation of the suggested practices or processes detailed in the research?

What is the feasibility of use in your practice?

At a time when healthcare institutions and professionals alike are keen on providing quality care, this research has great worth because it provides insight on the need to ensure that nurses are not overstretched since the said practice would only lead to ineffectiveness.

One of the strengths of this study is that it relies on a wide range of empirical studies that have already been conducted. Another strength is that the sample that has specifically been gathered address matters that are specifically connected with the variables thus increasing chances of success of the study. A limitation of the study is that the studies being analyzed were drawn from highly variant cultures, social environments, thus many other factors may have influenced their distinctive results. A more specific high quality study may, therefore, be needed.

The risk of implementing better staffing is that hospitals may record lower profits.

The results of the study provide a clear basis for nurses and managers to desist from implementing shifts longer than 8 hours as they would only lead to ineffectiveness.

The strength of this study is that it proves that nurses who work longer than 12 hours are more likely to experience job dissatisfaction and burnouts.

The limitation of this study was that it was conducted across 12 countries with a large sample size thus it may be difficult to infer causal relationships with respect to other factors.

The risk of implementing better staffing is that hospitals may record lower profits.

Whereas the provision of quality care is of utmost importance, this care cannot be provided if nurses are not effectively engaging in the aforesaid ‘ancillary’ activities. The results of this study provide a clear basis for alleviating the issue of low staffing levels.

The strength of the study is that the demographic scope that has been analyzed is relatively lean thus similar causal factors may apply across the board.

A limitation of the study is that since it involves the evaluation of cross-sectional survey data, relationships and associations that may be unveiled cannot infer causality.

The risk of implementing better staffing is that hospitals may record lower profits.

In order to limit work related hazards and the legal costs associated with them, it is imperative that healthcare institutions higher adequate staff so as to avoid overworking the nurses.

The strength of the study is that the demographic scope that has been analyzed is relatively lean thus similar causal factors may apply across the board.

A limitation of the study is that since it involves the evaluation of cross-sectional survey data, relationships and associations that may be unveiled cannot infer causality.

The risk of implementing better staffing is that hospitals may record lower profits.

Key findings

As opposed to nurses who are exposed to a 12-hour shift, those exposed to an 8-hour shift record better health wellbeing and job satisfaction.

Nurses exposed to shifts longer than 8 hours record higher rates of job satisfaction and this may hamper their effectiveness.

When nurses are exposed to working ≥12-hour shifts/overtime/lower staffing levels their ability to effectively engage in ‘ancillary’ activities is diminished.

When nurses are exposed to longer shifts, they are more likely to be ineffective and they may record adverse nurse outcomes.

Outcomes

As opposed to nurses who are exposed to a 12-hour shift, those exposed to an 8-hour shift record better health wellbeing and job satisfaction.

As opposed to nurses who are exposed to a 12-hour shift, those exposed to an 8-hour shift are more effective.

As opposed to nurses who are exposed to a 12-hour shift/overtime, those working for 8 hours or less and within the contracted time have are better able to engage in ancillary activities.

Nurses who are exposed to longer shifts are generally less efficient in their work.

General Notes/Comments

Health institutions should be keen on fostering adequate nurse staffing so as to foster effectiveness within the workplace.

Health institutions should be keen on fostering adequate nurse staffing so as to foster effectiveness within the workplace.

Health institutions should be keen on fostering adequate nurse staffing so as to foster effectiveness within the workplace. This effectiveness will be achieved when nurses are able to engage in ancillary activities.

Hospitals should ensure adequate staffing so as to limit the legal costs associated with adverse nurse outcomes.