Abouhmoud Final Thesis Study

Final ThesisDraft November 8, 2015 1
The 12 hour Registered Nurse work shift and its Downfalls.
Amer Abouhmoud
Dr. Su
HSC 484
11/8/2015
Cleveland State University

ABSTRACT
The path to becoming a registered nurse is a long and difficult road to travel and not
many do. For the ones who push on and make it out on the other side to become a successful
registered nurse, a life of strenuous responsibility awaits them. What I have chosen to do in this
research thesis is go out into the field of work and observe these registered nurses in action and
see how their daily shifts go. For this particular research, I wanted to look at 12 hour shift
registered nurses who work within a hospital. For comparison purposes, I have chooses to
observe and do research on three separate groups consisting of 20 registered nurses respectively.
Group A which will be 12 hour day shift registered nurses (7am-7pm) , Group B night shift
registered nurses (7pm-7am) as well as Group C registered nurses who work outside of a hospital
in a traditional Monday through Friday 8 hour work week. The hypothesis here will state that 12
hour registered nurses will begin to hit a proverbial wall around their tenth hour of work, and
will be even worse for the nurses who work the overnight shifts. However for the nurses who
work outside of the hospital in a more traditional work schedule in Group C, they will have a
smaller turnover ratio, and the error in care will be significantly less.
KEYWORDS
-Registered Nurses
-Circadian Rhythm
-Shift Work Disorder
-Hospital
-Hours of Sleep
-Diet
-Errors

-Melatonin
-Heart Rate
-Organ enzymes
Table of Acronym Definitions
RN – Registered Nurse
CR – Circadian Rhythm
RMR – Resting Metabolic Rate
HOS – Hours of Sleep
BP – Blood Pressure
SWD – Shift Work Disorder
Group A – 12 Hour Hospital Day Shift Registered Nurses
Group B – 12 Hour Hospital Night Shift Registered Nurses
Group C – Non Hospital Registered Nurses Who Work 12 Hour Shifts
Introduction
The topic will be to the benefit of numerous lives that that can be potentially affected by
this research proposal. As stated before, being an RN comes with a heavy responsibility and
requires dedicated passion to others as one you are sworn into a group of people who dedicate
their lives, their passion, sweat and time to ensuring that others’ lives around them and under
their care and supervision is better than when they first met. To my own amazement our society
does not hold being a nurse to the same prestigious levels of those that are doctors let us say.

People still look down upon RNs due to the over shadowing of the all mighty doctor titles in this
world. This is no more evident than when Miss American runner up Kelley Johnson came out on
stage at the Miss America Pageant in her nursing scrubs to prove a point about nursing because
she had just graduated with her nursing degree and was becoming a RN in the process of doing
Miss America. However when a day time talk show called The View talked about what Kelley
Johnson did, they made fun of her and one co-host was stated saying “why does she have a
doctor’s stethoscope on?” The issue was that the talk show hosts did not take her seriously for
only being just a nurse, and made the assumptions that only doctors can carry the all might
stethoscopes (HENSLEY, 2015). This proposal will truly show how hard being a registered
nurse is, which leads me to my thesis of why RNs should not be working 12 hour shifts,
especially overnight 12 hour shifts.
For RNs who work 12 hour shifts, it can be very beneficial to their at home lives. This is
due to the fact that they will then get days off during the week to be at home and do whatever
they need to do in their lives and be around their families more if they have any. However the
problems lie in the patient not caring about the RNs outside life, as they are in pretty rough shape
being stuck in a hospital, if not in deathly shape, as well in those who are signing off on these
schedules allowing these nurses to work at times 3 if not more days in a row where they can
become less effective to patient care. This means that the nursing staff better be on their A game
when on the clock because this is not like any other line of work due to the high level of stress,
that being a human life in your hands, and if you mess up you can really be dealing with a life or
death situation. These nurses who work within a hospital are working at all odd hours, seven
days a week, 365 days a year including all holidays. A problem with this is that the RNs are over
working themselves which in turn is putting the patients who are already vulnerable, in worse

