Nursing is the Most Trusted Profession and We’re Talking About 12-Hour Shifts?
Michael B. Grossman, DM, MSN, RN, NEA-BC, CNML
In 2001 Alan Iverson, a player for the Philadelphia 76er’s basketball team gave an infamous speech after his coach disciplined him for not showing up at practice (http://genius.com/Allen-iverson-practice-press-conference-annotated). Iverson’s argument was that he should be judged on what he does on the playing court, not practice. Iverson said he didn’t agree with the coach that as the team leader he had a responsibility to be a role model to the other players, including attending practice. Iverson suggested that as long as he performed at his best during the game that is all that matters. It reminds me of a classic nursing argument: Suzie’s a good nurse, she just doesn’t get along with people.
Every time I hear nurse’s argue about how 12-hour shifts are an acceptable practice, I think of Iverson’s argument. But, before we continue take a moment to think of your own reaction to this topic? Are you defensive? Are you concerned about what you would do if 12-hour shifts went away? Are you thinking you would leave nursing if you couldn’t work 12-hour shifts. So, before you stop reading just take a few minutes to hear my arguments, as I am not suggesting 12-hour shifts go away. There is another solution, which we will discuss later.
There has been extensive research on the perils of 12-hour shifts without breaks since it was first identified as a factor in 90,000 estimated patient deaths per year due to medical errors (Institute of Medicine, 2000). Today, it is estimated that 400,000 deaths occur per year in healthcare due to preventable errors (James, September 2013). Those are staggering numbers! When nurses and physicians were administered a driving test at the end of a 12-hour shift without breaks their cognitive ability was equivalent to someone who was clinically drunk (Smith-Coggins, et al, 2006). The State of Washington took this issue so seriously they appointed a commission to look at nurse schedules and fatigue (Ellis, 2008). The Joint Commission has formally addressed the dangers of 12-hour shifts twice, once suggesting it was a factor undermining a culture of safety (Joint Commission, 2008) and then again in specifically addressing the issue of health worker fatigue and calling for every hospital to have a plan of correction (Joint Commission, 2011).
The Nursing Reaction to 12-Hour Shifts
I teach health care ethics at the graduate school level and have discussed the ethics of 12-hour shifts over the past 60 semesters I have taught. The topic raises a lot of emotional reaction and invariable several students give Iverson-like reactions in which they essentially argue that: We’re talking about 12-hour shifts, not taking care of patients, not all the unethical things going on in health care, we’re talking about 12-hour shifts. I go out there and die for my patients. I work 12, 13, 14 hours and never leave my patients side. I work five or six 12-hour shifts in a row and go to school full-time, and am raising 3 kids. I don’t take lunch break, I don’t go to the bathroom, I work overtime and never leave my patient’s side. But, you don’t talk about that. No, you want to talk about 12-hour shifts causing fatigue. What about the fact that nursing was just rated the most trusted profession by patients? What about that fact that I’m taking care of my patient? What about the fact that I care enough to never leave my patients side no matter how tired I am? But we’re not talking about that. We’re talking about 12-hour shifts. Not my nursing care, not my dedication, not that we don’t have enough nurses. We’re talking about 12-hour shifts, how silly is that?
What’s the Real Issue?
There clearly are advantages to 12-hour shifts. Most nurses prefer them. Most nurses believe it provides them with a more balanced life and the ability to get a second job, go to school, raise children, or just have an extra 4 days off ever week. But the ethical question is whether 12-hour shifts, without breaks are safe for patients? No matter how much nurses like 12-hour shifts we cannot ignore the safety concerns?
If you were on the witness stand following a serious patient error that occurred in the 11th hour of a 12-hour shift, could you prove you were not fatigued? More important would the jury believe the argument that you prefer 12-hour shifts and didn’t believe you were tired that night? What if the prosecuting attorney presented research evidence that nurse who don’t take breaks on 12-hour shifts are equivalent to being clinically drunk (Smith-Coggins, 2006). What if the prosecuting attorney asked how your organization addressed the Joint Commission Sentinel Alerts around nurse fatigue (2008, 2011)? What if you said, well my adrenalin kicks in when I’m tired and the prosecuting attorney brought in a physiologist who said adrenalin sends blood to your limbs and away from your brain so critical thinking is impaired when adrenalin kicks in. Meanings when your adrenalin kicks in you are even more likely to cause a patient error.
What Happens When We Take the Time to Listen?
