Nurse Fatigue and Shift Length: A Pilot Study

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

Disclosures

Nurs Econ. 2015;33(2):81-87. 

In This Article

Discussion

Knowledge was obtained related to the processes associated with the project. The background, significance, and synthesis of the evidence introduced the topic of shift length and nurse fatigue to the stakeholders in the project. Most elements of the project were underpowered to yield results, and as such would not support a change in scheduling practices.

Multiple influences impacted the project through all its phases. These included an available study site, participants for an adequate sample size, cultural drivers for change, the resignation of a nurse director, and the support of the CNO. Some influences were supportive of the project; other influences provided opportunities for determining ways of managing the inputs in a way that would produce a positive outcome.

The development of this project began as a result of reviewing evidence supporting the association between shift length and nurse fatigue. The project was developed under the leadership of the author as the project leader, and the director of nursing at the hospital level as the local leader and project champion. The two leaders complemented each other's skill sets, providing global and local leadership for the project. This synergy moved the project forward at a pace that could not have been accomplished by the leaders working individually.

For this project, Rogers' (2003) definition of innovation, "an idea, practice, or object that is perceived as new by an individual or other unit of adoption" (p. 12), was used. This definition supports the notion innovation does not need to be a new discovery, but can be the implementation of a new or repurposed way of doing something that was already in existence. Nurses historically worked 8-hour shifts until the past several decades. Therefore, the concept of an 8-hour shift is not materially new, but it is considered an innovation since it is new for the nurses in this project. Using change management strategies, key stakeholders were identified and apprised of the project. Permission was gained from the CNO, chief executive officer, chief human resources officer, other nursing directors, and nurses to be included in the project. Nearing the end of the project development, and prior to implementation, the nurse director of the 12-bed unit resigned her position to assume another role. This required a change in the facility contact and resulted in teamwork with new members.

The initial plan was to change an entire nursing staff's schedule on a unit from 12-hour to 8-hour shifts. However, during discussion with the CNO and additional stakeholders, it was decided that instead of requiring all staff to change schedules, this would be done on a volunteer basis. This component of system complexity impacted the revision of the original plan since it became voluntary on the part of the nurses. The nurses would need to have the same skill set, work the same days of the week and the same weekend in order to have 24-hour, 7-day per week coverage of the unit. This proved to be a challenge; however, it was one the leadership of the new team was willing to tackle. Informational sessions were held with staff and literature related to nurse fatigue was provided. Three sets of staff for a total of nine individuals were identified to cover the three 8-hour shifts in a 24-hour period. Instead of being on one unit as originally designed, they were on three units.

One of the last steps in the process was the approval by the organization's institutional review board (IRB) for the protection of human subjects as well as the university IRB where the author was a doctoral student. A final change, adding additional units to the IRB proposal, was obtained prior to the pre-test being administered to the participants.

The fifth step of the Rosswurm and Larabee model is the implementation phase. With out leadership to embrace the principles of complexity leadership and teamwork, this project would not have been implemented. Included were the complexity principles of multiple influences and actor interrelatedness, principles that describe the wide-ranging influences of actions and relationships (Porter-O'Grady & Malloch, 2010). The principles used included realizing relationships are key, and there is no one model for organizational change (Porter-O'Grady, 2014). The leaders collaborated with the staff to coordinate their schedules. They also encouraged staff to complete the pre and post-surveys to assess fatigue.

The median difference between the two times for inter-shift recovery at p=0.027 was an unexpected finding. The difference in sleep increased an average of 22 additional minutes a day. A suggested reason for this finding is that the nurses were not accustomed to having more time in their day while working, and therefore added activities that would not have been undertaken had they been working a 12-hour shift. While working 8-hour shifts, they were also at the hospital 1 to 2 days a week more than when working 12-hour shifts and only 3 days per week. The additional commute time and days at work could contribute to the perception of less recovery. It is also possible additional time worked at 8-hour shifts would allow time for nurses to adjust their personal lives to balance work time and personal activities that could impact inter-shift recovery.

The assumption to be assessed was the median differences between 8-hour shift and 12-hour shift acute fatigue, chronic fatigue, and inter-shift recovery would be zero. The project was underpowered to detect small differences that may be detected when fully powered for acute and chronic fatigue at p<0.10. To be powered at a high level with this p-value, the sample size should have been 215.

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