Hospital nurses often work shifts of 12 hours or longer, either by choice or because of pressure from their managers. But what effects do such long hours have on job satisfaction, and equally important, on the quality of patient care? A new research paper — “The Longer the Shifts for Hospital Nurses, the Higher the Levels of Burnout and Patient Dissatisfaction,” by Amy Witkoski Stimpfel, Douglas M. Sloane and Linda H. Aiken — offers some perspectives. Knowledge at Wharton asked Stimpfel, a research fellow at the Center for Health Outcomes and Policy research at the University of Pennsylvania School of Nursing, to elaborate on the researchers’ findings.
An edited transcript of the conversation follows.
Knowledge at Wharton: Amy, thank you so much for joining us today.
Amy Witkoski Stimpfel: Thank you for having me.
Knowledge at Wharton: I would like to ask you about a study that you and your colleagues have done on working conditions for nurses. What’s interesting to me in reading your paper is that U.S. labor history has had such a long tradition of trade unions supporting an eight-hour work day. But in your study, you found that nurses actually are not part of that. Many of them work 12- or 13-hour shifts. Why does this situation exist, and how has it come about?
Stimpfel: Nurses traditionally worked eight-hour days. Then in the 1980s and 1990s, when some structural changes in health care and cost containment measures [were] put in, it was actually less expensive to have nurses work 12-hour shifts, because that [meant] only two nurses per day [were needed] instead of three. So nurses began working these 12-hour shifts. In fact, they decided that they really liked it because it offered better work life balance. Nurses could work three days instead of five, so they had more time off with their family and friends and fewer commutes. And they had more time to go back to school. So it’s really become very prevalent.
Knowledge at Wharton: Do nurses have a choice? Is it voluntary?
Stimpfel: It depends on the hospital. Sometimes it depends on the unit in which they work. Some hospitals may give the option when the nurse is hired. [Some units] may only schedule 12-hour shifts, or they may do a mix of 12 hours and eight hours.
Knowledge at Wharton: So based on your research, it seems like there are no work hour policies for nurses. Are there other professions where such policies exist? And why is there a difference?
Stimpfel: There are. Other safety sensitive industries like physicians, pilots and long distance truck drivers all have work hour restrictions. There aren’t any national work hour restrictions for nurses. In certain states, there are mandatory overtime prohibitions, but nurses can work as much voluntary overtime as they want. For example, in the state of Texas a few years ago, the State Board of Nursing was considering doing some work hour restrictions. When they put it to a vote, over 90% of the nurses said that they did not want any restrictions on their work hours. So it’s a very complex situation.
Knowledge at Wharton: It certainly seems like it. You looked at the impact of long shifts on things like burnout and job satisfaction. What were some of your major findings?
Stimpfel: We found that when nurses worked above the standard eight-hour shift that they were at increased odds of being burned out and dissatisfied and also intending to leave their employer in the next year. This was worse for the nurses who worked the longest shifts. If they worked over 13 hours, they had a two fold increase in the odds of being burned out and dissatisfied and intending to leave their employer. So their overall well being was definitely being impacted by these long shifts.
Knowledge at Wharton: Yours was not a national study. You covered four states. In which ones was the condition the worst?
Stimpfel: It was very similar across the states. This wasn’t a phenomenon found only in California but maybe not in New Jersey. It was found in all the states where nurses were working these extended shifts.
Knowledge at Wharton: When the nurses are overworked, does it also have an impact on patient outcomes?
Stimpfel: Yes. This is actually the first study to look at the relationship between nurses’ shift length and how patients perceive their care in the hospitals. We found that when there is a higher proportion of nurses working those really long shifts of over 13 hours, patient satisfaction went down. That was in things like whether or not patients would recommend the hospital to their family and friends, and whether they would rate the hospital low on a scale of one to 10, [along with] things like communication with their nurses. Conversely, we found that in hospitals that had a high proportion of nurses working the standard eight-hour shifts, patient satisfaction was improved.
Knowledge at Wharton: That’s very interesting. If making nurses work for very long hours brings down patient satisfaction, then the business implications for the hospital are clearly very negative. In spite of that, why does this situation exist? Did your research point out any reasons for that?
Stimpfel: We found that when we asked nurses questions about their scheduling and their shift length, overall they are very satisfied with having flexible schedules and being actively involved in their scheduling. So that’s something that we found was really interesting, that although most of the nurses work these 12-hour shifts and they appeared satisfied with them, that there were still these negative implications for their well being and then also for the patients.
Knowledge at Wharton: What are some of the business implications of not addressing these issues in hospitals?
Stimpfel: Typically when nurses become burned out and dissatisfied, those are precursors to voluntary turnover. If they leave the hospital, the costs for recruiting, retraining, rehiring and staffing temporary nurses [are high] and can [equal] the annual salary of a nurse — which can be anywhere from $50,000 to $80,000 or so. So it’s very costly for hospitals if they have high turnover. It’s also bad for staff morale, and it’s not good for the patients either. So there’s certainly a big cost associated with having overworked, dissatisfied, burned out nurses.
Knowledge at Wharton: What implications do your findings have on hospital reimbursements by Medicare and Medicaid?
Stimpfel: Under the Affordable Care Act, there was a provision put in place such that hospitals now face reductions in their reimbursement if they don’t achieve national standards on patient satisfaction. We use the Hospital Consumer Assessment of Health Care Providers and Systems, better known as H-CAPS. That was a survey we used in our study. If [hospitals] don’t achieve this benchmark, then they face reductions in reimbursement. One easy way to help increase the likelihood of achieving those benchmarks is to have a well rested, adequate nursing staff. So by investing in nursing, hospitals have the potential to reap more rewards through reimbursement.
Knowledge at Wharton: Based on your research, what changes would you recommend that hospitals make in the way in which nurses’ jobs are structured?
Stimpfel: We were able to see that the nurses who worked the longest shifts — and we presumed that they were overtime shifts — [suffered] the most detrimental [effects]. So certainly curbing overtime, completely reducing mandatory overtime and then monitoring the rest of the nurses work hours will be really important, [along with] also educating the nurses’ and the managers about the effects of working these long shifts, so that they’re aware of how it can impact the staff as well as their patients.
Knowledge at Wharton: What was the most surprising finding of your research project?
Stimpfel: I think the most interesting piece was what I mentioned earlier –that most of the nurses really seemed on paper to be satisfied with these shifts and are actively involved in scheduling them. So, despite the fact that they seem satisfied with this scheduling, there’s a disconnect because those nurses were also at highest risk for being burned out and dissatisfied. So we have to uncover a little bit more about what’s going on there.
Knowledge at Wharton: Maybe that’s a topic for future research.
Knowledge at Wharton: One final question: Based on your research, what advice would you give high school students who are considering going into nursing as a career?
Stimpfel: I would definitely recommend it. It’s a very rewarding career, and there are many, many opportunities as a nurse and many different places to work aside from just hospitals. I would caution nurses to make sure, though, that when they go out on their first job, that they ask about their scheduling and how much overtime is used on their unit. Make sure that they take care of themselves so that they can take care of their patients.
Knowledge at Wharton: Amy, thank you so much for speaking with Knowledge at Wharton.