Ironically, in recent years Allen Iverson admitted his tirade about practice was an emotional, defensive reaction to his feeling criticized in public. Is that why nurses react to the question of fatigue and 12-hour shifts? Research has suggested that when people do not totally understand a topic they are not really capable of addressing the topic (Ehrlinger, Johnson, Banner, Dunning, & Kruger, 2008). In the 1970’s nurses defended smoking cigarettes right at the nurses station, because the research on second hand smoke was still too new and not fully accepted. Kuhn (1996) suggested all change is resisted the more closely people are tied to the history. From a change standpoint resistance to transitions is rarely about the virtues of the new innovation, but about what people are giving up (Bridges, 2004). Rogers (2004) suggested that only 15% of people are early adopters of any new innovation. Think of the adoption of electronic books. Ten years ago all you heard was but I like the look and feel of a book. Rogers suggested 34% of people are late adopters and need to watch others adopt the innovation before they test the water. This week my mother in law bought my wife a Kindle. I find it significant that an 85-year-old woman took years to accept the Kindle technology, then discovered the convenience and passed it along to her younger daughter. Finally 16% of people are laggards, according to Rogers. They will never adapt to change and are still talking about the convenience of paper charts. But that’s a topic for another time. So is there a solution to 12-hour shifts?
A Simple Solution
Thomas Huxley (2001) suggested that the most valuable result of all education is to make you do the things you have to do, when it ought to be done, whether you like it or not. It is the first lesson that ought to be learned. And however early a man’s training begins, it is probably the last lesson that he learns thoroughly. Perhaps that explains why we learn by failing and must experience things to develop our personal meaning and ethical approaches to life. But does another patient need to get hurt for us to realize we need to do something about 12-hour shifts and nurse fatigue?
One of the problems with any change is that change is more about loss than it is the transition. Indeed the issue around electronic books was the loss of that multi-sensory experience of sitting on the sofa and turning the pages of a good book that you could see, and feel, and smell. Nothing like the smell of a new book or a newspaper fresh off the presses with a good cup of coffee at the kitchen table. Covey (2013) suggested that communication does not take place as long as you are trying to push your view on the other person. Highly effective people first build trust and then seek first to understand the other person’s viewpoint. So here’s my viewpoint: 12-hour shifts do not need to go away. Smith-Coggins, et al (2006) found that when nurses and physician’s took an adequate break during their 12-hour shift they were as alert as when they arrived at work 12-hours earlier. There was no impairment of cognitive ability if they took an adequate break. So, can we change this discussion from doing away with 12-hour shifts to how can we make sure nurses get adequate breaks so they are not fatigued? Let’s change the topic of the conversation, then have an effective conversation about how to come up with a win-win solution so nurses get adequate breaks and 12-hour shifts don’t need to go away.
Dr. Michael Grossman, DM, MSN, RN, NEA-BC, CNML has over 35 years of nursing leadership experience and is a nursing leader, consultant, academician, and career coach. As a professor in the graduate schools of nursing at both University of Phoenix and Walden University, he specializes in healthcare ethics, leadership development, career coaching, mentoring, teambuilding, motivation, change, communications, and dealing with “difficult” people. He also teaches nursing leadership certification review courses.
For further information go to: http://www.nurseleadershipbuilders.com/
He can also be reached at 610-331-8470 or Mike@NurseLeadershipBuilders.com
Reference
Bridges, W. (2004). Transitions: Making Sense of Life’s Changes, Revised 25th Anniversary Edition. Cambridge, MA: Da Capo Press.
Covey, S. R. (2013). The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. New York: Simon & Schuster.
Ehrlinger, J., Johnson, K., Banner, M., Dunning, D., & Kruger, J. (2008). Why the
Unskilled Are Unaware: Further Explorations of (Absent) Self-Insight Among the Incompetent. Organizational Behavior and Human Decision Processes, 105(1), 98-121.
Ellis, J. R. (2008). Quality of Care, Nurses’ Work Schedules, and Fatigue: A White
Paper. Seattle: Washington State Nurses Association.
Geiger-Brown, J., & Trinkoff, M. (2010). Is it time to pull the plug on 12-hour tours:
Part 1 The evidence. Journal of Nursing Administration, 40(3), 100-102.
Huxley, T. H. (2001). Collected Essays of Thomas H. Huxley. Bristol, UK: Thoemmes.
Institute of Medicine. (2000). To Err Is Human: Building a Safer Health System.
Washington, DC: National Academies Press.
James, J. T. (September 2013). A New, Evidence-based Estimate of Patient Harms
Associated with Hospital Care Journal of Patient Safety, 9(3), 122-128.
Joint Commission. (2011). Health Care Worker Fatigue and Patient Safety. The Joint
Commission Sentinel Event Alert(48), 1-4.
Joint Commission. (2008). Behaviors That Undermine a Culture of Safety. Sentinel Event Alert(40).
Kuhn, T. S. (1996). The Structure of Scientific Revolution. Chicago: University of Chicago Press.
Rogers, E. M. (2004). A Prospective and Retrospective Look at the Diffusion Model. Journal of Health Communication, 9(1), 13-19.
Smith-Coggins, R., Howard, S. K., Mac, D. T., Wang, C., Kwan, S., Rosekind, M. R., . . . Gaba, D. M. (2006). Improving Alertness and Performance in Emergency Department Physicians and Nurses: The Use of Planned Naps. Annals of Emergency Medicine, 48(5), 595-604.
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