International Journal of Nursing Studies 52 (2015) 605–634
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
Review
Impact of 12 h shift patterns in nursing: A scoping review
Ruth Harris a,*, Sarah Sims a, Jenny Parr b, Nigel Davies a
a
b
United Kingston University and St. George’s, University of London, United Kingdom
Waitemata District Health Board, New Zealand
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 2 July 2014
Received in revised form 10 October 2014
Accepted 28 October 2014
Objectives: To provide a comprehensive scoping review of evidence of the impact and
effectiveness of 12 h shifts in the international nursing literature, supplemented by a
review of evidence in other, non-nursing related industries.
Data sources: A search of the academic literature was undertaken in electronic databases
(AMED, MEDLINE, CINAHL, PsychInfo, Scopus, HMIC, the Cochrane Library, Business
Source Premier, Econ Lit, ASSIA and Social Policy and Practice).
Review methods: A total of 158 potentially relevant nursing research papers and reviews
were published between 1973 and 2014. Two reviewers independently reviewed the
articles, leaving 85 primary research studies and 10 review papers in the nursing field to be
included in the scoping review. Thirty-one relevant primary research papers and reviews
were also identified in the non-nursing related industries literature.
Results: Research into 12 h nursing shifts fell within five broad themes: ‘risks to patients’,
‘patient experience’, ‘risks to staff’, ‘staff experience’ and ‘impact on the organisation of
work’. There was inconclusive evidence of the effects of 12 h shift patterns in all five
themes, with some studies demonstrating positive impacts and others negative or no
impacts. This also mirrors the evidence in other, non-nursing related industries. The
quality of research reviewed is generally weak and most studies focus on the risks,
experience and work/life balance for staff, with few addressing the impact on patient
outcomes and experience of care or work productivity.
Conclusions: There is insufficient evidence to justify the widespread implementation or
withdrawal of 12 h shifts in nursing. It is not clearly understood where there are real
benefits and where there are real and unacceptable risks to patients and staff. More
research focusing on the impact of 12 h nursing shifts on patient safety and experience of
care and on the long term impact on staff and work organisation is required.
ß 2014 Elsevier Ltd. All rights reserved.
Keywords:
12 h shifts
Extended days
Long shifts
Compressed working week
Nursing workforce
Scoping review
What is already known about the topic?
12 h shifts have been widely implemented in North
America and the UK to address resource (human and
financial) pressures.
Evaluations have focused on staff acceptability rather
than patient measures.
There is increasing concern about the impact of 12 h
shifts on safety for both nurses and patients
What this paper adds
* Corresponding author at: Faculty of Health, Social Care and Education,
Sir Frank Lampl Building, Kingston University, Kingston Hill, Surrey KT2
7LB, United Kingdom. Tel.: +44 020 8417 5500.
E-mail address: Ruth.Harris@sgul.kingston.ac.uk (R. Harris).
The most comprehensive scoping review to date of the
evidence for 12 h shifts in nursing.
The evidence for the impact of 12 h nursing shifts on
nurses’ safety and wellbeing, patient experience and
safety, and the organisation of work is inconclusive.
http://dx.doi.org/10.1016/j.ijnurstu.2014.10.014
0020-7489/ß 2014 Elsevier Ltd. All rights reserved.
606
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
The majority of research focuses on the experience and
work-life balance for nurses, with considerably less
research about patient safety and experience.
The quality of research is generally weak and few studies
include an analysis of costs or cost-effectiveness.
This uncertainty mirrors the evidence of the impact of
12 h shifts in non-nursing occupations.
1. Introduction
Twelve-hour shifts or ‘‘long-days’’ have become an
increasingly standard shift option for nursing over recent
years across the USA, UK and to a lesser extent in Europe
and Australia/New Zealand. This paper presents a scoping
review of the literature to illuminate the themes associated
with the actual or perceived benefits and disadvantages of
this shift pattern.
Shift work dominates nursing work, with recent
surveys showing that large proportions of the nursing
workforce work 12 h shifts. In the UK, a Royal College of
Nursing member survey showed that, of the respondents
working shifts (76% of nurses), 45% worked a 12 h shift
system (Royal College of Nursing, 2008). Similarly, a recent
study in the USA reported that 70% of nurses worked 12 h
shifts or longer (Stimpfel and Aiken, 2013). Across Europe,
the RN4Cast study has shown that in medical and surgical
units, while 50% of nurses work shifts greater than 8 h, this
mostly occurs in the 8–10 h range with only 16% working
12 h or more (Griffiths, 2014).
The key drivers for introducing 12 h shifts have been
seen as potential financial savings, a positive impact on
recruitment and retention and improved continuity of care
(National Nursing Research Unit, 2013; NHS Evidence,
2010). The motivation for change can initially be associated with nursing staff shortages in the 1990s, staff
preference linked to greater employee friendly initiatives
and more recently to austerity pressures. The financial
saving has been assessed at around £3 m per year for an
average sized UK district general hospital, based on one
case study site (NHS Evidence, 2010). Concerns have been
raised that longer shifts may have a negative impact on
patients, workers themselves and the organisation of care
(Hughes, 2008). Increasing concern has been raised in the
past few years in respect of the impact on patient safety
and that cost savings are the primary driver (Royal College
of Nursing, 2012), with calls for review of the shift pattern
in both the USA (Geiger-Brown and Trinkoff, 2010) and UK
(Calkin, 2013). In New Zealand, collective agreements have
been drawn up between employers and unions which
recommend that 10 and 12 h shifts are not implemented as
a standard rostering pattern primarily to protect nurses
from harm resulting from shift work and the way work is
organised (New Zealand Nurses Association, 2012).
The literature in both the USA and UK suggests that the
term ‘‘12 h shift’’ is used colloquially to refer to a two shift
system associated with an extended working day and
compressed working week pattern, as opposed to a three
shift, 8 h day, traditional shift system. However, the
literature shows that the definition can vary and either
include or exclude rest break periods although there are
commonalities across different countries. A typical 12 h
shift pattern would be for a day shift to start at 07.30 and
end at 20.00, with the corresponding night shift commencing at 19.30 and finishing at 08.00. Usually, a 1 h
unpaid rest period would be scheduled, therefore equating
to 11.5 h rostered work, which for a full time employee
would require 13 shifts per month. Different approaches
are adopted to either compress the shifts into short
periods, thereby giving the nurse longer periods away from
the workplace or to spread the extended shifts with the
aim of preventing fatigue. For this review we have included
all studies that are typical of these configurations.
2. Method
Using Arksey and O’Malley’s (2005) methodological
framework, a comprehensive scoping study was undertaken between October 2013 and February 2014 to review
the literature on 12 h nursing shifts to date. This method
was chosen as a technique to ‘map’ the literature in the
field, examining the extent, range and nature of research
activity and identifying any gaps in existing knowledge
(Arksey and O’Malley, 2005). This is the first scoping
review of its kind to be undertaken in this field.
The research question asked by the scoping review was:
‘What is the extent, range and nature of evidence available
around the impact of 12 hour nursing shift patterns?’ The
main literature search was undertaken between October
and November 2013 and expert advice about generating
relevant search terms and suitable databases was sought
from Library and Information Sciences Specialists. A search
of the academic literature was undertaken in the electronic
databases AMED, MEDLINE, CINAHL, PsychInfo, Scopus,
HMIC and the Cochrane Library using the search strategy
shown in Table 1. To ensure that the review of research in
this field was as comprehensive as possible, no limits were
put on the date of included research but the review was
limited to English language publications.
Seven hundred and ninety records were retrieved from
the database searches and the titles and abstracts were
screened by SS. Ninety four papers were determined as
potentially relevant (i.e. either directly or indirectly
addressing nursing shifts lasting 12 h or more) and the full
articles were accessed. Bibliographies of the 94 papers were
checked to identify any additional articles that may have
been missed in the database searches. A further 71 potentially relevant papers were identified and the full articles
accessed. One possible reason for the large number of papers
identified outside of the database searches was that a
number used the hyphenated terms ‘‘12-hour shift’’ or ‘‘12-h
shift’’ and these terms were not included in our search
strategy. Unfortunately, 9 of the 165 potentially relevant
papers identified were inaccessible to UK libraries, resulting
Table 1
Strategy for search.
In abstract only:
‘‘12 hour* shift*’’ OR ‘‘Twelve hour* shift*’’ OR ‘‘long shift*’’ OR
‘‘shift pattern*’’ OR
‘‘extended shift*’’ OR ‘‘extended day*’’ OR ‘‘long day*’’
AND
‘‘nursing’’
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
in a total of 156 papers, which were read in full by either SS
or ND between November 2013 and February 2014. Broad
inclusion criteria were used, meaning that papers were
included if they described published/unpublished primary
research or literature reviews that addressed extended
nursing shifts of 12 h or more. News articles and opinion
pieces were excluded from the scoping review, as were
those papers that gave no methodological details or were
not specific to nursing care. Any uncertainties about
inclusions and exclusions were discussed between SS, ND
and RH.
As research papers and literature reviews were read,
they were inputted into a data charting form by SS and ND,
which was created using the database programme Excel.
For all included studies and reviews, the following
information was recorded:
Study title.
Author(s).
Year of publication.
Location.
Study populations.
Aims.
Methodology.
Outcome measures.
Important results.
Recommendations made for further research/policy.
A note was also made in the data charting form of all the
key themes which arose in each of the papers. These
themes, identified from reading the papers during the early
stages of the review, were coded as:
Risks to patients.
Patient experience.
Risks to staff.
Staff experience.
Impact on the organisation of work.
A separate chart was created for all excluded papers,
noting key reasons for their exclusion.
In February 2014, the same database searches were
conducted again in order to identify any new research
published during the period in which the review was
undertaken. The search strategy highlighted in Table 1 was
used again, with an additional limiter of publication date
for October 2013 to February 2014 (N.B. some databases
were not able to identify such specific parameters and
were therefore searched between 2013 and 2014). Twenty
eight papers were identified during this second stage
search, although some had already been included in the
review. Two new papers were determined as potentially
relevant, resulting in a total of 158 papers reviewed. These
two new papers were read in full by SS and inputted
into the data charting form, as detailed above. A total of
85 primary nursing research studies were included in this
scoping review. Ten nursing review papers were included
but analysed separately and 63 papers were excluded.
Fig. 1 provides a flow chart summarising this process.
There is a large range of industries beyond the nursing
profession that have implemented 12 h shift systems to
organise staff working patterns, including energy plants,
607
metal plants, processing plants, the police force, transportation and administration. Therefore, a scoping review of
evidence of the impact of 12 h shifts in other types of
occupation, where they may have been implemented for
longer than in the nursing profession and where working
conditions may be different, was undertaken by RH. The
same search strategy was used omitting the search term
AND ‘‘nursing’’ in the same search engines and also in
Business Source Premier, Econ Lit, ASSIA and Social Policy
and Practice. Unlike the review of the nursing papers,
secondary references were not retrieved. This was because
our research question was primarily concerned with the
impact of 12 h shifts in nursing and the review of nonnursing literature was intended to refine our understanding of shifts of extended duration by examining different
occupational contexts. Therefore, we focused only on the
suitable papers identified in the primary search. Two
hundred and ninety eight non-nursing papers were
identified, of which 23 primary research and 8 review
papers were included. The studies were charted in the
same way as above, and also coded, although the themes
were slightly different due to not having a patient focus.
Non-nursing themes were ‘staff risks’, ‘staff experience’,
‘productivity/quality of work’ and ‘impact on work’.
3. Results
3.1. Nursing literature
An overview of the findings of the nursing literature
from this scoping review is presented in two ways. Firstly,
numerical analyses of the extent, nature and distribution
of included studies are presented, highlighting the dominant areas of research in this field. Secondly, the literature
is organised according to theme, and an overview of all
material reviewed within each theme presented.
3.1.1. Numerical analyses – primary research studies
The review revealed a total of 85 nursing research
papers published between 1973 and 2014. There appears
to have been an increase in the number of papers published
in the last ten years compared to previous decades (see
Fig. 2), however, it is interesting to note that the profile of
origin of the papers has changed over the years. Most
papers (n = 40) come from the USA, with the UK having the
second highest output, despite having less than half the
number of papers compared to the USA (see Fig. 3).
However, only three of the studies in this review come
from the UK in the last decade (the most recent paper
2007), and there has been less published research in
Canada recently compared to their pioneering work in this
area.
