So, what got me interesting in looking at this topic? Over a nursing career spanning 24 years and 16 acute-care facilities in 8 states, both as a traveling nurse and as regular staff, I've never worked a rotating shift. Indeed, it wasn't until I came to the Twin Cities that I discovered that rotating shifts were being used by anyone, anywhere. This perception was corroborated by colleagues who, like me, worked in other areas of the country before coming to Minnesota. I have also heard regular complaints from my colleagues about how rotating shifts preclude a stable sleep pattern, are socially disruptive, and have potential negative effects on quality of care.
On reviewing available literature, we found most studies around the issue of shift work and rotating shifts focus on perceptions and preferences of eight versus 12 hour shifts. While they did not address issues surrounding rotating shifts specifically, the MeGettrick and O'Neill (2006) study was instrumental in helping us develop our methodology. Studies that did examine effects of rotating shifts evaluated psychological, physiological, and performance and impacts, such as sleep patterns, depression, homocystine and cortisol levels, and medication error rates. No studies could be found that specifically addressed what nurses thought of rotating shifts, nor of what effects nurses believed rotating shifts had on personal and professional domains.
The primary aim of our research was to determine what staff nurses' perceptions of rotating shifts and their effects on a variety of personal, patient care, and nursing unit domains actually were. We also had the secondary aims of Identifying correlates to nurses' perceptions of their own frequency of illness? Identifying nurses' preferences among rotating and/or straight shifts. In the interests of time, we will be discussing only the primary question.
So why should we bother, beyond intellectual curiosity? If the complaints I've been hearing reflect a broader sentiment, the use of rotating shifts could effect nursing satisfaction, retention, and recruitment. This current nursing market won't last, and the shortage will be back. Facilities that understand how nurses feel about rotating shifts and respond appropriately will have a retention and recruiting edge. Hospitals with ANCC Magnet designation need to demonstrate their responsiveness to nurse-identified issues. I bring up an issue, they need to show they're doing something about it. Evidence based practice requires evidence, and we don't have what we need to really address the question. Managerial and labor decisions on how nursing care is delivered is still nursing practice, and still needs an evidence basis. All too often, that decision-making is driven by tradition, politics, and crisis management.
The survey was developed by a task force with equal management and labor representation; specifically: a bedside medical-surgical nurse, a bedside critical care nurse, the nurse manager of the inpatient neuro/spine center, and the nurse manager of the medical cardiac ICU. The Likert-scale question concerning perceived impact of rotating shifts was developed from a similar question used by McKettrick and O'Neill. This included the parameters of communication amongst staff, quality of “off time,” fatigue and freshness, critical thinking/performance, staff morale, and continuity of care. We added the parameter of “health of the individual nurse,” as well as demographic questions and additional questions specific to our research aims. The survey was refined based on recommendations from the ANW Labor/Management Team and the Allina Institutional Review Board. I also leaned rather heavily on my co-investigators and their expertise as chair and vice-chair of the ANW Nursing Research Council to assure the methodological soundness of the project and navigation of the various procedures and protocols. Concurrently, a dedicated SurveyMonkey.com account was obtained to be used exclusively for this study. Meanwhile, an e-mail distribution list of ANW/MNA contracted nurses was compiled. Once IRB approval was secured and all the “infrastructure” was in place, an e-mail was sent to the 1906 ANW/MNA contracted RNs inviting them to participate in the survey, and included a link to the survey. Reminder notices with the survey link were sent each of the following three weeks. The survey was available for participation for a total of four weeks in August of 2009.
The inclusion and exclusion criteria were as follows: To be participate in the survey, the registered nurse had to meet all these inclusion criteria: the nurse had to be covered by the ANW/MNA collective bargaining agreement, the nurse had to work on one of the inpatient units, in a procedural area, or in the Emergency Department; and the nurse had to provide direct patient care. That is, his or her work had to involve touching patients on a regular basis. Therefore, the following nurses were excluded from the survey: Those not covered by the ANW/MNA contract, including nurse managers, risk managers, and nurse educators; Nurses who work any outpatient clinics housed within the hospital. Nurses who manage a caseload of patients (such as case managers and diabetes educators), even though the are under the MNA contract.
