Long days come with a high price for staff and patients

15 January, 2010 | By Jill Maben

Jill Maben explains why 12 hour shift patterns are having a detrimental impact

Long days or 12 hour day shifts seem to have crept inexorably into nursing rotas in acute care and have become the norm. Long gone, in many practice areas it seems, are the traditional early and late shifts in which nurses worked seven hours with a period of overlap in the afternoon. Previously, long days were used to cover shortages of late shift staff - those on the early shift were asked to work on until the night staff arrived at 8pm or 9pm. Now, however, such long shifts appear to be accepted practice in many trusts and across many ward areas.

On returning to practice this year in an acute trust, I was surprised at this development and asked staff what they thought of it. The views were overwhelmingly similar, with students and qualified nurses both suggesting that at first they “hated them”, found them “exhausting” and thought they’d “never get used to them”, but that, over time, they did get used to them. Most even concluded that they now “love them”.

On closer questioning it became apparent that what these nurses “loved” was working for an average of three shifts a week with four days a week off, and who can blame them? Such working patterns can be particularly helpful, especially if you have child care or other caring responsibilities, as many nurses do.

‘In the nursing day there is little opportunity to discuss care, to talk about what nurses are trying to achieve for patients or support patients to achieve for themselves’

However, I have some concerns. Twelve hour day shifts may have implications for staff wellbeing in terms of stress, burnout and physical injuries. It is known that when staff are tired, their stress and physical injury rates can be higher.

Such long days can also have implications for the patient experience. Providing good care across a 12 hour shift requires high levels of resilience in staff; nurses need to be able to pace themselves and to be sure that they can give the same unwearied, dignified and compassionate care after 11.5 hours as they can after just one hour when fresh on duty. I think this is a tall order - it is asking an enormous amount of staff who are already under immense pressure from the intensification of nursing work that has come about as a result of more patients who are more acutely ill, higher patient throughput and shorter patient stays.

Long days were heralded as a way of ensuring continuity across the patient’s day. This continuity has no doubt been achieved, but what has been sacrificed is a continuity across the patient’s stay or week, which means patients may have one nurse for 12 hours and then potentially see different staff for each of the next two days. For staff this can also mean long gaps between shifts - returning after four or five days off and knowing few patients on the ward can result perhaps in patients being referred to by bed number for ease of communication. Learning the names of 28 or 36 patients in a few hours can prove very challenging.

Moreover the long day pattern of working has removed the traditional overlap period in the afternoon, when previously there
was double the amount of staff on the ward. This often enabled those nurses on the morning shift to take time to chat to patients, to undertake the “little things” that matter so much to patients, like washing their hair, having a bath, taking them outside, or to the shop. With no shift overlap the opportunities for chatting with patients and the prevalence of these little things appear to have diminished in many settings.

This new amended shift pattern has also removed a more relaxed handover period from the nursing day altogether. The lunchtime handover was often an opportunity to discuss patient issues in more depth. As the staff giving handover were not immediately rushing off shift, there was time to reflect on challenges, undertake problem solving within the team and to pass on more patient information than just name age and diagnosis.

My concern is that in the nursing day there is very little opportunity to discuss care, to talk about what we as nurses are trying to achieve for patients or to support those patients to achieve for themselves. Without the opportunity for such discussion there is a danger that we could lose our collective sense of purpose, and lose the opportunity to discuss patient care with our colleagues, lose the opportunity for senior nurses to role model to juniors and for students to hear the business of nursing and caring for patients discussed.

As we enter a period of resource constraint it is unlikely that long 12 hour day shifts will diminish, as they can often offer savings across the workforce. However, not all areas operate long days and I would urge any trusts pondering such a change to consider the issues raised here. I would also be interested to hear the experiences of staff working long days, especially those who have experienced both systems. Increasingly, as the “long day” trend spreads, nurses - particularly those who are new to the field - are only able to experience this way of working and, consequently, are given little opportunity to talk about patient care.