The majority of studies included in the review were
undertaken with nurses working in hospital wards or
departments (see Fig. 4). Only two studies specifically
looked at community settings (Hodgson, 1995; Josten
et al., 2003). Fifteen studies included all nurses in a specific
geographical area and these may therefore have included
some nurses working in community settings, however
acute hospital settings predominate, particularly general
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R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
790 records
Titles and abstracts screened for original research/reviews related to nursing shis
lasng 12 hour or longer
Addional 71 papers
idenfied through
94 records remain
searching bibliographies
165 papers idenfied as potenally relevant but 9 not accessible in full text. Thus, 156
papers read in full
Search repeated to idenfy any new papers published between October 2013 and
February 2014.
28 papers found, 2 idenfied as potenally relevant and read in full: total of 158
papers read in full.
63 excluded
85 primary research
10 reviews
studies included
Fig. 1. Flow chart of literature search process (nursing literature).
medical or surgical wards and critical care settings. Some
studies included staff from more than one setting.
The 85 studies in the nursing review have been
authored by a total of 194 people. Twenty six of these
authors have contributed to more than one publication.
The major inter-relationships are illustrated in the
authorship map shown in Fig. 5. It is evident that there
are three main groupings of collaborations between
authors accounting for 23 (of the 85) papers:
1998 and 2012 (Geiger-Brown et al., 2012, 2011; Lang
et al., 2010; Lipscomb et al., 2002; Trinkoff et al., 2006a,b,
2011; Trinkoff and Storr, 1998).
The third grouping is associated with Rogers and Scott,
and Aiken and Stimpfel, who have collaborated together
and with others independently between 2003 and 2014
(Hoffman and Scott, 2003; Rogers et al., 2004a,b; Scott
et al., 2014, 2007, 2006; Stimpfel and Aiken, 2013;
Stimpfel et al., 2013, 2012).
The first major grouping is associated with Todd, Reid
and Robinson, who have published six papers together
between 1989 and 1994 (Reid et al., 1994, 1993, 1991;
Todd et al., 1991, 1989, 1993). These papers relate to
different aspects of the same study.
The second grouping revolves around Trinkoff, who, with
different collaborators, has published 8 papers between
A further 8 papers come from groups of authors who
have published two papers.
Of the 85 papers included in the nursing review, the
majority employed quantitative research designs either
solely (n = 63) or as part of a mixed methods approach
(n = 19). The stance of only three studies could be described
as qualitative (Dwyer et al., 2007; Hodgson, 1995; Rossen
and Fegan, 2009). Sixty-nine papers reported using some
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
Fig. 2. Numbers of nursing primary research papers published by decade
(publication year).
form of staff survey or self-reported questionnaire, either to
gain nurses’ views on satisfaction or to administer tools
gaining ratings of fatigue, stress, health effects and
wellbeing and workforce issues such as job satisfaction.
Six papers reported data based on nurses completing
daily log books or diaries. Most studies focussed on staff
experience and risks. Fourteen papers directly studied
patient measures. This included surveying patients as part of
the study design (Bajnok, 1975; Ganong et al., 1976;
Gillespie and Curzio, 1996; Hibberd, 1973; Todd et al.,
1991), evaluating patient records (Stone et al., 2006),
observing patient care in general (Hibberd, 1973; Mills
et al., 1983; Nelson and Blasdell, 1988; Reid et al., 1991;
Todd et al., 1989; Vik and MacKay, 1982), or specific tasks,
for example, medication administration (Bellebaum, 2008;
Girotti et al., 1987) and using patient scenarios to assess
decision making (McClelland, 2007). Only 8 studies considered some form of nursing workforce analysis, including a
review of resources such as sickness and temporary staffing
use (Bloodworth et al., 2001; Hibberd, 1973; Lea and
Bloodworth, 2003; Niemeier and Healy, 1984; Richardson
et al., 2003; Wootten, 2000a) and specifically in some cases
the effect of 12 h shifts on recruitment and retention
(Campolo et al., 1998; Niemeier and Healy, 1984) and
occupational injury (Hopcia et al., 2012).
609
Fig. 3. Number of nursing primary research papers published by country/
region.
Less than half of the studies used any form of validated
assessment tool as part of the data collection. Those studies
that did use validated measures (n = 41; see Table 2) used
tools which can be grouped into four main areas (some
studies used more than one tool): studies measuring the
impact on patient care using existing tools designed to
measure quality of care; studies assessing the effects of
12 h shifts on nurses’ psychological wellbeing; studies
including recognised work satisfaction or job opinion
tools; and studies reporting secondary analysis of more
generic recognised national surveys.
3.1.2. Overview of themes – primary research studies
Themes are presented in order of the number of papers
included within them. A summary of all nursing primary
research studies included in the scoping review is provided
in Table 3. More information about the studies within each
theme (e.g. participants, setting, intervention, research
methods, outcomes) is provided in Table 4.
3.1.2.1. Staff risks (n = 48). The majority of papers focus
upon the impact of long shifts on nurse fatigue, with
contradictory evidence provided. Several studies found
nurses report increased fatigue during 12 h shifts (McGettrick and O’Neill, 2006; Mills et al., 1983; Nelson and
Fig. 4. Number of nursing primary research papers by clinical work setting.
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R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
Fig. 5. Authorship map of nursing primary research papers showing author collaborations.
Blasdell, 1988; Richardson et al., 2007; Simunic and
Gregov, 2012; Szczurak et al., 2007), and extended shifts
have been associated with increases in physical fatigue
(Barker and Nussbaum, 2011; Todd et al., 1993), acute
fatigue, chronic fatigue and inter-shift recovery (Chen
et al., 2014; Iskra-Golec et al., 1996), mental fatigue (Todd
et al., 1993) and burnout (Estryn-Behar and Van der
Heijden, 2012; Stimpfel et al., 2013, 2012). However, other
studies have found no significant differences (Fields and
Loveridge, 1988; Hazzard et al., 2013; Takahashi et al.,
1999; Washburn, 1991) and some have noted a reduction
in fatigue when changing from 8 to 12 h schedules (Eaton
and Gottselig, 1980; Freer and Murphy-Black, 1995;
Gillespie and Curzio, 1996; McColl, 1982). Two studies
found that nurses become sleepier towards the end of 12 h
shifts (McClelland, 2007; Ugrovics and Wright, 1990), with
another stating that 12 h nurses work at a slower pace
towards the end of their shift than those working for 8 h
(Szczurak et al., 2007). However, one study found the level
of fatigue experienced during the last 2 h of a shift to be
comparable for nurses working 12 and 8 h (Vik and
MacKay, 1982). Reid et al. (1993) found that nurses
working 12 h shifts were more likely to take unofficial
breaks towards the end of their shift but two other studies
found they were no more likely to take a break than those
working shorter shifts (McGettrick and O’Neill, 2006;
Rogers et al., 2004b). Three studies found that nurses
working extended hours are more likely to have inadequate sleep or report worse sleep quality than those who
work 8 h shifts (Geiger-Brown et al., 2012, 2011; IskraGolec et al., 1996), but others found they had better
sleeping patterns or felt more rested after their days off
than 8 h nurses (Dwyer et al., 2007; Eaton and Gottselig,
1980; Freer and Murphy-Black, 1995). It is notable that a
number of the studies reporting no adverse impact of
extended shifts on tiredness and fatigue state that either
12 h shift working was not compulsory, that nurses in
these studies were responsible for initiating and driving
the introduction of 12 h shift working, used self-scheduling, or had nurse fatigue reduction schemes, such as
scheduled naps during shifts, in operation during the
study period (Eaton and Gottselig, 1980; Freer and
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
611
Table 2
Studies which used recognised or validated tools as part of the data collection.
Grouping
Number
of studies
References
Quality care measures
6
Mills et al. (1983), Todd et al. (1989, 1991), Nelson and Blasdell (1988), Vik and MacKay (1982), and
Fitzpatrick et al. (1999)
Nurses’ psychological
wellbeing
(i) Stress/Burnout
(ii) Fatigue/Sleep
8
13
Gowell and Boverie (1992), Iskra-Golec et al. (1996), Hoffman and Scott (2003), Lang et al. (2010),
Makowiec-Dabrowska et al. (2000), van Servellen and Leake (1994), Yoder (2010), and Estryn-Behar
and Van der Heijden (2012)
Mills et al. (1983), Hazzard et al. (2013), Kaliterna and Prizmic (1998), Barker and Nussbaum (2011),
Fields and Loveridge (1988), Borges and Fischer (2003), Geiger-Brown et al. (2012), Washburn (1991),
Scott et al. (2014), Ugrovics and Wright (1990), Szczurak et al. (2007), and Todd et al. (1991)
Work Satisfaction
17
Gowell and Boverie (1992), Hazzard et al. (2013), Kaliterna and Prizmic (1998), Eaton and Gottselig
(1980), Trinkoff and Storr (1998), Trinkoff et al. (2006a,b), Geiger-Brown et al. (2011), Todd et al.
(1993), Stanton et al. (1983), Woodworth (2014), McGillick (1983), Simunic and Gregov (2012), EstrynBehar and Van der Heijden (2012), Fitzpatrick et al. (1999), and Rossen and Fegan (2009)
National Survey secondary
analysis
5
Trinkoff et al. (2011), Stimpfel et al. (2012, 2013), Stimpfel and Aiken (2013), and Wilkins and Shields
(2008)
Murphy-Black, 1995; Gillespie and Curzio, 1996; Hazzard
et al., 2013; Takahashi et al., 1999; Vik and MacKay, 1982).
Some studies have explored the physiological impact of
working long shifts, again, with conflicting results. One
study identified a moderate physiological strain experienced by nurses working 12 h shifts, with over one third of
participants experiencing average working heart rates of
above 100 bpm and moderate cardiac stress (Chen et al.,
2011). In comparison, another study found that the
physiological differences experienced between normal
and extended work shifts were minor (Jarvelin-Pasanen
et al., 2013). Self-reported levels of stress have been
identified as significantly higher for nurses working 12 h
than those working 8 or 10 h shifts (Gowell and Boverie,
1992; Makowiec-Dabrowska et al., 2000), particularly for
those nurses with less work experience (Hoffman and
Scott, 2003). Extended work shifts have also been
identified as a risk factor for cognitive anxiety (IskraGolec et al., 1996), decision regret (Scott et al., 2014),
emotional exhaustion (Iskra-Golec et al., 1996) and
experiencing frequent worries about making mistakes
(Estryn-Behar and Van der Heijden, 2012). However, other
studies have found that nurses’ health is not adversely
affected by the 12 h shift (Dwyer et al., 2007; Jennings and
Rademaker, 1987; Kaliterna and Prizmic, 1998), and some
have concluded that it can actually have positive health
benefits, including a significant decrease in subjective
symptomatology in the areas of general health, cardiovascular related complaints, anxiety and frustration (Eaton
and Gottselig, 1980), reduced emotional exhaustion (Stone
et al., 2006; van Servellen and Leake, 1994) and eating
more healthily (Freer and Murphy-Black, 1995). One study
found that nurses working 12 h shifts experience significantly less compassion fatigue than those working for 8 h
(Yoder, 2010).
A smaller number of studies have explored the
relationship between work hours and the likelihood of
incident or injury to nurses but these too have contradictory results. One study found that the risk of ‘drowsy
driving’ doubled and the risk of being involved in a motor
vehicle crash or near motor vehicle crash almost doubled
when driving followed shifts exceeding 12 and a half
hours in duration (Scott et al., 2007). However, another
study found no differences reported in difficulty driving
home pre and post implementation of 12 h shifts (Mills
et al., 1983). Trinkoff et al. (2006a) found that working
13 h or longer was significantly associated with incidence
of neck, shoulder and back injury/disorder, although
Lipscomb et al. (2002) concluded that working more
than 12 h a day did not increase the risk of musculoskeletal
disorders. İlhan et al. (2006) found that working more
than 8 h a day increased the rate of needlestick injury for
nurses.
Some studies conclude that it is the combination of
various work schedule characteristics that have an
important impact upon nurses’ health and wellbeing,
rather than extended shift lengths alone. For example, one
study examined staff work patterns preceding an injury
and found a trend of increasing odds ratios with increasing
number of consecutive days worked, noting that the
relationship of cumulative shifts to injury was stronger
when combined with 12 h shifts (Hopcia et al., 2012).