782 of the 1906 ANW/MNA contracted nurses participated in the survey, completing it to varying degrees. The total response rate worked out to 41.03% of the available nurses. While this is substantially less than the 80% required by the Office of Management and Budget for government use, it greatly exceeds the 15-20 percent response common to mail and internet-based surveys. Additionally, the demographic information completed by each respondent is of value here. These data indicate that the respondents represent a broad range of ages, shifts worked, years at ANW, and work areas. On this basis, we believe the survey is provided valid data on the research questions.
The centerpiece of the survey was the five-point Likert scale. The nurse was asked to evaluate the impacts of rotating shifts using scale of 1 (strongly negative) to 5 (strongly positive) one each of the following: Communication amongst staff; Fatigue and Freshness; Quality of “off time”; Job satisfaction; Continuity of care; Health of the individual nurse; Critical thinking/performance; and Staff morale. Our null hypothesis was that rotating shifts have no effect, positive or negative, which predicts a mean response of “3” and a normal, bell-curve distribution for each of the aforementioned parameters. The actual survey response mean was compared to the null hypothesis with a two-tailed t-test, using a confidence interval of ninety-five percent. There were seven to twelve “No opinion” responses for each parameter; these were not used in the statistical analysis.
As noted earlier, not all nurses participating in the survey completed it. The first result column shows how many nurses completed this pivotal question, and it works out to closer to 37% of the nurses invited to participate. As you may remember, the mean value for the null hypothesis is 3. None of the parameters queried produced a mean of 3, but is the difference big enough to be signifcant?
Turns out, all parameters were significantly low than the null hypothesis mean of 3, and the p value less than 0.0001 indicates a high level of significance. Therefore, the null hypothesis can be rejected for each of these parameters.
Personally, I also find it helpful to look at graphical representations. When you look at the histograms of the responses, the negative skew on each curve is readily apparent and consistent with the statistical analysis. However, I'd like point out the one concerning “Communication amongst staff.”
The curve is nearly bell-shaped, which would seem to support the Null Hypothesis, that is, the nurses are pretty much neutral on this topic. Even so, the statistical findings are still significantly negative. As helpful as looking at graphs may be, The lesson is clear: “Your eyes can fool you, so crunch the numbers.”
As with all studies of this nature, it has limitations. We've already discussed the response rate. While I would like to see a stronger response, we believe the demographics support the validity of the findings. That participation in the survey was voluntary was a practical necessity, so the possibility that “only the squeaky wheels (on both sides of the issue)” were heard cannot be dismissed outright. The survey was self-administered, also a practical necessity. While this might not normally be considered a limitation, I have discovered the human capacity to misinterpret a what I though was clearly-worded question well exceeded my expectations. There were also issues with Survey Monkey. It's a very good system, but I thought I'd set more “response required” items, it didn't function to the extent I expected. Thus, we had approximately seventy nurses who “participated,” but somehow evaded completing the survey, particularly the pivotal Likert-scale question. There were also some errors in the way the data collection parameters were set, such that some nurses had trouble accessing the survey and required undue tenacity on their part. This may have affected the overall response rate.
Even so, there is still evidence that can be translated into practice. As noted earlier, this needs to happen not only at the bedside, but in the executive suites. They asked for evidence, now they have evidence. And they need to act on it. Facilities will one day again be fighting over nurses, and those who act on this evidence will have an advantage; everyone else will be late to the party. What is the responsibility of the bedside nurse? We have to hold our managerial and labor leaders responsible for evidence based practice.
There are numerous opportunities for additional research on this question. The survey could be repeated in a larger number of facilities, be it across the Allina system, metro-wide, or even state-wide. While there's a possibility of a nation-wide survey, I'd first want to know that it's a nation-wide issue. We have a lot of information amenable to secondary investigation. One thing I found already was the all rotating shifts are not equally hated, and some are actually desired. Which shifts? Also, as this study demonstrates a consistently negative attitude towards rotating shifts, subsequent statistical analysis could be one-tailed. And of course, there are always questions I wish we'd asked. One pivotal Likert scale questions would be concerning the impact of rotating shifts on patient safety. While one might be able to infer attitudes from responses on the questions posed, there's no substitute for a direct question.