Jill Maben is deputy director, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College, London

Readers' comments (118)

Anonymous | 17-Jan-2010 1:39 am
I do agree that short shift staff nurses give better quality care than those nurses doing long days especially during the last 2 to 4 hours of the shift. In medical wards where the heaviest tasks are, make it more difficult to give enough time to patient especially with poor ratio of nurses to patients. With this given situation coupled by tired and fed up nurses because of doing long hours could result in poor patient's care and high risk to commit mistakes. But here we are in UK practicing this kind of system that is not helping to improve the care and staff experience.
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Anonymous | 17-Jan-2010 8:52 am
Although I agree with the princioles of shorter shifts, as a manager I would be unable to staff my unit as the majority of my staff have partners in Health care and need to work long days to work opposite eachother. Unless child care is made more available and cheaper, short days are not an option. I also would prefer to work 4 longer shifts and have 3 days off for better work life balance, r better still have 2 band 7's so we can both work 3 long days each.
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cymraeg.FN@gmail.com | 17-Jan-2010 9:14 am
I think how each nurse is able to preform on a particular shift is individual to each nurse. I have worked both short and long shift systems, and have to say, I now look for 12 hour shifts before applying for a position. If you were to examine how well an individual nurse is preforming on day 4 or 5 of the short shift system, I think you will also find that a lot of nurses are not functioning as well as on hour 1 of that week. I found myself much more stressed and tired having to go in to work, for what felt like 'every day', without any reasonable break from the ward, and what felt like just shuttling myself from my bed to the ward and back to my bed again!
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Karen Whysall | 17-Jan-2010 9:15 am
As an ex Ward Manager on a Stroke Rehabilitation Unit I fought hard to block the introduction of long shifts but was overruled. Long days also means long nights and I found staff were burning out resulting in increased sickness levels. From a managerial point of view this was a nightmare, if a member of staff called in sick you had to cover 12 hours not 7.5 and those who were off were less reluctant to provide cover. I agree continuity is compromised as is the quality of handover, which can be a problem if you have been off for 3 or 4 days. Establishments need to be increased if Senior Managers feel 12 hours is the way forward.
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cheryl felix | 17-Jan-2010 10:13 am
Leave 12 hour shifts alone! If I had to go back to the insufferable days of 5 shorter shifts a week I would be out of nursing like you wouldn't believe. When I was doing 5 shifts a week I felt like I was married to the damned place and was absolutely shattered, travelling an hour there and back didn't help either. Now I work three 12-hour shifts a week, cut down on my journeys per week and I have 4 days which I can call my own and have a life. Let each individual decide what is best for them. If a member of staff feels too tired let them switch back, but leave the rest of us alone. If you want to retain your staff you will fit in with what they want and not dictate unpopular shift patterns by deciding what you think is best for them. Since they were introduced at my workplace, we all say we wouldn't go back to the old days. Long shifts contribute to quality of working life and without this, nurses will go.
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Anonymous | 17-Jan-2010 10:13 am
on my ward the nurses work a total of 14 hours 7am to 9pm they have 3 half hour breaks if they have time to get them i think they all start to get couldnt care after 10-12 hours i have seen it as i work with them
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Anonymous | 17-Jan-2010 10:16 am
Having worked in A&E for several years the long days have worked exceptionally well and there has been no compromise in the quality of nursing care. In Fact the ability to ensure you have adequate rest days off versus quick change over has been beneficial for some.
Ultimately it is up to the individual to decide on what is the best choice of working pattern for them, as flexible working patterns need to be more widely accepted within the NHS as a whole.
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Stephen O'Connor | 17-Jan-2010 10:42 am
Having worked a mixture of both long and short shifts, I have to say that I much preferred the latter from the perspective of patient care and agree that it is very frustrating for patients who do not see the same nurse from one day to the next as their 'primary' carers go off duty for extended periods of time. One other aspect of the long shift that appears to have been forgotten is the lack of time now available between shifts for teaching purposes. I know as a tutor that students constantly complain that their mentors are too busy and often do not have time to undertake discussions about their progress, plan goals, discuss progress etc. This is largely because that precious cross over period is now largely extinct from the working day and there is little slack time now for ward teaching or any other pre-planned activities. I wonder if this has anything to do with students' frustration with their learning environments and the constant claims by clinical staff that students are not developing their clinical skills in the workplace as they should be. The period after handover was always used for meetings, case-discussions and student teaching when I was doing my training but all of these seem to be disappearing rapidly in the ever increasing rapidity of the ward environment made worse by a very transient staffing arrangement.
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Anonymous | 17-Jan-2010 10:50 am
If there is a problem with working long shifts (12 hours) then what will the NHS do about night shifts as these are usually 11 hours long, and in my experience, without a break!!!!

