Jill Clendon and Veronique Gibbons published a systematic review in the International Journal of Nursing Studies that examined the effects of extended shifts on error rates. They reviewed the Cochrane, Joanna Briggs Institute, CINAHL, MEDLINE, Embase, Current Contents, Proquest, and Dissertations International databases for English language research (published or unpublished) conducted prior to August 2014. 5429 studies were identified using: "length of time", "shift work", "error rate", and "nursing" key words and assessed for review. 86 studies were identified as potentially relevant; 60 did not meet inclusion criteria and were discarded, 26 studies met the broad definition and were included for review.
The 26 Studies that met the broad inclusion criteria were quantitative observational study designs, of nurses (any level, excluding students), who work in acute care hospitals, that compared extended (12hrs or more) to non-extended (<12hrs) shift patterns, and examined error rates (based on Benner et al.'s taxonomy). Of the 26 that met inclusion criteria 13 were excluded from the final analysis due to lack of methodological rigor. Of the 13 included studies: 8 were from the USA, 2 from Japan, 1 from Canada, and 1 was European. The majority reviewed RN's only, used convenience sampling, and assessed for self reported errors. The average education level, years experience, and primary work environment of the nurses reviewed were not discussed.
The authors note that the results are too heterogeneous (X2 = 34.29, p = 0.01) to draw conclusions on the whole population reviewed; but they do discuss some conclusions drawn by studies of similar designs and results. 4 studies found lower error rates associated with extended work days, 6 found higher error rates with extended work days, and 3 found no difference. The 6 studies reporting higher error rates comprised 89% (60,780) of the total review population (n= 67,967), this is what the authors spend the bulk of the paper discussing.
Half (n = 31,627) of the patients in this cohort come from a 2014 study (Griffiths et al) that assessed rates of unfinished work among nurses of varying shift lengths. The study showed higher rates of unfinished care with extended shifts (OR = 1.13; CI 95% 1.09-1.16); but failed to discuss the characteristics of the studied groups, and the nature of the unfinished care. Because the RN's surveyed in this study came from 488 hospitals across 12 European countries, failing to discuss the similarity or differences in patient acuity and hospital census weakens the evidence, as regional characteristics could result in large differences between groups; similarly, not knowing the nature of the unfinished work prevents extrapolation of what the clinical effects of these errors were.
The next largest subset of this group study (n= 25,985) to associate negative outcome with extended shift length was a study that assessed the differences in central line associated infections, urinary tract infections, and pain control among patients cared for by groups of nurses working extended or non-extended shifts. These studies are two separate analyses of results from the same study. The study did find central line associated infections were 2.5 (n = 3710) times more likely to be reported in areas were nurses worked extended shift, that pain was less well controlled (OR = 0.9, p <0.01, n = 22,275) and that shift length had no effect on UTI rates. This subset of the study could prove interesting to review, as it examines a quantifiable clinical outcome, and would certainly be worth evaluating to determine if the statistically significant results are clinically significant.
Of the remaining 3 studies 2 assessed for rates of reported error, or near miss errors. One study (Rogers et al., 2004) used a binary (yes/no) system to code for error during extended work days. They found that extended shifts were associated with an error rate 3 times higher than non-extended shifts (OR = 3.29; p = 0.001). The second study, by Scott et al (2006), used a self reporting log of error, or near errors to assess for risk of error (vigilance) in extended shifts. They found that extended shifts resulted in an "error/risk for error events" rate twice that of regular shifts (OR 1.94, p = 0.03). Taken together these studies observed error rates 2-3 times higher in extended shifts. These are alarming numbers; but the evidence may not be strong enough to make conclusions on the effects of shift length on adverse events. Unfortunately a binary system of coding errors prevents any discussion about the true error incidence rate (actual number of errors), nature of the error, or clinical relevance of the error. Furthermore a tool that assesses for both error and "near error: is likely to be a very sensitive tool, one that doesn't differentiate between error types (true rates of actual error and near error), and is likely to produce a disproportionately large rate of "positives", which limits the clinical relevance of the findings.
The final study was a longitudinal survey (n = 2273) that examined the rate of needlestick injury for nurses working differing length shifts. It found that nurses who worked 12 hours or more were more likely (OR = 1.68, p = 0.001) to have a needlestick injury in the previous year compared to nurses working less than 12 hrs. This, much like the study examining pain and infection rate would be need to be reviewed to assess if the statistically significant increase was in any way clinically significant.
The authors suggest that there may be an increased risk for errors associate with extended work days. However the generalizability of this review is limited by the heterogeneity of the studies, the conflicting results, and the broad definition of error. It does provide an overview of some of the literature examining the effect of shift length on error rates; but it falls far short of generating usable recommendations. I don't think the quality of evidence presented here is strong enough to make generalizations about the safety of extended shifts in general. From a nursing perspective I would suggest reviewing the primary research included in this review in isolation if you're attempting to examine the effects of extended work days on nurse or patient clinical outcomes. I would suggest considering your own quality of life measures if you're attempting to determine if extended work days are a better fit for your individual nursing practice.
Clendon, J., & Gibbons, V. (2015). 12h shifts and rates of error among nurses: A systematic review. International journal of nursing studies.
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