shape because now the room for human error has grown because of the RNs body and brain
becoming fatigued. Working a 12 hour shift is bad enough due to the long hours and doing a 12
hours shift as a nurse overnight has to be even worse, especially for new RNs who have never
done it before coming right out of nursing school and have to be able to think clearly at all odd
hours of the night. This proposal will take a look at how working these kind of hours affect
patient care, the RNs themselves and what we can do to fix these issues that arise.
SPECIFC AIMS OF THIS STUDY
1- To see if 12 hour shifts are beneficial to registered nurses, or if they are causing too
much distress and error in the field of being a registered nurse working within a
hospital.
HYPOTHESIS
My hypothesis for this proposal is that if RNs were to work no more than 10 hours shifts,
error in care would occur less, and the RN turnover rate would come down substantially. This
would also mean that the health issue diagnosed as Work Shift Disorder (WSD) would start to
diminish and appear less in RNs who work odd hours such as 7pm to 7am. This will now let RNs
go home when they start to become dangerous to patient health caring, and allows them to still
maintain their days off during the week if they so choose by working up to the ten hour mark if
they can. Although the schedule of three days on and four days off is appealing, that should not
be the deciding factor of someone wanting to go into nursing because the degree of difficulty due
to this profession of taking care of human lives.

BACKGROUND AND SIGNIFICANCE
The whole point to this proposal is effectively to make more people healthier and safer
inside the work sector of a hospital setting, patients and RNs alike. In the big picture, the thing
that will make patient care even better and safer will effectively be making a RNs job more
convenient and less stressful. To do this we have to dive into the lives of an RN and seek
information into their lives outside of the hospital as well. For instance, it is important to obtain
the number of hours of sleep an RN gets before coming into work for a day shift, versus the
number of hours of sleep for an RN coming onto do the night shift. Then to compare the two, we
will add in the number of hours of sleep for nurses we have working a traditional 8 hour day
outside of a hospital. Within that information, we will be able to tell is WSD is occurring due to
lack of sleep in these nurses. According to Horng et al, they conducted research into a group of
all female nurses who worked all sorts of shifts in nursing. Their research was not environment
oriented in a hospital like mine as they were truly trying to observe a nurses home life. They
were more interested in surveying these nurses and finding out who had a more productive life
outside of work and how happy they were outside of work as well. They came to the conclusion
that nurses who worked an 8 hour day had a more productive life style outside of work and
nurses who worked an overnight shift had a more robust activity rhythm (Kang, Miao, Trevor, &
Min, 2015, pp. 348-355).

(Saleh & Awadalla, 2014)
A key factor into the 12 hour work shift becoming a very serious problem for nurses is
when it comes to error in their work, specifically in this case medication errors which have led to
death in some cases. When you go to the hospital, or have a loved in in the hospital, you are
putting your whole trust fund into the hands of another human being in hopes that they will take
care of you or your loved one. Your expectation is to get better and move on. However according
to this graph done above by Saleh et al. it shows us that the number of hours of sleep an RN gets
can greatly increase the chances of error when it comes to passing medications to their patients.
This graph shows us how when a an RN gets 6 hours of sleep or less, there is a much greater risk
of medication error occurring to the patient. 9 dots, which in this case 1 dot represents 1 nurse,
were plotted at the 6 hours of sleep mark, opposed to only 4 dots on the side of an RN obtaining
more than 6 hours of sleep. That is over a 50% increase in error to happen when an RN does not
obtain enough sleep. Whether you are working the day shift or night shift, getting the right
number of hours of sleep is very important when it comes to taking care of your patients, as well