It doesn't matter how long we work as it seems that as long as the job gets done and the figures all add up to keep the government happy that is all that matters. No wonder nurses are so fed up these days! The welfare of doctors, nurses and patients is not a priority as far as the pen pushers are concerned these days, and wishing for shorter shifts will be like trying to get blood out of a stone!
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Anonymous | 17-Jan-2010 11:17 am
i have to say i agree with all the comments- i have done long days to cover- he odd one is ok, i have had staff doing the 3 long days a week and i suited them. it made it easy to cover the rota but yes if tey went sick it was a nightmare to cover.
it should be left to the staff member themselves to decide and be accepted for their decision and knowing their own limits. Our students are not allowed to do long days unless the mentor is, and then a maximum of 2 a week, but it has its disavantages- it means thay often miss the admission cycle of a patient- admitting them but not seeing the full care pathway, long days do not help with work life balance- it frees them up for more bank-- which i accept they might need to be able to manage but it eats into the private study time of the course- then they struggle become stressed and often either withdraw or are withdrawn from the course-
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carley vaudrey | 17-Jan-2010 12:07 pm
Having worked 14 hour shifts as a support worker and now as a student, i feel i benefit more from these than short shifts. Working long days means you have more time in the day to get through your mountain of tasks, you have more time to spend on each patient and its also an opportunity to get to know your patients better, as you have spent so much time with them, where as on short shifts your running around like a headless chicken getting things done for the next shift to start. And because you have 4 days off, you feel like you are not constantly at work, and with me, i look forward to my shift as i have had time to relax on my days off.
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Anonymous | 17-Jan-2010 12:07 pm
Long days are equally tiring and exhausting as 8 or 9 or 10 short days stretch or four night shifts followed by just one day off which is often practiced where short days exist. The most important thing in doing long days is that break is spaced out and ensure that the nurse have their break to prevent burn out and exhaustion.
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Anonymous | 17-Jan-2010 12:14 pm
As a matron for a very busy acute tertiary service in the East Midlands - I agree with many of the comments above. However I am into my 32nd year as a nurse/midwife & really think that long days are detrimental in the longterm for the reasons detailed in the article. It was part of our role to do the chatting/ meetings/tutorials during handover, doing the vistors ward round was just part of your day now - mmm we have to pilot 'hourly rounding' as an incentive to do things we always used to do.(I am sure this used to go a long way to reduce the complaints/family understanding & discharge planning etc). I try hard to encourage my overworked staff to follow what some see as 'old fashioned principles' - I also do this in my role.
At my age long clinical shifts esp. nights is a no no I gave them up back in 2006, so understand those who struggle. The ideal is & would be a combination of short & long shifts - I have worked with this in other management jobs - but you have to be flexible as a team member & manager, tip top with your rota & manage you absence to the letter, & also have a bit of play in your budget - which sadly none of currently have. If your trust uses the 'Telford' model forget it despite AUKUH. Somehow we have to get the balance right for patients & staff.
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Anonymous | 17-Jan-2010 12:25 pm
Personally, I think flexible working and staff choice is a good thing.

However, I have just changed jobs after four years of working long days, 7.15-21.30. The shifts themselves were not the issue. Often there was no time for an afternoon break. Also the off duty was done in an often chaotic way, coupled together with chronic short staffing meant sometimes you could end a week on long days and begin the next, meaning up to six 14 hour shifts in a row.

This was clearly not only dangerous for the patients, but dangerous for the health of staff.

I also found that 'days' off were like a sleep catch up and felt constantly tired. Complaints from staff to the management over so many long shifts in a row were met with 'well we're short staffed, you'll have to try and swap' which obviously sounds easier than it is.

I now work shorter shifts and although have to go into work for more days, my work life balance has returned! I am now eating and sleeping at normal times and don't feel constantly tired. I wouldn't go back to long days ever and can now see clearly that the '4 days off' is actually an unhealthy myth.
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Anonymous | 17-Jan-2010 12:37 pm
What fairy tale world do you live in that the afternoon handover is a place to discuss patient issues in more depth ?

Maybe on a ward where patients have a length of stay measured in weeks, but not where they have a length of stay managed in days or hours.

Usually it's a race to get everything tied up, as to hand it over would take more time than actually doing it.

On a short day, you have the terror of facing visitors having only really known about the patients for 30 minutes, and duplicating a lot of the work that has already been done by morning staff (getting to know patients, sorting out medication issues for _your_ shift, identifying those who are poorly, familiarising yourself with discharge plans) this gets in the way of getting to know your patients.

I actually find a long day free's up my afternoon shifts greatly as i've sorted out medication issues in the morning, i know all of my patients, i've identified the ones i've got concerns about, and i've pre-empted most issues.

