12 hours: the long

and the short of it

a few hospitals are trying to
Evidence on the risks of longer shifts is building, move away from them, and NHS
England chief nursing officer
but some nurses love them. Alison Moore reports Jane Cummings announced last
year that a report on them would
be commissioned. Initially it
There are few issues more likely appeared that if this would be
to upset at least some nursing completed quickly, but NHS
staff than changes to shift
The risks of working extended hours – England now says the scope for
lengths and patterns. a briefing paper the study is still being decided.
Over the past few years, many Several studies suggest the risks to patient Jill Maben, director
trusts have moved towards safety significantly increase once nurses work of the National Nursing
operating just two shifts a day beyond 12 hours. Research Unit at King’s
on some wards, reducing the Nurses who work 12-hour shifts are at College London, returned to
number of handovers when they increased risk of occupational hazard, practice a few years ago and
need double staffing. Nurses will compared with those on eight-hour shifts. was surprised at how many
typically do three long shifts a This includes physical exhaustion, trusts had adopted 12-hour
week, with four days off. musculoskeletal problems, sharps injuries, road shifts. ‘It has almost become
Many nurses love 12-hour accidents and near misses when driving home. the norm now. I feel we have
shifts: they can reduce the cost of There is insufficient evidence to determine the sleepwalked into this process
childcare and travel, and allow effect of shift length on the quality of patient without any understanding of
more days free to do something care and healthcare provider outcomes. the implications for staff, for
else – whether that is bank shifts, Source: www.kcl.ac.uk/nursing/research/nnru/policy/ patients and whether it is a good
By-Issue-Number/Policy--Issue-38.pdf or bad thing,’ she says. ‘Staff
looking after children or elderly
relatives, or a hobby. get very tired. There is a dip in
But others find 12-hour shifts may not get their breaks and they energy around 5pm when people
exhausting and would prefer are worried about making errors,’ need to sit down and take stock.’
shorter ones that allow them to she adds. ‘When I worked in the She is also concerned that
spend a part of each day with private hospital sector, I worked 12-hour shifts remove a short
their family and to do other 12-hour shifts and I found them period of double staffing in the
things on a working day. really tiring, but I liked the early afternoon, when staff from
At Worcestershire Acute Trust, extra time off.’ two shifts traditionally overlap.
nurses on 12-hour shifts like An RCN survey in 2009 ‘That was often when the little
having to travel in to work only found that more than four out of things important to staff could
three times a week, says patient ten NHS hospital nurses worked be done,’ she says. ‘You handed
safety adviser Jane Brown. ‘But 12-hour shifts, but they were over the essential stuff to
they do find they are getting tired, more common in care homes, the staff coming in, but you
where more than 60 per cent could do things like washing
Many nurses prefer 12-hour shifts because it
of nurses reported working someone’s hair.’ This overlap is
suits them to work three days a week and have
them. These numbers may have also often time for mentoring
four days off. However, concerns that such shifts
increased since then as more and offers an opportunity for
SUMMARY

are too tiring for staff and increase the risk of

hospitals have moved staff to informal education sessions
errors have prompted some trusts to try to
longer shifts. with nursing students.
return to traditional, shorter shifts. The evidence
However, there are concerns Professor Maben adds that
is still unclear and it may be that a mixed
that the trend has gone too many of the moves to 12-hour
approach, allowing some staff choice, is best.
far. Some board-level nurses shifts were ‘justified’ by financial
have raised concerns about the savings rather than improvements
Author Alison Moore is a freelance journalist
consequences of 12-hour shifts, for patients or staff. ‘We have