as yourself. From the same group of researchers, they have added another graph to prove how
important it is for the RN to take care of themselves as well.
(Saleh & Awadalla, 2014)
This study also helped show how depression in nurses effects their work as well.
Looking into the graph, the regression line is trending upwards, which means the more someone
is depressed, with respect to levels of depression, that the RN is more prone to making errors in
their care of medication use to patients. This is proof that nurses with a higher rate of depression
are obviously more prone to being side tracked at work and cause error in patient care as well.
Another issue for nurses is the 12 hour night shift, and is especially hard for the nurses who are
beginning to work on that shift that have never done work, or even been awake typically during
those off-set hours (Summa & Turek, 2015). Being an RN is hard enough, being one from the
hours of 7p to 7a is a whole different challenge. This is proved when Summa and Turek studied
how ones circadian rhythm is thrown off when you begin to work during hours your body is not
used to. They came to a conclusion that every human has a master clock embedded within our

brains that regulates mass functions occurring within our bodies. Thus, humans typically find
themselves becoming sleepy when it is night time and dark outside, and we begin to function
when the sun arises and have more energy. They also looked into the idea that there are also
other clocks in the human body, referred to as peripheral clocks, which micromanage the organ
they are in. Something interesting they found was how someone’s weight and diet could play
into making the transition into being up during your bodies not normal hours can affect your
function (Summa & Turek, 2015, pp. 5063-6755)
Based off the work they did, it would be ideal that we could figure out when each
person’s circadian rhythm is at peak performance, which would in turn allow us to place nurses
on a more efficient work schedule for their life and health, and also help treat people with WSD
and other medical conditions. This would allow a breakthrough in the medical treatment world
and pharmaceutical world as well, as it would allow us to understand certain conditions more,
and avoid them as well, making RNs more efficient at work and allowing them to work when
their bodies are at full functional capacity.
Another reason to find out the true importance of the humans circadian rhythm is to find
out how it effects our moods. According to a study done by Zhang, Zeng and Huang, the CR is
what also affects our relationships at home, along with our social lives in general. This research
was important because their theory is that people are more social between the hours of 8pm and
midnight, making them less inclined to be sociable at 8am. This does no good for the RNs who
are at work during these hours. If these are the true peak hours of being social, then their social
lives at home are taking a major hit which will turn into some sort of depression or anger down
the road (Zhang, Zeng, & Wang, 2015, pp. 1-8)

-MORE BACKGROUND TO BE WRITTEN-
METHOD
There will be three (3) groups with 20 RNs in each group.
1- Day Shift RNs (7am-7pm)
2- Night Shift RNs (7pm-7am)
3- RNs who work outside of a hospital on an 8 hour schedule
A mix of male and female RNs will be requested, with no specific target or male RN to female
RN ratio. Consent will be mandatory from the research participants by a hand written signature
from each nurse. We will never request and not adhere to hearing any patient information, or any
information regarding to any patient in particular, and we will adhere to the HIPA laws in
accordance to the law.
This will also include observations of the nurses inside their working environments on site, and
interviews on site as well as questioners on a daily basis to each member.
RESEARCH DESIGN
A quantitative experiment that will be supplemented by onsite interviews and questionnaires to
be answered by the RNs as well.
Procedures- Mood will be measured every time an RN comes into work by asking the
RN how they feel right before they clock in, how their day went, and if anything happened to
make them frustrated during their day before work to gage how emotionally stable they are going
into their shift ahead.

- I will also be asking how many hours of sleep the RN had and compare it to the
national average of HOS set forth by the World Health Organization (eight hours).
- My data and analysis plan will be quantitative.
RESOURCES AND ENVIRONMENT
For resources, I will be using not much more than the following
- Voice recorder for interviews to compare tone of voice on a daily basis.
- Pencils
- Notepad paper
- Blood pressure and heart rate monitors
- Thermometers
- A Hospital with both Medical Surgical Unis in it, as well as an emergency room.
- We will also be in need of a doctor’s office or nursing facility which is not a hospital,
which has a nursing staff who works on 8 hour rotations.
LIST OF ALL MATERIALS
-A hospital, specifically Cleveland Clinic Fairview Hospital with permission from the
Nursing directors who I share an office with here at Fairview Hospital.
- Other nursing facility
- Nurses Station with office available for interviewing
- Blood pressure cuffs
- Heart rate monitors
- EKG machines
- Psychiatrist
- Dieticians
- Physicians
- Questionnaires
- Snacks such as chocolates and vegetables

