How Many Hours Are Too Many?

Nurses work long hours, sometimes at their own peril.

Questions about the impact on nurses of working long hours have led nurse researchers to investigate. At the 2004 National Congress on the State of the Science in Nursing Research, researchers reported on several studies showing that long workdays and work weeks affect the retention and the health of nurses and other health care workers and may contribute to workplace violence.

Illness and injury.

Claire C. Caruso, PhD, RN, of the National Institute on Occupational Safety and Health, reported on an integrated review of 52 research reports that examined the relationships between long work hours and illnesses, injuries, health behaviors, and performance. One of five authors of the report, Caruso noted that there is evidence that extended work hours are associated with fatigue, decreased performance, injuries, and health problems. Future research should address the factors that influence how health care workers respond to long work hours, such as preexisting health conditions in the worker. The report, Overtime and Extended Work Shifts: Recent Findings on Illnesses, Injuries, and Health Behaviors, is available online: http://www.cdc.gov/niosh/docs/2004-143/pdfs/2004-143.pdf.

Fatigue and safety.

University of Maryland nurse researcher Alison M. Trinkoff, ScD, RN, FAAN, reported that fatigue and acute and chronic health problems can result from nurses working more than 12 hours per day, having less than 10 hours off between shifts, floating to other units, and experiencing heavy psychological demands of the work. Such work also can undermine patient safety, Trinkoff said.

Workplace violence.

Another University of Maryland researcher, Jane Lipscomb, PhD, RN, FAAN, reported on her research on the link between long work hours and assaults against staff in state psychiatric hospitals. The study found that 40% of the staff surveyed (nurses, physicians, therapists, teachers, and therapeutic aides) reported working more than 40 hours per week. Mandatory overtime was common; 37% worked overtime one or two times a month, and 18% worked overtime more than twice a month. Almost half of the staff had floated to other units during the past month. Working more hours per week and per month as well as floating were associated with higher rates of assaults against staff by patients. Questions remain as to whether the higher assault rate reflects more hours at work or whether worker fatigue leads to interactions that result in assaults.

Depression.

Jeanne Geiger-Brown, PhD, RN, also from the University of Maryland, studied depression and work schedules in nurse's aides working in nursing homes. She reported that 31% worked more than 40 hours per week (15% worked more than 50 hours per week), and one-third worked more than two weekends per month. Many aides worked two or more jobs. Those who worked six or seven days per week were more likely to exhibit symptoms of depression and somatization of the symptoms. Those working more than two double-shifts per month had higher rates of depressive symptoms and disorders. Geiger-Brown noted that "the quality of care is related to the capable and caring presence" of these assistants, but the extended work hours compromise workers' capability.

Emotional health.

In another study, Geiger-Brown and colleagues conducted telephone interviews with more than 1,600 unionized home care workers on the West Coast. They spoke of the stressful emotional demands of their work, the long hours, the illness and pain witnessed, and the need to suppress their own emotions when with patients. Although many workers worked fewer than eight hours per day, two-thirds worked every weekend, and some worked seven days per week. Even so, many were unable to make ends meet financially.

These studies generated a discussion with the audience that provided additional insights into the need for more research into the effects of extended work hours. For example, what is the association between extended work hours and depression? Depression is associated with absenteeism among nurses, but it may be part of a cycle in which nurses are required to work overtime because of staffing shortages. This leads to too many hours of work, fatigue, and depression, which in turn leads to greater absenteeism and more mandatory overtime. One participant suggested that future research should examine whether people who are at risk for depression are attracted to nursing or whether nurses become depressed because of working conditions .-DM

Unit by Unit

Traits of the patient care unit that affect safety and quality.

What workplace characteristics most affect patient safety and quality outcomes? Nurse researchers from the College of Nursing at the University of Arizona in Tucson have tried to find out. Their studies targeted patient care units, rather than the organizational level of hospitals, as the most likely place to effect change.

For these studies, workplace characteristics were divided into patient characteristics (age, comorbidities, complexity of care required, and insurance coverage), organizational characteristics (hospital culture and hospital life cycle), and unit characteristics (nursing culture, team culture, staffing, and unit turbulence). "Nursing culture" included control over practice, nursing communication, and job satisfaction, whereas "team culture" referred to communication, relationships, and self-regulation. "Unit turbulence" included support services, perceived control, accessibility of resources, distance required to accomplish work, and the number of patients per day.

Gerri Lamb, PhD, RN, FAAN, and Joyce A. Verran, PhD, RN, FAAN, reported on their studies that found that organizational characteristics had no direct impact on safety. Three of the four unit characteristics-turbulence, team culture, and nursing culture-were significant predictors of medication errors, but staffing had no direct impact. Turbulence had the strongest relationship to both medication errors and falls. Along with turbulence, team culture and the number of patients over age 75 on the unit were strongly linked to the rate of patient falls. Lamb concluded that reducing the turmoil that exists at the unit level and allowing nurses greater autonomy and control over their practice are two ways to improve patient outcomes. -KK