You also get longer to spend with the patients and to get to know them, something you don't have the luxury of on shorter shifts. A significant amount of the evening part of my shift on a 'long day' have been really enjoyable due to this. You can chat, have a joke, and just enjoy the more relaxed atmosphere.
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Anonymous | 17-Jan-2010 12:57 pm
I spent six months having the torture of short days, a hour and a half round trip commute on top of an 8 hour day for seven, eight, nine even ten days in a row had me exhausted. I now do 3 long days a week and feel like I have my life back. A long day allows you to plan your workload over a longer period and i feel gives you more time to organise yourself, and come visiting you know your patients and what kind of day they've had.
Also nobody seems to mention that doing early - lates is actually illegal and that staff are meant to have at least eleven hours rest from there place of work.
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Anonymous | 17-Jan-2010 1:24 pm
As a student in my final few months of training I have experienced both short shifts and long days. I have to admit that personally I prefer long days as it means I get to spend more time at home with my children. When having worked short shifts I have noticed how the nurses are run off their feet ensuring the drug round is completed in the morning, making sure patients discharge paperwork is carried out and patients due for theatre are checked, they have little time to help patients with their hygiene needs before having to carry out another drug round and then writing their notes and giving a handover to the next shift. On a long day they seem more relaxed and can get the time to spend talking to patients and relatives where they are able to learn more about that patients background etc.
At present though the trust I am currently at have stopped long days and are only trialling these on a few wards so they can establish if they are better for patients and staff.
To be honest I feel more tired after working 5 short days and only getting 2 off (which most of the time are not together) than being able to work 3 long days and then relaxing for the other 4.
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kathleen white | 17-Jan-2010 1:26 pm
Stephen O'Connor 10:42,has said most of what I want to say. I have worked short & long shifts & I am in no doubt that better patient care and student teaching is provided on the former.
Employers are deluding themselves if they think that long shifts, without crossover time, are an effective use of resources. Poor patient care and lack of learning opportunities leads to increased morbidity and mortality.This is not cost effective. How many of us have heard of people dying of dehydration & starvation because there was no one available to give them a drink or feed them their meal? How many older people have been told to wet their bed,and they will be changed when someone has time? I certainly never heard of such malpractice when we had crossover time from 1-4PM, and reasonable staff ratios. My neighbour is now in hospital with a fractured femur. She fell climbing over the bedrails, rather than wet her bed. It looks like she will not be coming home. How cost effective is this?
8 hour shifts over 5 days a week, will still leave 2 days off. If this suits other professions, why should it be different for healthcare professions? One commentator said,working 5 days a week made them feel "married to the dammned place". I can understand that comment, but that has more to do with poor working environments and relationships than the length of shifts, and certainly needs to be explored. I don't hear teachers, lawyers,or business people saying that they can only tolerate being in their chosen career workplace for 3 days a week. That might be because they are highly valued,supported and rewarded for their input. That is what healthcare professionals and their so called unions need to address. We need strong, courageous leadership to advocate for patients and students.

I agree with the concept of flexibility. It should be possible to provide long shifts for those with child-care needs and those who want to reduce petrol costs.

Why are we in the job? If it is not to provide the highest standard of evidence-based care, and teach our students, then perhaps a career change is the solution.
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Anonymous | 17-Jan-2010 1:37 pm
I have been nursing since 1974.In those days we had an afternoon overlap, but that stopped long before long days came in.We also often had to work the dreaded 'splits' back then.Anyone remember them?
I much prefer long days for continuity of care and being able to pace yourself throughout the day with paperwork etc.The main advantage though is having four days off. I can actually have a life outside of work these days.I do not have childcare to worry about at my age, but do have a retired husband with health problems and I enjoy spending time with him too.
Things like hospital and dental appointments can be attended during the week and pre planned.
Nurses tend to be very resilient and many hold down second jobs (enabled by working long days).I would not by choice change to short days.I do days and nights and feel I deliver excellent care at all times.
To my knowledge no patients at my place of work have ever complained about the way the nursing rota is organized.
I am not sure it is the length of the shifts that affect nurses so much as general increased workload and understaffing.
Long live long days!!
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hazel fry | 17-Jan-2010 1:51 pm
I currently work early and lates but we never manage to go home on time working an extra 30-60 minutes of unpaid overtime every day (usually to complete paperwork!)This is ignored even though it means we are not getting the legal number of hours off between shifts. For example if we work till 9pm instead of 8pm after a late and return for the early at 7am we only have 10 hours break! I am changing to long days to reduce this!

Furthermore the 'crossover' couple of hours between early and late shifts is not used for extra patient care but to catch up with the ever growing mountain of paperwork!!
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