TIME LINE
The time line for this research shall be done and completed within 6 months. Each month I will
compare my data to the previous month and see how the 12 hour work shift is effecting the
nurse’s work. I will recruit nurse by telling them how this study will help me depict to others
why some do and do not like the 12 hour work shift for being a nurse. I will get this done in 6
months by being on site every day, calculation my research to fit within that time span as well as
basing a half way point at the 3 month mark to compare and see if regression happens at the end
of 6 months.
CONCLUSION
This study was done to make numerous lives in the world of health care much safer and
much happier. This is also going to make a RNs job a lot less stressful as they will be able to get
home quicker, then having to stay at work and stew over something bad that has happened to
them over the course of their day. This will hopefully make the patients stay at the hospital much
more efficient and enjoyable. This will show an increase in a RNs attitude, and thus make the
turnover rate for RNs much smaller. This will also drive dow (Paschos, 2015)n the numerous
cases of WSD. Getting all RNs to work on an 8 hour schedule will reduce anxiety of being away
from home for upwards of 12 to 14 hours, including commute time and pass off report time, it
will stave off depression, and make attitudes and moods in general go up for the better for each
RN. Night shifts will never go away in the area of work that is in a hospital, however there is a
way to make those hours of work more efficient and safer for everyone involved, not just the
patients.

PERSONAL BIOGROPHIES
This will include all research members who accept to give us information about
themselves. If they decline, they will not be featured under this section in respect to their wishes.
BUDGET
The budget for this research will hopefully remain small, as the most costly items will be
the snacks and paper we have to go through. Our hope is that we can get these RNs and maybe
doctors to join in on this research as it pertains to their livelihood, their field of work which we
would hope that they are passionate about and are interested in being a part of research about, as
well as we hope that the RNs will be enticed by our offer of food as compensation instead of
being financially compensated. We will ask to borrow and use all medical related items from the
hospital floors while we are there. This does not look to break the bank by any stretch of the
imagination, and should be more then fine to get done without having to stress about finances.
(Saini, 2015)
References
HENSLEY, N.(2015, September16). Nursesupsetwith ‘TheView’hostsJoy Behar and Michelle Collins for
making fun of MissColorado’sstethoscope .RetrievedfromNEWYORKDAILY NEWS:
http://www.nydailynews.com/news/national/nurses-upset-view-making-fun-colorado-article-
1.2363266
Kang,J. H., Miao,N. F.,Trevor,S., & Min, C. H. (2015). ResearchIntoWork Shifts. BiologicalResearch for
Nursing,17(3),348-355. doi:10.1177/1099800414549454
Saleh,A.M., & Awadalla,N.J.(2014, January1). Impacts of nurses’circadianrhythmsleepdisorders,
fatigue,anddepressiononmedicationadministrationerrors. Egyptian Journalof ChestDiseases
and Tuberculosis,63(1), 145-153. RetrievedNovember5,2015, from
http://www.sciencedirect.com/science/article/pii/S0422763813002380
Summa,K.,& Turek,F.(2015). THE CLOCKSWITHIN US. Scientific American,312(2), 5063-6755.

Zhang,P. C.,Zeng,C., & Wang, X.X. (2015). CircadianRhythmsinSocializingPropensity. PlosONE,10(9),
1-8.
Questionnaire:
1.) Do you enjoy the work that you do?
2.) Are you happy with your life?
3.) Are you happy at work?
4.) If no to the previous answer, would a change of work place make it different?
5.) Do you like the hours you work, if not, what hours do you wish you could work?
6.) Are you single, domestic partner, married or other?
7.) Do you have children?
8.) Are you currently enrolled in classes?
9.) Do you plan to farther your education or advance in the work place?
10.) Where do you see yourself in 5 years?