Another found that the combination of working more than
12 h per day and more than 40 h per week was associated
with a statistically significant increase in the odds ratios of
reported musculoskeletal disorders of the neck, shoulder
and back (Lipscomb et al., 2002). Others have found that
nurses at greatest risk of cigarette and alcohol use are those
working night shifts combined with shifts longer than 8 h
(Trinkoff and Storr, 1998) and that night nurses are more
vulnerable to sleepiness by the end of extended shifts than
day nurses (Geiger-Brown et al., 2012). The study focussing
on USA Army and civilian nursing personnel found that
those who worked the day shift, worked no more than 8 h
and had fewer patient care contacts with military injured
personnel in Iraq and Afghanistan reported lower levels of
emotional exhaustion and depersonalisation (Lang et al.,
2010). Individual differences such as being of older age and
having family caregiving responsibilities have also been
identified as potentially exacerbating the negative impacts
of 12 h shifts (Chen et al., 2011; Kaliterna and Prizmic,
1998). Chen et al. (2014) found that nurses who worked
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
612
Table 3
The terms provided under the ‘type of nursing’ heading are using the authors’ own words. However, ‘ICU’ and ‘ITU’ are used interchangeably across the
papers and so, for consistency, are all reported here under ‘ICU’. Included nursing primary research papers NB.
Author and
date
Country
Study sample
Type of nursing
Methodology
Theme(s)
Scott et al.
(2014)
USA
Critical care
Questionnaires
Staff risks
Woodworth
(2014)
USA
605 full time nurse randomly
sampled from nursing
association membership list
Examination results of
309 student nurses in the
final semester of a 2-year
nursing degree programme
were explored plus
31 nursing students were also
surveyed.
Medical-surgical
Impact on work
Jarvelin-Pasanen
et al. (2013)
Finland
51 female nurses working
across various wards in
1 hospital
Various acute care
wards
Chen et al.
(2014)
USA
Hazzard et al.
(2013)
USA
Various (medicalsurgical, telemetry
and step-down
units)
Post-anaesthesia
care unit
Stimpfel and
Aiken (2013)
USA
130 female registered nurses
convenience sampled from
three acute care community
hospitals
20 full-time nurses all
working 12 h shifts on 1 ward
of an academic medical
centre
22,275 nursing staff from
577 hospitals in 4 states
First time NCLEX
examination results of
nursing students working
either self-selected 6 or 12 h
shifts on clinical placements
were investigated
supplemented by
questionnaire
Completion of two
comparable 36-h heart rate
variability measurements
(once during normal working
hours, once during extended
working hours)
supplemented by
questionnaires
Data analysed from
questionnaires distributed in
Chen et al. (2011)
Stimpfel et al.
(2013)
USA
3710 registered nurses
working in 342 acute care
hospitals treating children
across 4 states
Simunic and
Gregov (2012)
Croatia
Hopcia et al.
(2012)
USA
Stimpfel et al.
(2012)
USA
128 nurses (all married
mothers) working in
hospitals across 3 areas of
Croatia on a variety of 8 and
12 h shifts
502 injured hospital
registered nurses and patient
care associates and
502 matched controls from
66 units at 2 hospitals
22,275 registered nurses
working across 577 hospitals
in 4 states
Various (NICU,
paediatric ICU,
newborn nursery
and general
paediatrics)
Not specified
Estryn-Behar
and Van der
Heijden (2012)
Europe-wide
25,924 nurses across
10 European countries
Geiger-Brown
et al. (2012)
USA
Chen et al.
(2011)
USA
80 female, full-time
registered nurses from
various units in one hospital
145 female registered nurses
convenience sampled from
three acute care community
hospitals
Geiger-Brown
et al. (2011)
USA
2246 nurses across North
Carolina and Illinois
Various medicalsurgical units
Various (including
medical, intensive
care and
paediatrics)
Various (medical,
surgical and ICU)
Various (including
hospitals, nursing
homes and home
care)
Various (medicalsurgical and critical
care)
Various (medicalsurgical, telemetry
and step-down
units)
Not specified
Staff risks
Staff risks
Pilot study – logbooks
completed on a daily basis for
4 weeks plus questionnaires
Staff risks
Secondary analysis with
observational, cross-sectional
nurse survey data and
administrative hospital data
Secondary analysis of crosssectional nurse survey data
Patient risks
Questionnaire
Cross-sectional nested casecontrol analysis of
administrative data to
examine staff work patterns
preceding an injury
Secondary analysis of crosssectional data from 3 sources
linked by common hospital
identifiers
Secondary analysis of large
European nursing data set
collected in 2003
Staff risks
Staff experience
Patient risks
Patient
experience
Staff risks
Staff experience
Staff risks
Staff risks
Staff experience
Patient
experience
Staff risks
Staff experience
Questionnaires and wrist
monitor actigraphy
Staff risks
Questionnaires and work
logs, measurement of
physiological and
behavioural response
patterns over shift
Secondary analysis of data
collected from first wave of a
3-wave, cross-sectional
mailed survey study
Staff risks
Staff risks
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
613
Table 3 (Continued )
Author and
date
Country
Study sample
Type of nursing
Methodology
Theme(s)
Trinkoff et al.
(2011)
USA
Not specified
USA
Data used from a 2004 survey
plus collection of mortality
measures
Online survey
Patient risks
Barker and
Nussbaum
(2011)
Lang et al.
(2010)
USA
Questionnaires
Staff risks
Yoder (2010)
USA
Various (including
home care,
emergency
department, ICU
and oncology)
Questionnaire
Staff risks
Rossen and
Fegan (2009)
Canada
Paediatrics
USA
Wilkins and
Shields (2008)
Canada
4379 nurses providing direct
care to hospital patients
Not specified
Dwyer et al.
(2007)
Australia
19 staff (RNs, nurse
managers, doctors and allied
health personnel) in
1 hospital ward
ICU
Questionnaire distributed
twice – when students had
only worked 8 h shifts (time
1) and when they were likely
to have worked 12 h shifts
(time 2)
Non-blinded observation
based study of the
medication administration
process at 3 time points
supplemented by
questionnaires for staff
Secondary analysis of a subsample of data from national
survey of the work and health
of nurses
3-month trial of optional 12 h
shifts followed by evaluation
questionnaire
Impact on work
Bellebaum
(2008)
633 nurses working in
71 acute hospitals in North
Carolina and Illinois
745 registered nurses
convenience sampled
through nursing
organisations
Convenience sample of
364 active duty full time
Army and Army employed
civilian nursing personnel
Convenience sample of
106 nursing staff (only
71 completed the qualitative
component of the
questionnaire) working
across various units in
1 hospital
13 senior year students on a
paediatric clinical course at
time 1 and 10 at time 2. All
participants were female,
unmarried and without
children
30 nurses participated and
548 medication
administrations observed
Richardson
et al. (2007)
UK
Critical care
Questionnaire and focus
groups
McClelland
(2007)
USA
147 staff working across
3 units in 1 hospital
completed questionnaire
plus 16 participated in focus
groups. All worked 12 h shifts
65 registered nurses working
12 h shifts in 1 hospital
Various (including
critical care,
medical/surgical
and emergency
room)
Szczurak
et al. (2007)
Poland
108 reports on fatigue
symptoms obtained from
8 and 12 h shift nurses
working on 2 clinical wards
Various (cardiology
and surgical)
Scott et al.
(2007)
USA
895 full-time registered
nurses
Scott et al.
(2006)
İlhan et al. (2006)
Trinkoff et al.
(2006a)
Trinkoff et al.
(2006b)
USA
502 full-time nurses
Various (including
critical care,
obstetrics,
psychiatric/mental
health, paediatrics
and surgery)
Critical care
Thesis. Exploratory study
using fractional factorial
policy-capturing design.
Questionnaires completed at
the beginning and end of 12 h
shift
Questionnaire distributed at
the beginning, middle and
end of 12 h shifts and at the
beginning and end of 8 h
shifts
Logbooks completed on a
daily basis for 4 weeks
Turkey
USA
449 nurses in one hospital
2617 registered nurses in two
states of the USA
2273 registered nurses in two
states of the USA
USA
Various (including
acute hospital,
psychiatric facility,
community care)
Not specified
ICU
Not specified
Not specified
Not specified
Logbooks completed on a
daily basis for 4 weeks
Questionnaire
Longitudinal, 3-wave survey
Analysis of data set collected
as part of longitudinal survey
conducted 2002–2003.
Staff risks
Patient risks
Patient risks
Staff risks
Staff experience
Impact on work
Patient
experience
Staff risks
Staff experience
Impact on work
Patient
experience
Staff risks
Patient risks
Staff risks
Staff risks
Patient risks
Staff risks
Staff risks
Staff risks
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
614
Table 3 (Continued )
Author and
date
Country
Study sample
Type of nursing
Methodology
Theme(s)
McGettrick and
O’Neill (2006)
UK
Critical care
Questionnaire and focus
group
Staff risks
Staff experience
Impact on work
Patient
experience
Stone et al.
(2006)
USA
54 nurses from 3 critical care
areas within 1 hospital, all
working 12 h shifts.
6 volunteers (3 staff nurses,
3 charge nurses) also
participated in a focus group
805 nursing staff working
8 and 12 h shifts across
99 nursing units in
13 hospitals in 1 state
General wards
Staff risks
Staff experience
Patient risks
Impact on work
Breeding (2005)
Australia
52 nursing staff on 1 ward
(for questionnaire
completion, number of focus
group participants not stated)
ICU
Chudleigh
et al. (2005)
UK
88 nurses working either 8 or
12 h shifts across 6 NICUs
Neonatal ICU
Rogers et al.
(2004b)
USA
393 nurses sampled from
nursing association list
Rogers et al.
(2004a)
USA
393 nurses sampled from
nursing association list
Borges and
Fischer
(2003)
Brazil
Yuh (2003)
Singapore
and UK
The
Netherlands
5 registered nurses and
15 practical nurses all
working the 12 h night shift
in 2 participating centres
(Heart Institute or
Orthopaedics and Trauma
Institute) in one hospital
76 RNs in 1 ICU in Singapore
and 2 ICUs in the UK
134 nurses from 3 nursing
homes (one group working
8 h shifts, the other working
9 h shifts)
208 nurses selected from a
nursing association
membership list working
either 8, 10 or 12 h shifts
30 staff (nurses, night sisters
and therapists) on 1 ward
Various (including
medical–surgical,
intensive care,
obstetrics,
paediatrics)
Various (including
medical–surgical,
intensive care,
obstetrics,
paediatrics)
Not specified
Cross-sectional design with
data collected from multiple
sources, including a nurse
survey and examination of
administrative and patient
records
6-month trial of optional 12 h
shifts with pre- and postimplementation evaluation
questionnaires and focus
groups. Unit data also
compared before and after
trial
Observations of hand
decontamination at the
beginning and end of shifts
Logbooks completed for
28 days to provide
information such as work
hours, errors, episodes of
drowsiness and sleep on duty
Logbooks completed for
28 days to provide
information such as hours
worked, mood, caffeine
intake, overtime and days off
Logbooks completed for
15 consecutive days plus
wrist monitor actigraphy to
determine sleep/wake
episodes and duration
ICU
Questionnaire
Nursing homes
Questionnaire
Patient
experience
Staff experience
Various (including
critical care,
medical-surgical
and paediatrics)
Acute ward for
older people
Questionnaires
Staff risks
Staff experience
12 month trial of optional
two 12 h shifts plus two 6¼ h
shifts per week followed by
evaluation questionnaire.
Unit data also compared
before and after trial
3 month trial of 12 h shifts
with pre- and postimplementation evaluation
questionnaire. Unit data also
compared before and after
implementation of 12 h shifts
Questionnaire
Staff experience
Impact on work
Patient
experience
Questionnaire
Impact on work
Josten et al.
(2003)
Hoffman and
Scott (2003)
USA
Lea and
Bloodworth
(2003)
UK
Richardson et al.
(2003)
UK
41 nurses working on 1 unit.
ICU
Lipscomb et al.
(2002)
USA
Not specified
Zboril-Benson
(2002)
Canada
Probability sample of
1163 nurses randomly
selected from list of actively
licensed nurses in Illinois and
New York
1079 nurses drawn from
nursing association database
Various acute and
long-term settings
Staff experience
Patient risks
Impact on work
Patient risks
Staff risks
Patient risks
Patient risks
Staff experience
Patient risks
Impact on work
Patient
experience
Staff risks
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
615
Table 3 (Continued )
Author and
date
Country
Study sample
Type of nursing
Methodology
Theme(s)
Bloodworth
et al. (2001)
UK
23 staff (nurses, night sister,
therapists) on 1 ward
Acute ward for
older people
Staff experience
Patient risks
Impact on work
Patient
experience
Wootten (2000a)
UK
14 current nursing staff and
students on 1 ward
Cardiology
4 month trial of optional two
12 h shifts plus two 6¼ h
shifts per week followed by
evaluation questionnaire.
