Nurse Fatigue and Shift Length: A Pilot Study

Deborah Maust Martin, DNP, MBA, RN, NE-BC, FACHE


Nurs Econ. 2015;33(2):81-87. 

In This Article


The evidence-based practice Rosswurm and Larabee (1999) model was used in this pilot as it served to guide the processes needed to conduct the project. According to Melnyk and Fineout-Overholt (2011), the model can guide practitioners through the entire evidence-based practice process. There are six steps to the evidence based practice model (see Figure 1) (Rosswurm & Larabee, 1999).

Figure 1.

Rosswurm and Larabee Model
SOURCE: Rosswurm and Larabee, 1999.

Step One

Assessment of the need for change began with research presented in the literature, and brought to light from a regulatory perspective with a Sentinel Event Alert by the Joint Commission (2011) regarding the issue of shift length, health care worker fatigue, and safety. The safety aspect was related to the health care worker as well as the patient. As mentioned previously, this incudes needlesticks (Trinkoff et al., 2007), and other injuries (Brown & Thomas, 2003). Stakeholders, in addition to the nursing director and CNO, were identified including those from the human resources department, other nurse leaders, and direct-care nurses. Internal data indicated all of the nurses on the director's units were scheduled 12-hour shifts.

Step Two

Standardized language was determined and outcome indicators were identified. These included nurse fatigue, nurse job satisfaction, and nurses' perception of the care they delivered.

Step Three

The PICO(T) question "in nurses working in acute care hospitals [P] how does working 8-hour shifts [I] compared to 12-hour shifts [C] affect fatigue [O]?" guided the literature search. A literature search was conducted using the search terms nurses, acute care, shift workers, fatigue, health care errors, medication errors, sleep, sleepiness, performance, 12-hour shift, shift work, nursing staff hospital, work schedule tolerance, safety and shift length. Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane Review, Psyc-INFO, MedNar, and ancestry/hand searching were used to locate outcomes and interventions related to nurse fatigue and shift length that could improve both nurse and patient safety. Shift work is a separate variable and was not included.

Step Four

The change for this project was to alter shift lengths from 12 hours to 8 hours for a 4-week period to evaluate fatigue levels associated with 12-hour and 8-hour shifts. The initial design included all nurses on a particular unit required to change their shift length. In further discussion with stakeholders, it was determined the project would be more successful if the nurses volunteered to make the change. The unit had recently undergone a variety of other changes including a new nurse manager and movement of the entire unit for remodeling and upgrading of the nurse call system. Instead of requiring the entire unit to modify their shift length, the project was modified to nurses volunteering in sets of three for the project, and not confined to one unit. This limited the number of participants. The volunteers needed to be in sets of three so that a 24-hour period was covered by the three 8-hour shifts. This took into consideration the context of the environment in which the change would take place, where care is provided by the nurses 24-hours a day, every day of the week. This form of scheduling provided the same nurse coverage pre and post-shift length change, providing one nurse for the unit staffing for a 24-hour period. The three nurses in each set collaborated among themselves to determine days scheduled as well as weekends they would have off.

Stimpfel and colleagues (2012) noted 80% of nurses re ported being very satisfied with working 12-hour shifts. Information sessions and one-to-one discussions took place with the nurses to garner support for the change and acquire volunteers to change their shift length. By involving stakeholders at the unit level, support was obtained. According to Rogers (2003), personal communication is important in the persuasion stage when individuals are determining if they want to make the change.

Nine nurses volunteered for the project. Knowing the project may not have power to be statistically significant, the project and subsequent assessment of outcomes was carried out to find what could be learned from the project.

Step Five

The nurses who volunteered for changing their shifts were located in an acute care hospital. The nurses completed an electronic survey developed with Checkbox Survey technology to assess fatigue levels at two different times, the last week they were scheduled to work 12-hour shifts, and then again as a post-test after they worked the 8-hour shifts for 4 weeks. The Occupational Fatigue Exhaustion Recovery (OFER) was used to assess acute and chronic fatigue as well as inter-shift recovery. Nurses completed the instrument while working 12-hour shifts. The nurses then completed the instrument after working 8-hour shifts for 4 weeks.

Step Six

The final step is to integrate and maintain the change. Based on the data from this project, there is not enough evidence to support or encourage nurses to stay with their 12-hour shifts or to change their shift length to 8 hours.

Survey Tool

The electronic survey included four parts: (a) demographics, (b) job satisfaction, (c) questions about work and non-work related factors that may influence fatigue levels, and (d) fatigue levels as measured by the OFER scale. It was anticipated the respondent would need less than 10 minutes to complete the electronic survey. The OFER is a 15-item measure of chronic and acute fatigue as well as recovery between work shifts (Winwood, Winefield, Dawson, & Lushington, 2005). The instrument has high face validity and excellent psychometric properties. The reliability of three subscales yielded Cronbach's alpha of 0.93 (chronic fatigue), 0.82 (acute fatigue), and 0.75 (inter-shift recovery) (Winwood et al., 2005). The scale has been used with high reliability in studies involving nurses (Barker & Nussbaum, 2011; Geiger-Brown et al., 2012).

Acute fatigue, as a measure of acute work fatigue, assesses the available energy left after a worker completes a given work shift (Winwood et al., 2005). Chronic fatigue is a measure of an enduring trait of maladaptive fatigue/exhaustion comprising physical, cognitive, and emotional elements (Winwood et al., 2005). The subscale of inter-shift recovery is a measure of the extent to which a worker recovers energy expended during the previous work shift (Winwood et al., 2005). Permission to use the tool was obtained from the author (P. Winwood, personal communication, March 5, 2013). In addition to the OFER, demographic and satisfaction data were collected.