Institutional Review Board
Human Subjects in Research
Instructions and Checklist for Applicants
The Institutional ReviewBoard(IRB) of ClevelandState University(CSU) isresponsibleforensuringthe protection
and ethical treatment of human participants in research conducted under the auspices of the University.
Accordingly, the IRB must evaluate all such research projects, in compliance with Federal Regulations. Your
application to the IRB for permission to test human subjects should follow the guidelines provided below.
Proposed Departures from the guidelines should be justified thoroughly.
Some protocolsmaybe approvedthroughone of the expeditedorexemptcategoriesinthe Federal Regulations,
andsome require fullCommitteeconsideration.These determinationsare madebythe IRB, notbythe researcher.
If yourprotocol requiresfullCommittee consideration,the UniversityOfficeof SponsoredProgramsandResearch
must receive itnolaterthan two(2) full weeksprior tothe IRB meeting;thismeetingnormallyoccursduringthe
firstweekof the month.Protocolsshouldbe submittedtothe IRB, Office of SponsoredProgramsand Research,
2258 Euclid Avenue, Hannifin Hall, Cleveland, OH 44115-2440 ATTN: IRB Coordinator.
Issues of Particular Concern to the IRB

 Privacy: In mostresearch,subjects’willingnesstoparticipate will dependonthe researcher’sexplanationof
the project and its purpose, the subject’s understanding of risks and benefits, and the assurance that the
specifics of their participation will not become known to other individuals. A mismatch between your
assurance to the subjects and the procedures you explain in your Project Description will lead the IRB to
request revisions before approval can be granted. Issues of anonymity and confidentiality are of special
concern when subjects might divulge sensitive information, including situations in which their responses
mightplace theminjeopardy(e.g.,publicembarrassment,threatstojobsecurity,self-incrimination).The care
with which you address these issues in your procedures is very important to the IRB approval process
 Risk: In much research, subjects’ participationinvolves little or no risk. If this is genuinely the case, say so;
e.g.,“minimal risk,”“noforeseeable risk,”“norisksbeyondthose of dailyliving.” If there issome risk,where
physical,psychological,social,legal,orotherwise,the IRBwill be particularlyinterestedinthe safeguardsyou
implement to deal with these risks. The overall importance and soundness of the research project will be
especially important if subjects are placed at some degree of risk by participating.
 Special Populations: Testingminors,pregnantwomen,prisoners,mentallyretardedordisabledpersons,or
otherspecial populationsraisesseriousissuesregardingriskandinformedconsent,whichyourprotocolmust
address. On the other hand, recent federal guidelines mandate the inclusion of women and minorities in
research. The nature of your subject population must be clear in your proposal, and you must provide your
rationale for including/excluding identifiable subgroups based on gender and minority status.
 IRB Procedures: CSU’s IRB receivesapproximately300 applicationsayear,eachof whichmust be evaluated
for adequate protection of the subjects against research risks. You will enhance the acceptability of your
proposal,andthe speedwithwhichthe IRB can evaluate it,if your protocol isconcise,dealsspecificallywith
the issues discussed in these instructions, and shows your sensitivity to the overriding concerns of ethical

treatmentof humansubjects.Pleasefeelfree tosuggestanymodificationsorelaborationtothese instructions
that would be helpful to you as you write or revise your applications.

II. Participant Information
Total number of participants:
Age range (lower limit – upper limit):
Gender: Select one
Ethnic Minority: Select one
Inclusionary criteria:
Exclusionary criteria:
Source of participants:
Is the data going to be extractedfrom records that already exist on these participants (e.g. school records,
grade transcripts, medical records, etc.)?
Yes No
If yes, will the data be recorded in a way that prevents subjects from being identified?
Yes No
Length of participation (x time/session, y sessions, over z months):
Participants in Special Consideration Categories: (Check all that apply.)
None Military personnel