Unit data also compared
before and after trial
Questionnaire
MakowiecDabrowska
et al. (2000)
Poland
698 nurses (169 working 8 h
shifts, 536 working 12 h
shifts)
Fitzpatrick
et al. (1999)
UK
34 staff nurses within their
first year of practice from
2 hospitals within one Trust
Takahashi
et al. (1999)
Japan
40 single, female nurses in
their 20s (20 working 3 8 h
day shifts and 1 16 h night
shift and 20 working only 8 h
shifts) in 1 hospital in Tokyo
Various (including
ICU, medical,
surgical paediatric
and admissions/
diagnostic lab staff)
Various (medical,
surgical,
gynaecology,
oncology and
cardiology)
Various (surgical
and mixed wards)
Trinkoff and
Storr (1998)
USA
3917 registered nurses
Not specified
Campolo et al.
(1998)
Australia
28 nurses on 1 ward
ICU
Kaliterna and
Prizmic (1998)
Croatia
Iskra-Golec
et al. (1996)
Poland
Gowell and
Boverie (1992)
USA
208 shift workers (nurses
working 12 h shifts, air traffic
controllers working 12 h
shifts and police working
8 and 12 h shifts)
96 full-time nurses working
12 h shifts and 30 full-time
nurses working 8 h shifts.
Nurses over 35 and with
children were not eligible to
participate
84 registered nurses working
in one private, nonprofit
community hospital
Gillespie and
Curzio (1996)
UK
50 nursing staff (completed
questionnaires) and
20 nursing staff (interviewed)
across 4 medical wards
(2 working 8 h shifts,
2 working 12 h shifts), plus
interviews with 20 patients
across the 4 wards.
Questionnaire.
Impact on work
Patient
experience
Staff risks
Non-participant observation
of nurses–each nurse
observed continuously for
2.5 h on 3 separate occasions
Patient risks
Staff risks
Not specified
Subjective symptoms and
daily behaviour measured
every 30 min before, during
and after each shift as well as
during days off using a timebudget method. Physical
activity, heart rate and
posture also continuously
recorded every 30 s during
shifts using an ambulatory
monitor
Analysis of national, mailed
survey data set collected in
1994
12 month trial of 12 h shifts
with pre- and postimplementation evaluation
questionnaires and objective
performance tasks at the end
of and throughout the shifts.
Unit data also compared
before and after trial
Questionnaire
Cardiology
Questionnaire
Staff risks
Staff experience
Various (including
surgical,
orthopaedics,
critical care,
paediatrics)
Medical
Questionnaire
Staff risks
Staff experience
Questionnaires and semistructured interviews with
nurses, patient interviews,
review of patient records and
evaluation of unit data (e.g.
staff accident and illness
rates)
Staff risks
Staff experience
Impact on work
Patient
experience
Staff risks
Staff experience
Impact on work
Staff risks
Staff experience
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
616
Table 3 (Continued )
Author and
date
Country
Study sample
Type of nursing
Methodology
Theme(s)
Freer and
Murphy-Black
(1995)
UK
57 midwives/nursing staff
including 26 working on a
12.5 h neonatal ICU ward
Neonatal intensive
care
Staff risks
Staff experience
Impact on work
Patient
experience
Hodgson (1995)
UK
Independent
hospice
Kundi et al.
(1995)
van Servellen
and Leake
(1994)
Austria
11 qualified and unqualified
nurses working 12 h shifts in
one newly opened hospice
880 nurses from 12 hospitals
working either 8 or 12 h shifts
153 nurses working across
4 units in 4 hospitals
3 month trial of optional
12.5 h shifts with pre- and
post-implementation
evaluation questionnaire.
Comparisons made with
nursing/midwifery staff
working in 2 8 h shift
nurseries
Questionnaire distributed
14 months after the
implementation of 12 h shifts
Questionnaire.
Staff risks
Reid et al.
(1994)
UK
25 student nurses (phase 1)
and 22 student nurses (phase
2) working on 7 wards in
1 hospital plus 16 nurse
educators from the college of
nursing
Various (including
medical, surgical,
maternity and
geriatric)
Reid et al.
(1993)
UK
4232 hs of nurses’ time on
10 wards across 2 hospitals in
1 health authority were
observed
Various (including
medical, surgical,
maternity and
geriatric)
Todd et al.
(1993)
UK
320 qualified and unqualified
nurses working on 10 wards
across 2 hospitals in 1 health
authority were invited to
participate, with a response
rate of 73% in the first phase
and 64% in the second
Various (including
medical, surgical,
maternity and
geriatric)
Reid et al.
(1991)
UK
14,293 observations of
activity from student and
qualified nurses working
across 7 wards in 1 hospital
Various (including
medical, surgical,
maternity and
geriatric wards)
Todd et al.
(1991)
UK
143 patients on 10 wards
across 2 hospitals in 1 health
authority
Various (including
medical, surgical,
maternity and
geriatric wards)
Secondary analysis of data
from a sub-sample of a larger,
self-administered
multifaceted survey
Repeated measures
evaluation of the nonoptional move to 12 h shifts
for all nurses. Questionnaire
for student nurses
administered 1 month prior
to and 6 months after
introduction of 12 h shifts
Repeated measures
evaluation of the nonoptional move to 12 h shifts
for all nurses. Activity
analysis of nursing activities
for one month as an 8 h shift
ward then for another month
6 months after becoming a
12 h shift ward. Each nurse on
duty was observed every
15 min for their working
period
Repeated measures
evaluation of the nonoptional move to 12 h shifts
for all nurses. Questionnaire
for nursing staff administered
1 month prior to and
6 months after introduction
of 12 h shifts
Repeated measures
evaluation of the nonoptional move to 12 h shifts
for all nurses. Activity
analysis conducted to record
patterns of nursing and
educational behaviour for
one month as an 8 h shift
ward then for another month
6 months after becoming a
12 h shift ward
Repeated measures
evaluation of the nonoptional move to 12 h shifts
for all nurses. Questionnaire
distributed to patients in all
participating wards,
interviews conducted for
those unable to complete
questionnaire
USA
Not specified
AIDS care
Staff experience
Patient
experience
Staff experience
Impact on work
Staff risks
Impact on work
Staff risks
Staff experience
Impact on work
Patient
experience
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
617
Table 3 (Continued )
Author and
date
Country
Study sample
Type of nursing
Methodology
Theme(s)
Washburn
(1991)
USA
Various (critical
care and medical/
surgical)
Questionnaire and critical
thinking test distributed in
first hour of each work shift
and again in the last hour
Staff risks
Patient risks
Ugrovics and
Wright (1990)
USA
ICU
Questionnaires and critical
thinking and fatigue tests
Staff risks
Patient risks
Todd et al.
(1989)
UK
117 nurses (94 registered
nurses, 23 licenced practical
nurses) working in various
departments in 1 hospital.
68 nurses worked 8 h shifts
and 49 worked 12 h shifts
Convenience sample of
35 nurses in ICU units in
1 community hospital and
1 regional medical centre
MONITOR instrument
administered by fieldwork
assistants on 10 wards across
2 hospitals in 1 health
authority
Various (including
medical, surgical,
maternity and
geriatric)
Patient risks
Fields and
Loveridge
(1988)
USA
102 critical care nurses
working either 8 or 12 h shifts
in 1 department
Critical care
Nelson and
Blasdell
(1988)
USA
20 nurses (10 working 8 h
shifts, 10 working 12 h shifts)
in 2 units at 2 hospitals.
Nurses matched on a number
of criteria
ICU
Heaslip (1988)
Canada
Various (medicalsurgical and
coronary care)
Girotti et al.
(1987)
Canada
Jennings and
Rademaker
(1987)
Canada
25 students in the final year
of nursing studies in
1 university working 12 h
shifts
44 full-time and 25 part-time
nurses on 1 ward with a
standard shift of 12 h
Convenience sample of
149 nurses working on16
units in 1 hospital
Repeated measures
evaluation of the nonoptional move to 12 h shifts
for all nurses. MONITOR
instrument (providing an
index of quality of nursing
care) administered 1 month
prior to and 6 months after
introduction of 12 h shifts
Quasi-experimental research
design with two
experimental groups (one 8 h
shifts, one 12 h shifts).
Questionnaire and reasoning
tests distributed to nurses
during the first and last hours
of their shift
Observational technique with
rating scale (QUALPACS)
conducted in final two hours
of both shifts to evaluate the
quality of nursing care
provided
Questionnaire
Niemeier and
Healy (1984)
USA
93 registered nurses working
across 5 units in 1 hospital
Stanton et al.
(1983)
USA
McGillick (1983)
USA
Mills and
Arnold (1983)
USA
125 extended shift nurses
and 82 regular shift nurses
working across 8 hospitals in
New York, matched to
institution and clinical area
80 nurses across 6 units in
1 hospital–half working 12 h
shifts, half working 8 h shifts
Unit data on recruitment and
retention in 1 ward after
implementation of 12 h shifts
collected
Adult ICU
Various (medical
and surgical,
obstetrics and
gynaecology)
Various (including
paediatrics, labour
and delivery and
pulmonary
medicine)
Analysis of medications given
to all patients admitted to the
ICU within a 2-week period
Questionnaires distributed at
two collection points four and
a half months apart
Staff risks
Patient risks
Staff risks
Patient risks
Impact on work
Patient
experience
Patient risks
Staff risks
Staff experience
Staff experience
Patient risks
Impact on work
Not specified
Time series design, including
6 months of baseline data
prior to the introduction of
the 12 h shift and followed up
for ‘several years’ after its
implementation plus
questionnaires completed by
staff
Questionnaire
Critical care
Questionnaire
Staff experience
ICU
Trial after implementing new
shift pattern (3 12 and a half
hour shifts each week plus 1
8 and a half hour shift every
2 weeks). Unit data collected
for 1 and half years prior to
implementation and 2 and
half years after
Impact on work
Staff experience
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
618
Table 3 (Continued )
Author and
date
Country
Study sample
Type of nursing
Methodology
Theme(s)
Mills et al.
(1983)
USA
30 nursing staff in 1 unit
ICU
Staff risks
Patient risks
Metcalf (1982)
USA
426 nursing staff
Not specified
McColl (1982)
Canada
22 nursing staff and students
ICU
Vik and MacKay
(1982)
Canada
Not specified
Eaton and
Gottselig
(1980)
Canada
60 patients from 6 units in
1 hospital (3 12 h shift units, 3
8 h shift units). Units
matched for type and amount
of nursing care required for
patients
24 RNs on 1 ward
Trial of new shift pattern (3
12 and a half hour shifts plus
1 8 and a half hour shift every
2 weeks) with 1 month preand 3-month and 1 year postimplementation evaluation
questionnaires and fatigue
tests
6 month trial of optional 12 h
shift working at weekends
only (NB – optional for
existing staff only, nonoptional for new staff)
followed by evaluation
questionnaires
Pilot project implementing a
12 h schedule for students
followed by evaluation
questionnaire. Unit data also
collected from hospital
records before and after
implementation of pilot
10 patients from each unit
randomly selected and
observed for 2 h period using
QUALPACS technique to
measure quality of care
Ganong et al.
(1976)
USA
Not specified
Bajnok (1975)
Canada
91% of all nursing staff plus
30 patients and 30 dentists/
physicians plus management
and administration and
supporting services
personnel.
Nurses (number not
specified) working on
2 wards (one 8 h, one 12 h
shift) in 1 hospital plus
20 patients on each of the
2 wards
Stinson and
Hazlett (1975)
Canada
Hibberd (1973)
Canada
36 nursing staff working
across 2 paediatric wards
(8 RNs and 13 certified
nursing aides on 1 ward and
7 RNs and 8 certified nursing
aides on another) in
1 hospital. 19 staff physicians
and residents also
participated at Time 1 and
10 at Time 2
58 female nurses working
across 3 wards (1 control,
2 experimental), nonrandomly selected and
positively biased in favour of
12 h shifts at the start of the
study
ICU
Not specified
Paediatrics
Medical and
surgical
Impact on work
Staff risks
Patient risks
Impact on work
Patient
experience
Staff risks
Patient risks
6 month trial of 12 h shifts
with pre-and postimplementation evaluation
questionnaires and direct
physiological observations
Questionnaire
Staff risks
Staff experience
Questionnaires for nurses
and patients on each ward
plus audit of 25 randomly
selected medical profiles,
nursing care plans, nursing
histories and patient progress
notes on each ward
3-month trial of modified
shift pattern (6 12 h shifts
and 1 8 h shift every
fortnight) with pre- and postimplementation evaluation
questionnaires
Patient risks
Impact on work
Patient
experience
Questionnaires and
observations throughout a
15 week experimental period.
