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”
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”
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.
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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”
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.
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”.