Gates Shifts R
Staff Registered Nurse Perceptions of Shift Work and its Effects Damon Gates, BSN, RN, CCRN-CMC Sue Sendelbach PhD, RN, CCNS, FAHA Brian Goodroad, DNP, ANP-BC, AACRN
The Origin of the Question <ul><li>Anecdotal experience of the principal investigator suggest that while rotating shifts are commonly used in the Twin Cities, they are rarely used elsewhere in the country. </li></ul><ul><li>Expressions of dissatisfaction with the impact of rotating shifts on a variety of personal and patient care parameters voiced by those working rotating shifts. </li></ul>
Review of the Literature <ul><li>Most studies examining the impact of shift work focus on differences between 8-hour and 12-hour shifts, with varying findings. 1-4 </li></ul><ul><li>Studies examining the effects of rotating shifts evaluated psychological, physiological, and performance impacts. 5-7 </li></ul><ul><li>No studies could be found that evaluated nurses' perceptions of rotating shifts and their effects. </li></ul>1 Hoffman, A. J., & Scott, L. D. (2003). Role stress and career satisfaction among registered nurses by work shift patterns. Journal of Nursing Administration, 33 (6), 337-342. 2 Iskra-Golec, I., Folkard, S., Marek, T., & Noworol, C. (1996). Health, well-being and burnout of ICU nurses on 12- and 8-h shifts. Work & Stress, 10 (3), 251-256. 3 McGettrick, K. S., & O'Neill, M. (2006). Critical care nurses -- perceptions of 12-h shifts. Nursing in Critical Care, 11 (4), 188-197. 4 Tucker, P., Barton, J., & Folkard, S. (1996). Comparison of eight and 12 hour shifts: Impacts on health, wellbeing, and alertness during the shift. Occupational & Environmental Medicine, 53 (11), 767-772. 5 Gold, D. R., Rogacz, S., Bock, N., Tosteson, T. D., Baum, T. M., Speizer, F. E., et al. (1992). Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. American Journal of Public Health, 82 (7), 1011-1014 6 Lac, G., & Chamoux, A. (2004). Biological and psychological responses to two rapid shift work schedules. Ergonomics, 47 (12), 1339-1349. 7 Skipper, J., J., Jung, F. D., & Coffey, L. C. (1990). Nurses and shift work: Effects on physical health and mental depression. Journal of Advanced Nursing, 15 (7), 835-842.
The Research Questions <ul><li>Primary aim: </li></ul><ul><ul><li>Examine staff RNs perceptions of shift work and its effects. </li></ul></ul><ul><li>Secondary aims: </li></ul><ul><ul><li>Identify correlates of perceived incidences of illness; and </li></ul></ul><ul><ul><li>Identify nurses’ preference of rotating and/or fixed shifts. </li></ul></ul>
Significance to nursing <ul><li>Use of rotating shifts has potential implications for nursing satisfaction and retention & recruitment. </li></ul><ul><li>Abbott Northwestern Hospital’s ANCC Magnet® designation depends on its ability to address nurse-identified issues. </li></ul><ul><li>Evidence-based practice requires evidence </li></ul><ul><li>Evidence-based practice also happens in the executive suites. 1 </li></ul>1 Campbell, G. (2009) Evidence-based administrative decision-making: creating a rational approach to staffing standards. AACN National Teaching Institute, New Orleans.