Unit data also examined for
experimental period and the
15 weeks immediately prior
Staff experience
Patient
experience
Staff experience
Patient
experience
Staff experience
Patient
experience
Table 4
Information on the primary nursing research studies within each theme.
Participants
Setting
Intervention
Research methods
Outcomes
Sample sizes ranged from 19 to
25,924 (secondary analysis of data).
The majority of study participants
were registered nurses or licensed
practical nurses (USA) working
within hospital settings but some
studies focussed upon student
nurses, midwives or USA Army and
civilian nursing personnel and
others also included nurse
managers, doctors, allied health
personnel, air traffic controllers and
police. Some studies included
nurses working in nursing homes
and home care institutions. Some
had inclusion criteria such as being
in good health, without taking
regular medications, working full
time, working 12 h shifts for a
minimum of 6 months and not
having a second job; some excluded
those with children whilst others
only included those with children,
some only included married nurses
and others only single nurses.
Various/unspecified (31), ICU,
including neonatal ICU and
critical care (11), acute care/
medical ward (2), postanaesthesia care unit (1),
cardiology (1), paediatrics (1)
and AIDS (1).
Most studies looked specifically
at 12 h shifts, though some
classed extended shifts as
anything greater than 8, 12 and
half, 13 or 16 h.
The majority of studies used selfcompletion questionnaires, diaries or
logbooks, with some undertaking
observations of nursing care, semistructured interviews or focus groups
or the collection of physiological data.
Others conducted secondary analyses
of national survey data. Some studies
compared nurses working either 8 or
12 h shifts, whilst others used a
repeated measures design. One study
involved a cross-sectional nested casecontrol analysis of administrative data
and another undertook activity
analysis.
Most studies measured selfreported indicators, such as
health status, fatigue, sleep
patterns/quality, drowsiness,
stress, anxiety, decision regret,
musculoskeletal injury/disorder,
needlestick injuries, burnout,
and substance use. Two studies
used an observational technique
to evaluate the quality of nursing
care being given, one study used
activity analysis to describe
patterns of care and others used
monitors and actigraphs to
measure physiological data such
as heart rate, work pace, energy
expenditure, sleep activity and
body temperature curves.
Staff
experience
Sample sizes ranged from 11 to
25,924 (secondary analysis of data).
The majority of study participants
were registered nurses in hospital
settings but one focused on
midwives and others also included
certified nursing aides (Canada),
nurse managers, doctors,
administration and supporting
services personnel, allied health
professionals, air traffic controllers
and police. Some studies included
nurses working in nursing homes,
home care institutions and hospice
settings. Some excluded nurses over
the age of 35 and those with
children whilst others only included
married mothers. Some studies only
included those who had worked
12 h shifts for a minimum of
6 months.
Various/unspecified (13), ICU,
including neonatal ICU and
critical care (9), acute ward for
older people (2), medical/
surgical wards (2), paediatrics
(2), cardiology (1), nursing
homes (1) and hospice care (1).
Most studies looked specifically
at 12 h shifts, though some
classed extended shifts as
anything greater than 9 h, 12 and
half or 13 h. In some studies, staff
worked a combination of
extended and traditional shift
patterns.
The majority of studies used selfcompletion questionnaires, with some
also conducting focus groups or semistructured interviews. A number of
studies involved implementing a trial of
12 h shift working followed by an
evaluation or a repeated measures
study conducted pre and post
implementation of extended shifts.
Others compared nurses working either
8 or 12 h shifts or conducted secondary
analyses of national survey data.
Most studies measured selfreported indicators of staff
experience of 12 h shift working,
such as job satisfaction, morale
at work, impact on family and
social life, work-family conflict
and travel to and from work.
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
Theme
Staff risks
619
620
Table 4 (Continued )
Participants
Setting
Intervention
Research methods
Outcomes
Sample sizes ranged from 20 to
22,275 (secondary analysis of data).
The majority of study participants
were registered nurses within
hospital settings, but some studies
included licenced practical nurses
(USA and Brazil) or student nurses.
Some studies had inclusion criteria
such as having worked at
participating centres for a minimum
of one year, not having a second job
and not taking medications that
could interfere with sleep. One
study focussed only on night nurses.
Various/unspecified (14), ICU,
including neonatal ICU, MICU
and critical care (10), acute ward
for older people (1) and
paediatrics (1).
Most studies looked specifically
at 12 h shifts, though some
classed extended shifts as
anything greater than 12 and
half or 13 h. In some studies, staff
worked a combination of
extended and traditional shift
patterns.
Most studies used self-completion
questionnaires or logbooks, with some
undertaking focus groups with staff,
observations of nursing care, critical
thinking and reasoning tests, actigraphs
to determine nurses’ sleep/wake
episodes and the collection of hospital
data. Some conducted secondary
analyses of national survey data. A
number of studies involved
implementing a trial of 12 h shift
working followed by an evaluation or a
repeated measures study conducted
pre and post implementation of
extended shifts. Some studies
compared nurses working either 8 or
12 h shifts.
Most studies measured
indicators of care quality and
safety as reported by staff and/or
collected hospital data, such as
incident reports, patient
mortality measures, medication
errors and new isolates of multiresistant organisms. Some
observed nursing practice, with
one specifically focussing on
nurses’ hand decontamination
practices, one on the medication
administration process and
others on the quality of care
provided. Other studies
compared staff performance on
critical thinking or reasoning
tests or on policy-capturing
scenarios.
Impact on
work
Sample sizes ranged from 13 to
2000. The majority of study
participants were registered nurses
working within hospital settings but
some studies focused on student
nurses, nurse educators or
midwives and others included nurse
managers, doctors and allied health
personnel.
Various/unspecified: (10), ICU,
including neonatal ICU and
critical care (9), acute ward for
older people (2), cardiology (1),
medical (1) and paediatrics (1).
Most studies looked specifically
at 12 h shifts, though one classed
extended shifts as anything
greater than 12 and half hours. In
one study, 12 h shifts were only
implemented at weekends and
in others staff worked a
combination of extended and
traditional shift patterns.
Most studies used self-completion
questionnaires and/or the collection of
hospital data. A small number of
studies also conducted focus groups
with staff. Most studies involved
implementing a trial of 12 h shift
working followed by an evaluation or a
repeated measures study conducted
pre and post implementation of
extended shifts. A smaller number of
studies compared nurses working
either 8 or 12 h shifts.
Most studies measured selfreported outcomes from staff
and/or collected hospital data
around sickness rates, staff
recruitment and retention,
agency nurse use and attendance
at in-service education.
Patient
experience
Sample sizes ranged from 11 to
22,275 (secondary analysis of data).
The majority of study participants
were registered nurses in hospital
settings but others also included
patients, nursing auxiliaries or
certified nursing aides (Canada),
student nurses, midwives, allied
health personnel, doctors, dentists,
administration and supporting
services personnel and nurse
managers. One study focussed on
the hospice setting. Some studies
only included female nurses and
others only included those who had
worked 12 h shifts for a minimum of
6 months.
ICU including neonatal ICU and
critical care (7), various/
unspecified (5), acute ward for
older people (2), paediatrics (2),
medical/surgical wards (2),
cardiology (1) and hospice care
(1).
Most studies looked specifically
at 12 h shifts, though some
categorised extended shifts as
anything greater than 12 and
half or 13 h. In some studies, staff
worked a combination of
extended and traditional shift
patterns.
Most studies used self-completion
questionnaires or a review of nursing
records and some also used semistructured interviews or focus groups.
Most studies involved implementing a
trial of 12 h shift working followed by
an evaluation or a repeated measures
study conducted pre and post
implementation of extended shifts but
some compared nurses working either
8 or 12 h shifts. Other studies
conducted secondary analyses of
national survey data.
Most studies measured the
impact of extended shifts on
patient experience as reported
by staff (e.g. outcomes such as
assessing, planning,
implementing and evaluating
care, documentation and
communication) or by
comparing nursing records
completed under 8 and 12 h shift
working. A smaller number of
studies asked patients to provide
their own opinions on the care
provided.
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
Theme
Patient risks
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
12 h shifts and exercised weekly had better acute fatigue
scores than those who did not.
3.1.2.2. Staff experience (n = 31). Most studies evaluating
extended working hours conclude that nurses prefer
working 12 h shifts or/and like having the choice to work
extended hours (Bloodworth et al., 2001; Campolo et al.,
1998; Dwyer et al., 2007; Eaton and Gottselig, 1980;
Gillespie and Curzio, 1996; Lea and Bloodworth, 2003;
Richardson et al., 2003, 2007; Stinson and Hazlett, 1975;
Breeding, 2005). The majority of studies also focus on the
beneficial aspects of extended working hours for nurses,
though some have reported negative findings. For example, nurses frequently report the personal benefits of
increased flexibility (Bloodworth et al., 2001; Dwyer et al.,
2007); ease of childcare (Bloodworth et al., 2001; Lea and
Bloodworth, 2003); reduced work-family conflict (EstrynBehar and Van der Heijden, 2012); and the opportunity for
better management of/improved satisfaction with their
social and family time (Bloodworth et al., 2001; Campolo
et al., 1998; Dwyer et al., 2007; Estryn-Behar and Van der
Heijden, 2012; Freer and Murphy-Black, 1995; Hodgson,
1995; Iskra-Golec et al., 1996; Kaliterna and Prizmic, 1998;
McGettrick and O’Neill, 2006; Stinson and Hazlett, 1975).
However, two studies have found that extended shift
schedules interfere more with nurses’ social and leisure
time (Kundi et al., 1995; Todd et al., 1993); one found that
they make childcare and domestic duties more difficult
(Todd et al., 1993); and three found that they either
increase nurses’ intent to leave the job or discourage
them from returning to nursing (Stimpfel et al., 2013,
2012; Todd et al., 1993). Increased job satisfaction and
morale at work are frequently associated with 12 h shift
working for nurses (Dwyer et al., 2007; Eaton and
Gottselig, 1980; Freer and Murphy-Black, 1995; Ganong
et al., 1976; Lea and Bloodworth, 2003; McGettrick and
O’Neill, 2006; McGillick, 1983; Niemeier and Healy, 1984;
Stone et al., 2006) though some have found higher job
satisfaction associated with working shorter shifts (Gowell
and Boverie, 1992; Hibberd, 1973; Josten et al., 2003;
Simunic and Gregov, 2012; Stimpfel et al., 2013, 2012;
Todd et al., 1993) and others have found no significant
difference (Iskra-Golec et al., 1996; Jennings and Rademaker, 1987; Kundi et al., 1995; Richardson et al., 2003;
Stanton et al., 1983; Stinson and Hazlett, 1975). Two
studies found that the odds of job dissatisfaction were
highest for nurses working shifts of 13 h or more (Stimpfel
et al., 2013, 2012). Another found that 8 h nurses were
significantly more satisfied with their current salary and
12 h nurses significantly more satisfied with their professional status (Hoffman and Scott, 2003).
Nurses also highlight other benefits of 12 h shift
working, including having an increased number of days
off each week (Bloodworth et al., 2001; Ganong et al., 1976;
Gillespie and Curzio, 1996; Lea and Bloodworth, 2003);
working late less often (Bloodworth et al., 2001); being
less frequently obliged to take over shifts at short notice or
get up before 5 a.m. to go to work (Estryn-Behar and Van
der Heijden, 2012); less weekend working and split shifts
(Estryn-Behar and Van der Heijden, 2012); and no 10-day
stretches (Gillespie and Curzio, 1996). Fewer staff working
621
12 h shifts feel that the timing of shifts/travelling to and
from work threatens their personal safety compared with
those working 8 h shifts (Freer and Murphy-Black, 1995).
Decreased spending on travel due to the reduction in days
worked are also an important benefit of extended shift
working for some staff (Freer and Murphy-Black, 1995;
Richardson et al., 2007). However, once again it is notable
that in many of the above mentioned studies, 12 h shift
working was optional and/or was implemented or
supported by nursing staff (Bloodworth et al., 2001;
Breeding, 2005; Campolo et al., 1998; Dwyer et al.,
2007; Eaton and Gottselig, 1980; Freer and Murphy-Black,
1995; Gillespie and Curzio, 1996; Niemeier and Healy,
1984; Richardson et al., 2003).