Children (age range: ) Wards of the State
Cognitively impaired persons Institutionalized individuals
Prisoners Non-English speaking individuals
Pregnant or lactating women Students
Blind individuals
Other subjects whose life circumstances may interfere with their ability to make free choice in consenting
to take part in research (please specify):
Site(s) of data collection: Cleveland State University
Letters of approval from project site officials: Select one
*You MUST include letters of approval from appropriate administrative officials at the facility where you will
be collecting data.
III. Project Description
a. Give a concise statementof the areaof researchandbrieflydescribethe purpose andobjectivesof your
proposedresearch:

b. Provide adetaileddescriptionof howparticipantswill be recruitedandusedinthe project.Please
include adescriptionof the taskssubjectswillbe performing,the circumstancesof testing,and/orthe
nature of the subjects’involvement.
c. Make an explicitstatementconcerningthe possiblerisksandbenefitsassociatedwithparticipatingin
the research.Describe the nature andlikelihoodof possiblerisks(e.g.,physical,psychological,social) as
a resultof participationinthe research.Risksinclude evenmilddiscomfortsorinconveniences,aswell
as potential fordisclosureof sensitiveinformation.If ariskexists,how doesitcompare tothose of daily
living?Whatare your safeguardsforavoidingrisks,forprotectingsubjects’privacy,etc.?
d. Describe measurestobe takentoprotectsubjectsfrompossible risksordiscomforts.

e. Describe precautionstoensure the privacyof subjectsandconfidentialityof information.Be explicitif
data are sensitive.Describe codingproceduresforsubjectidentification.Includethe method,location
and durationof data retention.(Federalregulationsrequiredatatobe maintainedforatleast3 years)
IV. Informed Consent Form
Yes No N/A
Does the Informed Consent Statement?
1. Introduce youandyour research(including names andphone numbers).
2. Provide the subject with a brief, understandable explanationof the research.
3. Explainthe risks and benefits.
4. Explainthe details of the time commitment for participation.
5. Explainhow your protocol either protects confidentialityor is anonymous.*
6. Mentionthat participation is voluntary, andthat the subject may
withdrawat anytime without penalty.
7. Include the exact statement about contacting the IRB.**

8. Provide a phonenumber where the subject may contact you for further
information (students should include a phonenumber for themselves and
also for their supervising faculty member).
9. Have a signature/date block for the subject to complete.***
* Confidentiality and anonymity are not the same.Confidentiality means that the researcher willknow the identity of
specific subjects and their data. Anonymity means individuals’ responses cannot be associated with the data they
generate.
** “I understand that if I have any questions about my rights as a researchsubject I can contact the CSU Institutional
Review Board at (216) 687-3630,” or if a minor, “I understand that if I have any questions about my child’s rights as
a research subject I can contact the CSU Institutional Review Board at (216) 687-3630.”
*** If you wish to dispense witha signed consent form, for either procedural or substantive reasons,be sure to include
a clear statement of your reasons and your alternate procedure for obtaining consent.

VI. CERTIFICATION/SIGNATURE
I certify that the information contained in this protocol application and all attachments is true and correct. I
certify that I have received approval to conduct this research from all persons named as collaborators and from
officials of the project site(s). If this protocol is approved by the Cleveland State Institutional Review Board, I
agree to conduct the research according to the approved protocol. I agree not to implement any changes in
the protocol until such changes have been approved by The Cleveland State Institutional Review Board. If,
during thecourse of the research, unanticipated risks or harm to subjects arediscovered, I will cease collecting
data and report them to IRB immediately.
______________________________________________ ______________ __________________________________________________
Sign Name  PrincipalInvestigator/FacultyAdvisor Date Print NamePrincipalInvestigator/Faculty Advisor
______________________________________________ ______________ __________________________________________________
Sign Name  Co-Principal or StudentInvestigator Date Print NameCo-Principal orStudent Investigator

______________________________________________ ______________ __________________________________________________
______________________________________________ ______________ __________________________________________________
______________________________________________ ______________ __________________________________________________
______________________________________________ ______________ __________________________________________________

Forward this completed form to:
ClevelandState University
InstitutionalReviewBoard
Office of SponsoredProgramsandResearch
2258 EuclidAvenue
HannifinHall
Cleveland,OH44115-2405
V. Copies of Instruments andQuestionnaires
AmericanHealthAssociation/AmericanCollege of Sports Medicine:

This study’s runninghistory survey:

Abouhmoud Final Thesis Study

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