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Study reveals link between 12-hour shifts and delayed observations by HCAs


Vital signs observations are less likely to be completed on time on hospital wards staffed by healthcare assistants working 12-hour shifts or longer, according to new research.

Those behind the study told Nursing Times that their findings were “further confirmation of the negative effect” of long working days.

“The shifts that we were working made an enormous difference in how we were feeling”

Chiara Dall’Ora

Researchers analysed data from 32 general inpatient wards at Portsmouth Hospitals NHS Trust collected from March 2012 to March 2015.

They sought to find out if there was a connection between delayed and missed vital signs observations and the shift patterns of the nursing staff carrying them out.

The study focused on situations where vital signs observations were required at least every four hours in patients who had a national early warning score (NEWS) of six or above.

The results showed that on days when a higher proportion of hours worked by HCAs were from 12-hour or longer shifts, the risk of vital signs observations being delayed was increased.  

Specifically, every 1% of HCA care hours a day derived from long shifts was associated with a 5% rise in the rate of delayed observations, compared with days where no long shifts were worked by HCAs. 

There was a similar relationship between long HCA shifts and missed observations, but the results were not “statistically significant” enough to note, said the researchers  They also found no notable link between long shifts worked by registered nurses and delayed or missed vital signs observations.

“This in turn is likely to be a product of the increased fatigue”

Study authors

They stated: “In the context of a growing body of research suggesting that long nursing shifts on hospital wards are associated with lower quality of care and worse patient outcomes, this finding points to one possible mechanism, as using vital signs observations as an indicator, job performance would appear to be lower for HCAs working longer shifts.

“This in turn is likely to be a product of the increased fatigue that is frequently reported by those working long shifts,” they added.

The project was carried out by the “missed care study group”, which involved academics from the universities of Southampton, Portsmouth and Oxford, as well as the Portsmouth trust itself.

The study authors said it was the first to use “objective measures” to look at the links between shift patterns and missed care.

The study builds on a wealth of research carried out in recent years about the impact of 12-hour shifts on nurse wellbeing and standards of care – but this has mostly been drawn from nurse surveys.

The researchers noted that monitoring of vital signs was “increasingly being delegated” from registered nurses to HCAs.

However, in this study they were unable to determine whether it was a HCA or registered nurse carrying out the vital signs observations, which they admitted was a limitation to the findings.

Other restrictions cited by the academics were the fact they were only able to focus on one hospital and a single aspect of job performance.

“Many nurses love working long shifts so we cannot just think about scrapping them”

Chiara Dall’Ora

They also said the data did not capture whether observations were deliberately omitted for clinical reasons such as nursing staff not wanting to wake a patient as it may have a negative impact on their recovery, or patients being unavailable because they were receiving care elsewhere in the hospital.

Chiara Dall’Ora, research fellow in nursing workforce at the University of Southampton’s school of health sciences, was a member of the study group.

While acknowledging the study’s weaknesses, she told Nursing Times that health leaders should take the findings as “further confirmation of the negative effects of 12-hour shifts”. 

“Managers and leaders together with nurses should discuss and reflect on the implications of all this extensive research that is corroborating this message,” she said. “At least we need to start a dialogue on this and maybe stop believing the assumptions that 12-hour shifts are going to be good.”

Dr Dall’Ora was an adult nurse in Italy until she moved to the UK six years ago and switched to academia. She said she had spent most of her research career focusing on nurse shift patterns after seeing first-hand the impact of long working hours.

“What I am interested in as a researcher is workforce…because I am a nurse by background. So I myself realised that the way that we were manged, the way the workforce was organised in terms of staffing levels or even the shifts that we were working made an enormous difference in how we were feeling, how we were coping, and then of course made a difference in how we were performing,” she told Nursing Times.

“I was very aware that being tired and overworked meant that I wasn’t going to be performing very well, so when I moved from the clinical practice to research for me it was really an obvious step to go and look things around workforce issues,” she added.

Chiara Dall'Ora

Chiara Dall’Ora

Chiara Dall’Ora

Dr Dall’Ora said the next steps would be to expand the research by continuing to focus on “objective data” but from more than one trust.

She said she hoped the research could eventually be used to encourage leaders to rethink nurse shift patterns.

While accepting that many nurses enjoyed working 12-hour shifts, Dr Dall’Ora said there may be an argument for limiting the number they could work in a row.

“There is never going to be a one size fits all but maybe at least some limitations to the patterns that nurses work for example maybe limiting the amount of consecutive long shifts,” she said.

“Many nurses love working long shifts, so we cannot just think about scrapping them. But maybe we can find a way with nurses to make sure we do not have four or five long shifts in a row, maybe that’s a bit too much,” she added.

Dr Dall’Ora said her aim was to help make “life better for nurses and to make it better for patients ultimately”.


Readers' comments (5)

  • My experience with HCAs and patient care is the lack of accountability, they get a really good wage but a lot of carers don’t even want to be there. It can be so frustrating I’ve found myself looking for staff,they either sneak out to smoke or congeregate in cloakroom on their phones and having a chat, at the same time complaining about staff nurses not doing enough to help.
    The nhs really need to look at some form of accountability for HCA,s, they get good training, and support but don’t want to do the job.
    You may think I’m overgeneralising, you may be right but you will find the above scenario in every ward you walk onto.The rest of us are so busy we are unable to police the problem.
    As for long shifts we do like them and we should only work 2 and 1 shift pattern but you will have to speek to ward managers to comply with safe working arrangements for that. The other reason people want long shifts is to be able to work extra hours either overtime or agency.

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  • I totally agree with what Sammy above has said. HCA ‘s lack accountability and very few care about the patients they are there to look after They wanted extra responsibility and education but once they got that they complain that the staff nurses do not do enough to help them
    Registered nurses have a lot to put up with and a lot is put upon them
    without having to continuously chase up and check that things have been done and that care given is of a high standard I cannot and will not put up with poor care and inefficiency in recording

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  • There are some good HCA's but I agree with a lot of what is said above.

    Maybe a good idea to get rid of HCA's and replace them with nursing associates ??

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  • After 12 hours on their feet staff are too tired to do the job properly - and you need an academic study group to tell you that??? Some staff (who are young enough to cope with it) prefer long shifts because it gives them more days off in which to work bank or agency shifts, because they need the extra money to make ends meet or to send 'home'. Where I work, there is no option to work 8 hour shifts any more. If there was some option to work half days, they might be able to retain older nurses.

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  • I have bucked the trend and refuse to work 12 hour shifts. I tried one as a favour and felt hungover the next day. This to me is my body telling me this is not good for me. I now have a fixed hour contract so I can Plan my life. I am 59 this year and a normal shift of 7.5 hours is long enough. I always have my break as I need it. I work none stop most shifts, possibly a handful a year where I have time to catch up with other things such as CPD . I really believe it is high time that this cost saving practice was reversed or at least controlled as many believe a 7.5 shift is a short shift .

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