3.1.2.3. Patient risks (n = 26). Self-reported data from
nursing staff suggests that extended shift patterns may
have adverse implications for the quality and safety of
patient care. For example, Stimpfel and Aiken (2013) found
that the odds of nurses’ reporting poor quality of care and a
poor hospital safety grade increased for nurses working
10 h or longer compared with nurses working 8–9 h and
were highest for nurses working 13 h or more. Shift length
remained a significant predictor of nurse-reported quality
and safety even after adjusting for nursing demographics,
hospital structural characteristics and nursing organisational features (Stimpfel and Aiken, 2013). Two studies
concluded that nurses’ perceived risks of making an error
significantly increase when work shifts last 12 and half
hours or more (Rogers et al., 2004a; Scott et al., 2006) and
another, that nurses who work shifts of more than 13 h are
more likely to report frequent central line associated
bloodstream infections and patient/family complaints
(Stimpfel et al., 2013). Others have found that 12 h night
nurses’ believe their alertness decreases significantly as
the night shift progresses, suggesting a risk of compromised patient care (Borges and Fischer, 2003). Trinkoff
et al. (2011) compared nurse work schedules with
mortality measures and found that pneumonia deaths
are significantly more likely in hospitals where nurses
report schedules of 13 h or more. McClelland (2007) used a
policy-capturing design and found that the fatigue
experienced by nurses during 12 h shifts significantly
contributes to inconsistent policy judgements.
Some observational studies of the quality of nursing
care also suggest that extended work schedules may
impact patient care and safety, as clinical performance
scores were rated significantly higher for nurses working
8 than 12 h shifts. Nurses working 8 h shifts also obtained
significantly higher scores in the physical and professional
domains of practice than those working for 12 h or more
(Fitzpatrick et al., 1999). One study using the QUALPACS
observational technique concluded that the quality of care
received by patients on 8-h shift units is significantly
higher than that received by patients on 12 h shift units
(Vik and MacKay, 1982), although another using the
same technique found no significant difference (Nelson
and Blasdell, 1988). Another study, using the MONITOR
measurement of quality of care, found a significant
decrease in the overall quality of nursing care provided
on the same wards under 12 h shifts than under 8 h shifts.
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R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
This decrease in quality was apparent among each of the
four levels of patient dependency, from minimal care
patients to maximum care patients who required total
nursing care (Todd et al., 1989). One study observed the
hand hygiene performance of those working either 8 or
12 h and found significant differences between the
beginning and end of long shifts. At the beginning of long
shifts, nurses spent longer decontaminating their hands,
were more thorough and dried their hands more effectively than at the end of long shifts, whereas no differences
could be detected between performance at the beginning
and end of 8 h shifts (Chudleigh et al., 2005). Similar
findings were identified in another observational study,
which concluded that nurses make more errors of process
variation (e.g. not washing hands, not checking patients’
identity bracelets) at the 12 h time point compared to the
8 h time point of a shift (Bellebaum, 2008).
However, a number of studies have found no significant
difference in staff performance or quality of patient care or
have noted no difference in nurses’ reasoning or critical
thinking skills according to shift length, implying that the
quality of patient care may not be adversely affected by
extended shifts (Bajnok, 1975; Breeding, 2005; Fields and
Loveridge, 1988; Mills et al., 1983; Nelson and Blasdell,
1988; Stone et al., 2006; Ugrovics and Wright, 1990;
Washburn, 1991). Others have found no difference in the
number of incident reports associated with 12 h shift
working (Bloodworth et al., 2001; Breeding, 2005; McColl,
1982; Richardson et al., 2003; Stone et al., 2006), nor any
differences in the number of medication errors made
(Bellebaum, 2008; Breeding, 2005; Girotti et al., 1987;
McColl, 1982; Mills et al., 1983; Niemeier and Healy, 1984)
or new isolates of multi-resistant organisms (Breeding,
2005). One study found that nurses report less medication
errors on 12 h shifts than on shorter shifts (Wilkins and
Shields, 2008).
Again, some of the studies reporting no adverse impact
of extended shifts on patient care state that 12 h shift
working was not compulsory and/or was implemented at
the request of nursing staff (Bloodworth et al., 2001;
Breeding, 2005; Niemeier and Healy, 1984; Richardson
et al., 2003) and that the success of 12 h shift working is
dependent upon the support and cooperation of staff and
the method of implementation (Breeding, 2005; Niemeier
and Healy, 1984). Similarly, one study reporting negative
findings noted that the decision to move to 12 h shift
working was made by management, against the wishes of
nursing staff, and that this may have influenced the results
(Todd et al., 1989). The authors conclude that there is a
possible correlation between nurses’ attitudes and quality
of care and further propose that there may be a causal link
(Todd et al., 1989).
3.1.2.4. Impact on work (n = 24). There is contradictory
evidence around whether 12 h shifts impact the way in
which nursing care is delivered. For example, one study
found different patterns of nursing activity under 8 and
12 h shifts, with the 12 h shift associated with significantly
less direct patient care. This reduction in patient care
occurred throughout the day but was most marked within
the final 3 h, suggesting a ‘pacing effect’ (either consciously
or unconsciously) by nurses who face 12 h on duty (Reid
et al., 1993). However, other studies have found staff
generally report more time for direct nursing care during
12 h shifts (Gillespie and Curzio, 1996; Wootten, 2000a).
Wootten (2000a) also found evidence of a ‘pacing effect’
during 12 h shifts but nurses identified this as an
advantage, claiming they felt more able to stagger care
over the course of the day rather than feeling the need to
‘rush’ through all care in the morning.
There is some evidence that 12 h shifts can have a
detrimental impact upon the educational and professional
development opportunities afforded to nurses and nursing
students. A number of studies have noted fewer 12 h shift
nurses attend in-service educational opportunities than
those working 8 h shifts (Bajnok, 1975; Breeding, 2005;
Campolo et al., 1998; Freer and Murphy-Black, 1995;
McGettrick and O’Neill, 2006), with some attributing this
to the loss of overlap time with 12 h shifts (Campolo et al.,
1998; McGettrick and O’Neill, 2006), though one study
found no difference in educational opportunities (Dwyer
et al., 2007). Other studies have explored the impact of
extended shift working on student nurses and conflicting
findings have again emerged. For example, Woodworth
(2014) investigated the relationship between length of
clinical shift completed by students in the final semester of
their nursing programme and the NCLEX examination
failure rates and found no significant difference between
those working 6 and 12 h shifts. Others have found nursing
students hold very positive attitudes towards working 12 h
shifts, claiming that it enhances their learning opportunities, gives them more opportunities to perform skills,
makes them feel more accepted by the nursing staff they
work alongside and more inclined to study during their
time off (Heaslip, 1988; McColl, 1982; Rossen and Fegan,
2009; Woodworth, 2014). In contrast, Reid et al. (1991)
concluded that whilst student nurses work the same
number of hours under both 8 and 12 h systems, 12 h shift
students spend significantly less time undertaking direct
patient care, less time with qualified mentors and less time
learning the hands-on skills of nursing. A further study
found nurse educators unequivocal in their belief that 12 h
shifts were unhelpful in the education process and that
student learning is detrimentally affected by the shift (Reid
et al., 1994). Most educators believed that students
working 12 h shifts were too tired to learn effectively,
were not exposed to a wide enough spectrum of clinical
situations and used the long off-duty time for leisure rather
than study (Reid et al., 1994). Other studies have identified
a mixture of opinions from staff and students with regard
to the educational impact of 12 h shifts (Wootten, 2000a).
Findings are inconsistent about the impact of extended
shift working on recruitment and retention, absenteeism
and costs. Some studies have concluded that 12 h shift
working results in fewer episodes of staff sick leave
(Bloodworth et al., 2001; Dwyer et al., 2007; Lea and
Bloodworth, 2003), improved recruitment and retention
(Dwyer et al., 2007; McGettrick and O’Neill, 2006; Metcalf,
1982) and a reduced need for temporary/casual nurses
(Bloodworth et al., 2001; Lea and Bloodworth, 2003;
Metcalf, 1982), though others have found no impact upon
staff recruitment and retention (Breeding, 2005; Campolo
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
et al., 1998; Mills and Arnold, 1983; Stone et al., 2006) or
sick leave rates (Breeding, 2005; Campolo et al., 1998;
Niemeier and Healy, 1984; Richardson et al., 2003; Stone
et al., 2006; Wootten, 2000a). Zboril-Benson (2002) noted
an increase in nurse absenteeism. One study reports 12 h
shifts result in ward cost savings (Lea and Bloodworth,
2003), but others have found that costs remain unchanged
(Bloodworth et al., 2001; Metcalf, 1982; Stone et al., 2006)
or increase (Wootten, 2000a). It has been claimed that
extended shifts make it easier for senior nurses to produce
and plan off duty and arrange staff for future shifts,
although arranging cover at short notice could also be
more difficult (Richardson et al., 2007). Others report that
staff on wards operating a 12 h shift pattern are ‘borrowed’
by other wards more often, as they regularly have more
staff on shift compared with those using a shorter shift
system (Gillespie and Curzio, 1996; Lea and Bloodworth,
2003).
Again, almost all of the studies reporting no adverse
impact of extended shifts on organisational factors state
that 12 h shift working was optional and/or was implemented or supported by nursing staff (Bloodworth et al.,
2001; Breeding, 2005; Campolo et al., 1998; Dwyer et al.,
2007; Heaslip, 1988; Lea and Bloodworth, 2003; Metcalf,
1982; Niemeier and Healy, 1984; Richardson et al., 2003).
One of the papers reporting a negative impact noted that
the decision to implement 12 h shifts was not supported by
nursing staff and acknowledged that their findings were
undoubtedly influenced by the very negative attitudes
towards the shifts that they held (Reid et al., 1993).
3.1.2.5. Patient experience (n = 20). Only a small number of
studies have gathered patient opinions on the impact of
shift length on care provided. Overall, the effect of shift
length on patient views appears to be neutral, as most
studies uncover positive views on nursing care regardless
of shift pattern (Bajnok, 1975; Gillespie and Curzio, 1996;
Hibberd, 1973; Todd et al., 1991) and no statistically
significant differences in patient satisfaction (Hibberd,
1973). However, one study found that nurses’ shift length
was significantly associated with patient satisfaction, as
measured by a national patient satisfaction survey. The
authors found that increases in the proportion of nurses
working shifts of more than 13 h were associated with
increases in patient dissatisfaction. Having higher proportions of nurses working shorter shifts of less than 11 h also
resulted in significant decreases in patient dissatisfaction
(Stimpfel et al., 2012). In comparison, another study found
that patients rate the quality and quantity of nursing
service higher on 12 than 8 h shift wards (Ganong et al.,
1976). Contradictory results have also been found around
how well patients on 8 and 12 h shift wards feel they know
nursing staff, with one study concluding that more patients
on 12 h shift wards know their named nurse than on 8 h
wards (Gillespie and Curzio, 1996) and another concluding
the opposite (Bajnok, 1975). One study found that fewer
patients on 12 h shift wards felt their nurses were tired at
the end of their shift than patients on 8 h shift wards
(Bajnok, 1975) but another found some disquiet expressed
about the possible risk to which patients might be exposed
as a result of long working days (Todd et al., 1991).
623
The majority of studies have explored staff-reported
impacts of shift length on patient care or have compared
nursing records according to shift length and, again,
conflicting evidence has been highlighted. For example,
in numerous studies, nursing staff have reported that 12 h
shift working offers benefits for patients through improved
communication (Bajnok, 1975; Bloodworth et al., 2001;
Ganong et al., 1976), increased continuity of care (Bloodworth et al., 2001; Dwyer et al., 2007; Freer and MurphyBlack, 1995; Ganong et al., 1976; Heaslip, 1988; Lea and
Bloodworth, 2003; McColl, 1982; McGettrick and O’Neill,
2006; Wootten, 2000a; Yuh, 2003), better quality of
reporting (Freer and Murphy-Black, 1995), increased
chance to build a therapeutic relationship or rapport with
patients and their families (Ganong et al., 1976; Heaslip,
1988; Hodgson, 1995; Lea and Bloodworth, 2003; McColl,
1982; Richardson et al., 2007; Wootten, 2000a) and
extended opportunities to monitor patients and/or successfully plan and complete patient care (Bloodworth et al.,
2001; Dwyer et al., 2007; Heaslip, 1988; Lea and Bloodworth, 2003; McGettrick and O’Neill, 2006; Richardson
et al., 2007; Wootten, 2000a). Some believe that the
experience of care becomes less confusing for patients
during 12 h shifts as there are fewer individuals working
with patients within a 24-h period (McColl, 1982).