Methods <ul><li>Survey developed by task force with equal labor and management representation. </li></ul><ul><li>Survey refined based on recommendations from ANW Labor/Management team, co-investigators, and Allina IRB. </li></ul><ul><li>“ Infrastructure” elements were put in place. </li></ul><ul><li>IRB approval secured. </li></ul><ul><li>E-mail sent to 1906 ANW/MNA contracted RNs including a link to the survey. Reminder e-mails sent weekly x3. </li></ul><ul><li>Survey available for response for 4 (four) weeks of August, 2009. </li></ul>
Inclusion/Exclusion Criteria <ul><li>Inclusion </li></ul><ul><li>RNs covered by the ANW/MNA contract </li></ul><ul><li>RNs who work in inpatient and procedural areas, and the Emergency Department </li></ul><ul><li>RNs who provide direct patient care. </li></ul><ul><li>Exclusion </li></ul><ul><li>RNs not covered by the ANW/MNA contract </li></ul><ul><li>RNs who work in outpatient areas, such as clinics </li></ul><ul><li>RNs who work with a caseload of patients (e.g., case managers, diabetes educators. </li></ul>
Response Rate <ul><li>782 of 1906 nurses participated in the survey, completing it to varying degrees. </li></ul><ul><li>Total response rate 41.03% The US Office of Management and Budget requires a > 80% response rate for surveys undertaken for government purposes. However, in academia, 70% response rate may be considered quite high, and response rates of 15-20% are common for mail- or Internet-based surveys. 1 </li></ul><ul><li>Demographic information completed by each respondent indicates broad representation of ages, shifts worked, years at ANW, and work areas. </li></ul>1 Fowler, F.J. (2009). Survey Research Methods (4th ed.) . Los Angeles: Sage.
Statistical analysis <ul><li>Likert Scale questions coded from 1 (strongly negative) to 5 (strongly positive) </li></ul><ul><li>Null Hypothesis: [Response Mean]=3 </li></ul><ul><li>Actual survey response mean compared to H 0 using two-tail t test with CI =95%. </li></ul>
Results One-Sample Statistics Rotating shifts effect on: N Mean Std. Deviation Communication among staff 715 2.54 1.03 Fatigue/freshness 716 2.2 1.19 Quality of “off time” 716 1.99 1.07 Job satisfaction 714 2.32 1.09 Continuity of care 714 2.58 0.99 Health of nurse 714 2.32 1.15 Staff morale 712 2.51 1.05 Critical thinking/ performance 715 2.03 1.05
Results <ul><li>All parameters had a mean score significantly negative compared to the H 0 </li></ul>One-Sample Test Test Value = 3.00 p <0.0001 (two-tailed) 95% CI of difference Rotating shifts effect on: t df Mean difference Lower Upper Communication amongst staff -12.05 714 -0.46 -0.54 -0.39 Fatigue/freshness -17.98 715 -0.8 -0.88 -0.71 Quality of “off time” -25.29 715 -1.01 -1.09 -0.93 Job satisfaction -15.12 713 -0.68 -0.77 -0.59 Continuity of care -11.32 713 -0.42 -0.49 -0.35 Health of nurse -15.99 713 -0.69 -0.77 -0.6 Staff morale -12.37 711 -0.49 -0.56 -0.41 Critical thinking/performance -24.64 714 -1 -1.04 -0.89
One-Sample Test Test Value = 3.00 p <0.0001 (two-tailed) 95% CI of difference Rotating shifts effect on: t df Mean difference Lower Upper Communication amongst staff -12.05 714 -0.46 -0.54 -0.39
Limitations <ul><li>Response rate </li></ul><ul><li>Voluntary participation </li></ul><ul><li>Self-administered </li></ul><ul><li>Technical issues with the survey. </li></ul>
Translation into Practice <ul><li>Evidence-based practice needs to occur at both the bedside and in the executive suites. </li></ul><ul><li>Effective interventions may have retention and recruitment benefits. </li></ul><ul><li>The bedside nurse will be tasked with holding managerial and labor leaders responsible for acting on the evidence. </li></ul>
Future Research <ul><li>Survey a larger number of facilities. </li></ul><ul><li>Secondary investigations of data. </li></ul><ul><li>Additional “heart of the matter” questions. </li></ul>
Conclusions <ul><li>There is significant evidence that suggests registered nurses working in direct patient care at ANW have a negative perception of the impact of rotating shifts. </li></ul><ul><li>While this evidence is useful to guide initial Labor/Management policy, additional research is needed to identify the extent of these perceptions on a broader scale, additional quality-of-care implications, and optimal corrective actions. </li></ul>