20  april 23 :: vol 28 no 34 :: 2014 NURSING STANDARD

 to make sure that there are not
unintended consequences.’ Some
trusts have not only moved to
two handovers rather than three,
but have reduced the length
of these. Across a large number
of wards in a hospital, this
can save seven-figure sums
each year.
Lead RCN steward for acute
care at NHS Lothian Susan
Lloyd says it can be difficult
to find a solution that suits
nurses, employers and patients.
She suggests there are some
areas where 12-hour shifts are
necessary – such as in theatre,
where operations can take many
hours. However, she has concerns,
particularly in high-activity and
demanding areas.
‘Organisations see the cost
benefits, and staff like them
because they can get their shifts
over in three long days,’ she says.
‘But I am seeing an increase
in nurses joining agencies
and bank nursing,
and picking up shifts
elsewhere on their
days off.’
Ms Lloyd
says that long
GARRY PARSONS
shifts are associated with more
errors and she is seeing more
staff on these shifts with health
problems. Switching from a long
day to a long night shift can also
be exhausting.
Flexible mix
She has also noticed more nurses
approaching her for support to
return to eight-hour core shifts.
Sometimes the only option
is for the nurse to move to an
area where shorter shifts can
be accommodated. A flexible
mix of 12 and eight-hour shifts
would probably be the best way
forward, says Ms Lloyd
– there is no one-
size-fits-all
solution.
Professor Maben says the
evidence on the impact of long
shifts is not definitive, with
much of it coming from other
health systems. Her department
has produced a briefing paper
on the emerging issues (see
box, left).
Rejigging rotas can, to some
extent, minimise the drawbacks
of 12-hour shifts. Consecutive
long shifts can be particularly
tiring, as nurses will often go
home, eat and sleep, and then
get up and come 
 to work again, so rotas that
avoid those may work better.
However, this can have an effect
on continuity of care, especially
with shorter stays.
Rotations between night
and day shifts also need careful
planning so as not to add to
fatigue, which Professor Maben
identifies as an important
problem with 12-hour shifts.
Another issue is that, in large
hospitals, half an hour is often
not long enough to get to the
canteen and eat a meal, so nurses
tend not to leave the ward. ‘It is
very important for staff to come
Trusts’ experiences of moving to 12-hour shifts
The experience of trusts moving either
to or away from 12-hour shifts suggests
that change of any kind is likely to upset
at least some of the workforce and may
not yield all the benefits hoped for.
The Queen Elizabeth Hospital, King’s
Lynn, moved several hundred ward staff
to standardised shorter shifts last year,
arguing it would improve patient care.
Previously, many staff had been on
12-hour shifts.
However, a review of the trust carried
out soon afterwards by NHS England
raised concerns about the effect on
morale and retention. The trust
was struggling with low
staffing and the changes
resulted in ‘more than 20
qualified staff leaving’,
NHS England said. The
new shift pattern had
also meant that bank staff
were less available. A staff
survey found strong support
for either a return to the old shift
pattern or a mix of long and short shifts.
The trust moved back to offering
longer shifts at the end of last year,
allowing staff to choose what worked
best for them. Karen McGuire, associate
chief nurse, says fatigue can be an issue
with longer shifts. ‘Whatever shift you
do can be tiring,’ she explains. ‘You work
differently with a longer day than a short
one – you pace yourself. For us it was less
about the finance and much more about
the workforce.’ But the trust found it
struggled to get staff to work bank
shifts when they were working more
22  april 23 :: vol 28 no 34 :: 2014 NURSING STANDARD
together to have breaks,’ says
Professor Maben. ‘There is little
opportunity to have downtime
with colleagues to talk about
work.’ She suggests longer breaks
may be needed in some cases.
One of the challenges of this is
that staff are meant to have at
least an 11-hour break between
shifts – and more or longer
breaks during the shift can
make it harder to rota nurses
for two 12-hour shifts on
consecutive days.
The National Nursing
Research Unit also suggests
managers need to be aware
days. ‘If you have three to four days off in
a week, it has less effect on you to do an
extra shift,’ Ms McGuire says.
Two years ago, Ipswich Hospital
decided to move towards 12-hour shifts
for many of its nurses. The impetus came
from both staff members and patients,
who valued receiving care from the same
person throughout the day. The decision
was not financially driven, and the trust
was actually expanding its nursing
provision at the time.
This was piloted in some areas and
then, just over a year ago, more nurses
were moved to 12-hour shifts.
Although the trust ‘strongly
encourages’ nurses to work
these, they do have the option
of shorter shifts – and some
nurses have remained on
them. ‘We have not had any
negative feedback and we
monitored it carefully,’ says
a spokesperson.
But it is not always easy to separate out
the effects of a change in shift patterns
from other developments. At Bolton
NHS Foundation Trust, for example,
many ward-based staff have moved to
a 12-hour shift pattern. The trust says
this was about balancing quality of care
and cost-effectiveness: it allowed the
reduction of ‘lengthy’ handover times.
A pilot scheme had won the support
of around 70 per cent of staff. However,
a review of staffing levels has meant
the trust has also invested in additional
nurses, which has wiped out the financial
savings from the change.
of the risks associated with long
shifts. Safeguards include limiting
overtime and meetings at the end
of shifts, encouraging nurses to
understand the risks of fatigue,
and making improvements in
physical layouts, communication
and handovers.
RCN head of policy Howard
Catton says the college has
not come out in favour of any
particular shift pattern, but
employers should be aware of
risks such as fatigue and reduced
concentration. ‘These factors
have the potential to impact care
quality and there is also evidence
to suggest they increase health
risks to individuals.’
He adds that if saving money
is the driver for shift patterns,
it is important to identify and
monitor risks through quality
and safety indicators.
Childcare matters
Changing the shifts of existing
staff is always going to be a
challenge. North Lincolnshire
and Goole Foundation Trust
consulted staff about a move
from 12 to 7.5-hour shifts at its
hospital in Grimsby last year.
Chief nurse Karen Dunderdale
told the local media it would
be better for patients and
would allow staff to improve
knowledge and experience.
However, some nurses feared
their childcare arrangements
would be disrupted and there
were warnings that staff would
leave. The trust already has
staffing problems and has
recently recruited nurses from
Spain. The trust says it is still
pulling together responses from
the consultation and, like many
that have made or contemplated
change, is reluctant to discuss it.
Ultimately, it is the state of the
nursing labour market that may
prevent trusts changing shift
patterns against nurses’ wishes.
‘A big issue is childcare,’ says
Mr Catton. ‘So when the labour
market becomes tight, employers
start to say, “We need to get staff
in and we will offer you the shifts
that you want.”’ NS
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