However, other studies have found no differences or
mixed views about the impact of shift length on
communication, completion of paperwork and continuity
of care (Gillespie and Curzio, 1996; Hodgson, 1995;
Richardson et al., 2003; Stinson and Hazlett, 1975). One
study found that nurses who worked for 13 h or more had
double the likelihood of reporting lost information during a
shift change (Stimpfel et al., 2013). In Bajnok’s (1975)
study, whilst 12 h nurses believed they kept more
complete nursing records and were more knowledgeable
about patient details, an audit of randomly selected
nursing records found that the type and number of
recordings on patient progress notes and the use of
individualised care plans were somewhat superior on the
8 h ward. Again, some of the studies reporting no adverse
impact of extended shifts on patient experience state that
12 h shift working was optional and/or was implemented
or supported by nursing staff (Bloodworth et al., 2001;
Dwyer et al., 2007; Freer and Murphy-Black, 1995;
Gillespie and Curzio, 1996; Heaslip, 1988; Hibberd,
1973; Lea and Bloodworth, 2003). Others argue that the
timing and sequencing of shifts may be more important
than the actual duration of the shift (McGettrick and
O’Neill, 2006).
3.1.3. Gaps in the research
More longitudinal research investigating the cumulative effects of 12 h shifts on the health and wellbeing of
nursing staff (Eaton and Gottselig, 1980) and on staff and
patient experience (Campolo et al., 1998; Dwyer et al.,
2007; Richardson et al., 2003) is required. Research with
larger sample sizes; more precise measurements of error;
and the inclusion of other variables, such as workload,
patient acuity and other individual differences of patients
and staff are also recommended (Campolo et al., 1998;
Dwyer et al., 2007; Niemeier and Healy, 1984; Richardson
624
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
et al., 2003; Rogers et al., 2004a; Stimpfel and Aiken, 2013).
More research is needed on the combinations of work
schedule characteristics which may have an adverse effect
on nurses’ health. For many nurses, adverse working
conditions (e.g. night working, frequent rotations, long
working hours, long working weeks, working overtime on
short notice or on scheduled days off) do not occur in
isolation and such combinations may make working
extended hours unhealthy or unsafe (Trinkoff et al.,
2006b; Trinkoff and Storr, 1998). An evaluation of the
effectiveness of napping during longer shifts on nurses’
health outcomes and sleep quality is also required (Scott
et al., 2014). Finally, more consideration needs to be given
as to how in-service educational opportunities can be
improved for staff working extended shifts (Freer and
Murphy-Black, 1995).
3.1.4. Overview of themes – literature reviews
Ten nursing review papers published between
1982 and 2013 were identified. The most recently
published review was conducted by the National Nursing
Research Unit in the UK (National Nursing Research Unit,
2013). Only one systematic review was identified and this
included 12 studies exploring evidence on the effect of
shift length on quality of patient care and healthcare staff
outcomes (Estabrooks et al., 2009). This systematic review
explored the impact of shift length in healthcare settings
and therefore was not specific to nursing, but nurses were
the main focus of most of the included papers, therefore
the review was included. One other literature review also
focused on extended shift working in healthcare and this
too was included because its main focus remained on
nursing (Keller, 2009). All other included reviews were
specific to nursing.
The review papers identified note that most of the
documentation around 12 h shift working is anecdotal or
based upon small trials in single settings and that there are
relatively few studies based on systematic, comprehensive
research designs. They highlight the methodological
weaknesses of studies in this field, the varied outcome
measures and the small sample sizes which prevent metaanalyses from being conducted and make it difficult to
generalise about the impact of 12 h shifts (Bernreuter and
Sullivan, 1995; Davis, 1982; Estabrooks et al., 2009;
Fountain et al., 1996). Further limitations with research
in this field include the lack of consideration of intervening
variables, such as marital status and age of staff, type of
nursing, size and type of hospital setting and the lack of
longitudinal research (Davis, 1982; Fountain et al., 1996;
Keller, 2009). There is also a problem comparing studies
conducted in different countries with very different
healthcare systems (Fountain et al., 1996).
An overview of all material reviewed within each theme
is presented below. For consistency, themes are presented
in the same order as the previous section. A summary of all
nursing literature reviews included in the scoping review
is provided in Table 5.
3.1.4.1. Staff risks (n = 7). The systematic review states that
there is little evidence of significant effects of shift length
on the psychosocial wellbeing or physical health of
healthcare providers, including the effect on drug and
alcohol consumption, stress or fatigue (Estabrooks et al.,
2009). Others also conclude that the health of nurses does
not appear to be adversely affected on a short term basis
(Davis, 1982) and that the impact of shift length on fatigue
is inconclusive (Bernreuter and Sullivan, 1995; Davis,
1982). In comparison, some reviews have concluded
that nurses working 12 h shifts are at risk of health
disorders, needlestick and musculoskeletal injuries,
accidents, drowsy driving, drug and alcohol consumption,
sleep deprivation and/or fatigue (Fountain et al., 1996;
Geiger-Brown and Trinkoff, 2010; Keller, 2009). The most
recently published review states that there is currently
insufficient evidence to determine that 12 h shifts in
nursing are safe and concludes that occupational hazards
to nurses increase considerably when they work beyond
12 h or do not have sufficient rest days (National Nursing
Research Unit, 2013). It also acknowledges that the
evidence on extended shift patterns is particularly difficult
to distinguish from the evidence on working long hours
overall and that the risks and benefits of working long
shifts can vary depending upon the individual characteristics of the nurse (National Nursing Research Unit, 2013).
3.1.4.2. Staff experience (n = 4). It is acknowledged that the
advantages most frequently cited for 12 h shifts involve
benefits to staff, including increased time off (Fountain
et al., 1996). A number of reviews conclude that evidence
on the impact of shift length on job satisfaction is
inconclusive (Davis, 1982; Estabrooks et al., 2009;
Bernreuter and Sullivan, 1995).
3.1.4.3. Patient risks (n = 5). The systematic review identified 6 articles investigating the relationship between shift
length and quality of patient care. It concluded that results
were equivocal with respect to patient safety and length of
shift: only one study offered support for 12 over 8 h shifts,
with the remaining studies either finding no significant
association between shift length and quality of care or
favouring the 8 h shift (Estabrooks et al., 2009). Other
reviews have concluded that the quality of care provided
on 12 h shifts does not appear to be adversely affected
(Davis, 1982), though some state that quality of care may
be affected (Bernreuter and Sullivan, 1995) or that nurses
working 12 h shifts are at risk of making more errors in care
(Geiger-Brown and Trinkoff, 2010). The most recently
published review concludes that patient safety risks
increase considerably when nurses work beyond 12 h or
do not have sufficient rest days (National Nursing Research
Unit, 2013).
3.1.4.4. Impact on work (n = 6). Only one review mentions
the impact of 12 h shifts on education and professional
development and concludes that nursing student education may be negatively affected by 12 h shifts (Bernreuter
and Sullivan, 1995). Others focus on the cost implications
of 12 h shifts and conclude that there is no conclusive
evidence of its impact on staffing, recruitment and
retention, sickness rates, relief staff hours or cost
differences (Davis, 1982; Bernreuter and Sullivan, 1995;
Fountain et al., 1996; Kilpatrick and Lavoie-Tremblay,
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
625
Table 5
Included nursing reviews.
Author and date
Review study
sample
Methodology
Theme(s)
National Nursing
Research Unit
(2013)
Nursing
Policy Plus focusing on what is known about the impact of shift length on
patient safety, employee health and quality of care.
Staff risks
Patient risks
Impact on work
Patient experience
Geiger-Brown and
Trinkoff (2010)
Nursing
Overview of literature on 12 h nursing shifts.
Staff risks
Patient risks
Estabrooks et al.
(2009)
Healthcare
providers,
predominantly
nurses
Healthcare
providers,
predominantly
nurses
Systematic review of evidence on the effect of shift length (8 versus 12 h) on
quality of patient care and healthcare provider outcomes.
Staff risks
Staff experience
Patient risks
Literature review on the effects of extended shifts (i.e. anything over 8 h) in
healthcare.
Staff risks
Impact on work
Keller (2009)
Kilpatrick and
Lavoie-Tremblay
(2006)
Nursing
Overview of literature on shift working in healthcare, profiling the intensive
care unit.
Wootten (2000b)
Nursing
Overview of literature on 12 h nursing shifts.
Impact on work
Crofts (1997)
Nursing
Review of literature on night working, 8 versus 12 h shifts, flexible/selfrostering and annualised hours in nursing.
Patient experience
Fountain et al.
(1996)
Nursing
Review of research on 12 h shifts in nursing carried out in the UK since 1980.
Staff risks
Staff experience
Impact on work
Bernreuter and
Sullivan (1995)
Nursing
Review and critique of studies related to shift length variations in nursing from
1970 to 1993.
Staff risks
Staff experience
Patient risks
Impact on work
Patient experience
Davis (1982)
Nursing
Overview of literature on 12 h nursing shifts.
Staff risks
Staff experience
Patient risks
Impact on work
Patient experience
2006; Wootten, 2000b). The most recently published
review states that whilst 12 h shift systems are often
perceived to be less expensive to run, little research has
been undertaken to assess the costs of different shift
lengths (National Nursing Research Unit, 2013).
3.1.4.5. Patient experience (n = 4). It is acknowledged that
there are few studies exploring the impact of extended
shift working on patients, as most focus on the impact to
individual nurses and their managers (National Nursing
Research Unit, 2013; Crofts, 1997). Two reviews conclude
that no evidence of significant differences in patient
satisfaction between those patients with 8 h shift nurses
and 12 h shift nurses has been found (Bernreuter and
Sullivan, 1995; Davis, 1982).
3.2. Non-nursing literature
The following section presents the findings from the
scoping review of evidence of the impact of 12 h shifts in
occupations outside of nursing, such as in processing
plants, the police force, transportation and administration.
In total 23 research papers published between 1979 and
2012 were included. This was a similar time frame as
identified in the nursing literature. For consistency, themes
are presented in the same order as previous sections.
Summaries of all primary research studies and literature
reviews included in the non-nursing review, including
details of the countries and industries within which the
studies were conducted, are provided in Tables 6 and 7.
3.2.1. Overview of themes – primary research studies
3.2.1.1. Staff risks (n = 21). The findings of the 21 studies
that addressed staff safety and wellbeing demonstrate a
mixed pattern of positive, negative and neutral effects of
staff risks of working 12 h shifts. Some studies reported
that staff working 12 h shifts found it easier to sleep and
less tiring than traditional shifts (Breaugh, 1983), had less
circadian malaise i.e. disturbed appetite and sleep,
indigestion, constipation, flatulence, irritability, moodiness, depression, tiredness and fatigue (Smith et al.,
1998a), less physical tension (Kallus et al., 2009) and
were less likely to need stimulant drugs (Breaugh, 1983).
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
626
Table 6
Included non-nursing primary research papers.
Author and date
Country
Study sample
Methodology
Theme(s)
Korunka et al.
(2012)
Austria
64 railway controllers
Completion of diaries over
10 consecutive days.
Staff risks
Amendola et al.
(2011)
USA
275 officers in two large police
departments
Randomised block experimental design
with 3 groups (working either 8, 10 or
12 h shifts) using laboratory-based
simulations collected at the end of
shifts and questionnaires.
Staff risks
Staff experience
Productivity/quality
of work
Impact on work
Peetz and
Murray (2011)
Australia
135 miners and spouses in coalmining communities
Qualitative interviews with miners and
spouses plus secondary data analysis
from large, Australian work and life
survey.
Staff risks
Staff experience
Handy (2010)
New Zealand
27 male shift workers in a
petrochemical company and
17 female partners
Qualitative interviews supplemented
with data from informal discussions
with management and shift workers
and observations of both the work
environment and workers’ home lives.
Staff risks
Staff experience
Gerber et al. (2010)
Switzerland
460 police officers, of which
251 were shift workers
Questionnaires.
Staff risks
Staff experience
Baulk et al. (2009)
Australia
20 male employees at an Australian
lead smelting plant
Activity monitors, sleep diaries,
questionnaires and psychomotor
vigilance tasks.
Staff risks
Productivity/quality
of work
Kallus et al. (2009)
Austria
18 male rail traffic controllers
(9 working 8 h shifts, 9 working 12 h
shifts)
Comparative design using
questionnaires and diaries. Heart rate
during shift also monitored.
Staff risks
Staff experience
Son et al. (2008)
South Korea
288 randomly selected men from
two automobile factories
Completion of sleep diaries and
questionnaires.
Staff risks
Loudoun (2008)
Australia
137 machine operators in two
processing plants.
Longitudinal design with questionnaire
data collected from three groups of
workers over three time periods.
Staff risks
Staff experience
Shen and Dicker
(2008)
Australia
10 managers and 14 shift workers at
a food processing company
Structured interviews.
Staff risks
Staff experience
Impact on work
Ritson and
Charlton (2006)
UK
18 mangers and 37 staff working in
6 call centres
Case study design with semi-structured
interviews.
Staff risks
Staff experience
Bacon et al. (2005)
UK
2802 (time 1) and 2060 (time 2)
male workers at 2 major steelworks
participated in questionnaires plus
47 mangers and union
representatives participated in
interviews
Questionnaires completed pre-and
post- implementation of shift change
plus interviews with managers and
union representatives and
documentary analysis of departmental
agreements.
Staff risks
Staff experience
Sallinen et al. (2004)
Finland
12 male process operators in an oil
refinery
Cognitive performance tests,
continuous EEG and EEO readings and
questionnaires.
Staff risks
Productivity/quality
of work
Baker et al. (2003)
Australia
128 shift workers on 8-hour shifts
and 128 workers on 12 h shifts
working in mining and transport
matched on age, gender, parenting
and marital status
Questionnaire.
Staff experience
Heiler and
Pickersgill (2001)
Australia
National survey of the Australian
mining industry
National survey into shift work and
rostering arrangements in the
Australian mining industry.
Staff risks
Staff experience
Impact on work
Tucker et al. (1999)
UK
602 shift workers in manufacturing
and engineering industries
Questionnaire.
Staff risks
Lowden et al. (1998)
Sweden
32 shift workers working as control
room operators at a chemical plant
who changed from an 8 h to 12 h
shift schedule.
Questionnaires completed pre- and
post-implementation of 12 h shifts,
plus a subsample of 14 staff completed
sleep diaries, carried activity loggers
and carried out reaction-time tests at
the beginning and end of shifts.
Staff risks
Staff experience
Productivity/quality
of work
Impact on work
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
627
Table 6 (Continued )
Author and date
Country
Study sample
Methodology
Theme(s)
Smith et al. (1998a)
Australia
72 shift workers at 3 sewage
treatment plants
Questionnaire administered pre-and
post- implementation of change from
8 to 12 h shifts, plus sleep diaries
completed and personnel data
collected.
Staff risks
Staff experience
Impact on work
Pierce and
Dunham (1992)
USA
74 police officers
Questionnaire administered 2 weeks
pre- and 1 year post-implementation of
a 12 h shift roster.
Staff experience
Northrup (1991)
USA and
Canada
25 operating and human resource
managers in the mini-steel industry
Questionnaires and interviews.
Staff risks
Staff experience
Productivity/quality
of work
Impact on work
Northrup (1989)
USA
Human resource management
executives at 15 chemical and
petroleum companies using 12 h
shifts
Follow-up study of Northrup et al.
(1979) using questionnaires.
Staff risks
Staff experience
Impact on work
Breaugh (1983)
USA
671 employees at a continuous
process plant of a large
multinational organisation. Some
employees worked 8 h fixed or
rotating schedules and some
worked a 12 h rotating schedule
Questionnaire.
Staff risks
Staff experience
Northrup et al.
(1979)
USA and
Canada
Managers of 50 plants that had
recently implemented 12 h shifts in
petroleum and chemical industries
Interviews.
Staff risks
Staff experience
Productivity/quality
of work
Table 7
Included non-nursing reviews.
Author and date
Review study sample
Methodology
Theme(s)
Ferguson and
Dawson (2012)
Various industries including police, customs,
nursing and electronics
Overview of literature on 12 and 8 h shifts.
Staff risks
Staff experience
Productivity/quality
of work
Wagstaff and
Sigstad Lie (2011)
Various industries, including food processing,
healthcare and manufacturing
Systematic review of research regarding
accidents in relation to long work hours and
shift work, primarily based on
epidemiological studies.
Productivity/quality
of work
Sallinen and
Kecklund (2010)
Various industries, including healthcare,
firefighting, electrical power stations and
mining.
Narrative review examining the relationship
between different schedules of shift work and
sleep-wake patterns of workers.
Staff risks
Bambra et al. (2008)
Various industries including healthcare,
police, manufacturing and energy industries
Systematic review of studies on the effect of
compressed working weeks on the health and
worklife balance of shift workers.
Staff risks
Staff experience
Impact on work
Driscoll et al. (2007)
Various industries, including car
manufacturing, mining, police and air traffic
control
Systematic review of evidence on the effect of
various shift systems on neurobehavioural
and physiological functioning.
Staff risks
Productivity/quality
of work
Caruso et al. (2004)
Various industries, including manufacturing,
mining, transportation, construction and
healthcare
Review of research examining associations
between long working hours and illness,
injury, health behaviours and performance.
Staff risks
Bendak (2003)
Various industries, including power plants,
chemical production, nursing, police and
transportation
Literature review on 12 h shifts.
Staff experience
Smith et al. (1998b)
Various industries, including healthcare,
chemical and petroleum industries.
Review of literature examining the effects of
8 and 12 h shifts on fatigue, job performance,
safety, sleep and physical and psychological
health.
Staff risks
Staff experience
Productivity/quality
of work
Impact on work
628
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
Others reported increased health problems, fatigue, sleep
deprivation, weight gain and gastrointestinal problems
(Gerber et al., 2010; Shen and Dicker, 2008), increased
fatigue after a 12 h night shift (Baulk et al., 2009) and
increased sleepiness and reduced alertness than on 8 h
shifts (Amendola et al., 2011). Managing tiredness and
ensuring that they were physically fit for work were the
main concerns of staff working 12 h shifts in one study
(Handy, 2010). Twelve hour shifts were associated with
significantly higher work pressures and physical tension
(Bacon et al., 2005) to the extent that they were thought to
‘‘make you very old, very quick’’ (Peetz and Murray, 2011).
Sleepiness at work was found to be increased by existing
sleep debt and monotonous work and peaked at 6–8 h
(Sallinen et al., 2004). Recovery time between shifts was
found to predict levels of fatigue during day and night 12 h
shifts (Korunka et al., 2012) and although in Tucker et al’s
(1999) study the distribution of rest days had limited
impact on sleep, fatigue, physical and psychological
wellbeing, there were modest benefits where staff had
rest days between night and day shifts. One study
conducted in South Korea found severe sleepiness among
workers doing 12 h shifts, however these workers were
working up to 7 consecutive 12 h shifts plus additional
overtime, which would not be allowed in many countries
(Son et al., 2008). A national survey in the Australian
mining industry reported that a majority of workers
undertook significant overtime despite concerns about
increased risks, thus 12 h shifts were, in reality, extending
the working week rather than compressing it (Heiler and
Pickersgill, 2001).
However, some studies reported no identified difference in health outcome, quality of sleep and physiological
fatigue for staff working 12 h shifts (Amendola et al., 2011;
Lowden et al., 1998) and no increase in mental or
psychological strain (Loudoun, 2008; Lowden et al.,
1998). No health and safety concerns were identified in
studies conducted in the petroleum, chemical and steel
industry after the introduction of 12 h shifts (Northrup,
1991, 1989; Northrup et al., 1979), however extensive
measures to mitigate the impact and reduce the risks
associated with longer working hours were introduced by
managers (e.g. extra rest breaks, air-conditioned cooling
rooms, provision of cold refreshments, changing shift
times to divide up the hottest times of the day and sound
management including mandatory ear muffs, ear plugs
and annual audiograms). Similarly, a study in an administration setting found no health concerns of working 12 h
shifts, however, it was suggested that this was due to the
more sedentary nature of the work and that the risks
resulting from tiredness were likely to be correctable input
errors (Ritson and Charlton, 2006). Furthermore, staff
received health and safety training about posture and
computer ergonomics and took frequent, regular breaks
including naps on night shifts (Ritson and Charlton, 2006).
3.2.1.2. Staff experience (n = 18). The findings of the 18 included studies demonstrate mixed evidence of positive,
negative and neutral effects on staff experience of working
12 h shifts. However, on balance they appeared to prefer
working 12 h shifts primarily because of the reduced impact
of shift work on family and social life due to the reduced
number of days at work (Breaugh, 1983; Northrup, 1991;
Pierce and Dunham, 1992; Shen and Dicker, 2008; Smith
et al., 1998a; Ritson and Charlton, 2006), although there was
evidence that office hours (Monday to Friday 9 a.m. to
5 p.m.) were preferred (Gerber et al., 2010). Twelve hour
shifts also contributed to reduced commuting time and
costs (Breaugh, 1983). There was evidence of increased
satisfaction with working hours with 12 h shifts (Bacon
et al., 2005; Lowden et al., 1998; Pierce and Dunham, 1992)
and a preference for working daylight hours rather than at
night or early morning (Baker et al., 2003). One study found
that staff working 12 h shifts experienced less subjective
monotony at work than those on 8 h shifts (Kallus et al.,
2009). Loudoun (2008) found shift length (i.e. 8 or 12 h)
had no significant impact on work/non-work conflict or
balance. A study of police officers found quality of work life
was highest among those working 10 h shifts rather
than 8 or 12 h shifts although lowest for officers working
8 h shifts (Amendola et al., 2011). However, there was some
evidence of the considerable impact of rigid 12 h shift
patterns on female partners of workers, including career
loss, social isolation and shift worker mood swings. Family
life was also felt to be dominated by the shiftwork cycle and
required extra effort to manage (Handy, 2010; Peetz and
Murray, 2011). This was tolerated because of high salaries
for working long, anti-social hours (Handy, 2010; Heiler and
Pickersgill, 2001; Peetz and Murray, 2011; Shen and Dicker,
2008), but did cause relationship strain and in some cases
breakup (Shen and Dicker, 2008). Older workers were
found to have difficulty in adjusting to 12 h shifts in the
petroleum and chemical industries (Northrup et al., 1979)
although this was not identified in a follow up study
(Northrup, 1989). Similarly intensive 12 h shift schedules
were considered to lead to high turnover of staff with a loss
of older, more experienced and stable staff (Heiler and
Pickersgill, 2001) and one study found women with home
and childcare responsibility also had difficulty with 12 h
shifts (Northrup, 1989).
3.2.1.3. Productivity/quality of work (n = 6). The fewest
number of studies addressed the productivity of staff
working 12 h shifts and those that did demonstrated mixed
evidence of both neutral and negative effects. One study in
an Australian smelter found a marked decline in performance as measured by a psychomotor vigilance task at the
end of a 12 h shift, particularly after a night shift (Baulk
et al., 2009). However, other studies found no significant
difference in performance, efficiency or reaction time
(Lowden et al., 1998; Northrup, 1991; Northrup et al.,
1979) due to shift length. Sallinen et al. (2004) found that
errors in simulated cognitive performance tests did not
peak at 12 h irrespective of prior sleep or work pace and
Amendola et al’s (2011) study of 8, 10 and 12 h shifts in two
large police departments in the USA found no difference in
a range of productivity outcomes, including number of
arrests, report completion and simulator tests for driving
and shooting.
3.2.1.4. Impact on work (n = 7). Fewer studies were identified that addressed the impact of 12 h shifts on the
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
workplace and organisation of work. Consistent with other
themes there was a mixed picture of positive and negative
impacts of 12 h shifts on organisational issues. Employee
absenteeism was high in one study, particularly among
younger workers, with a need to employ casual staff to cover
(Shen and Dicker, 2008) yet lower in another (Northrup,
1989), with associated reduced turnover of staff. However,
managers did report reduced availability of staff to
undertake overtime with 10 and 12 h shift systems, which
reduced flexibility in meeting operational demands and
which required greater discipline over the use of overtime
(Amendola et al., 2011; Smith et al., 1998a). Conversely, in
another study, staff working 12 h shifts had so much
concentrated time off that they offered to sell back their
annual leave, which reduced the need for managers to hire
less experienced temporary staff (Northrup, 1991). One
study found that communication between shift workers
improved with 12 h shifts as there were only two shifts
rather than three in 24 h (Northrup, 1989) although another
found that there was less interaction between shift teams
(Lowden et al., 1998). However, communication between
staff and managers was identified as a challenge of 12 h shift
systems in several studies (Northrup, 1991; Shen and
Dicker, 2008; Smith et al., 1998a). This was because of
worker absence for longer periods and reduced contact
between managers and shift workers, which exacerbated
communication difficulties and required creative solutions
to support the integration of staff working shifts and those
working during office hours and to enable managers to
disseminate management strategies. Increasing the visibility of managers and personnel staff at times when staff were
working (e.g. at shift handovers and at night) was thought to
be important for successful 12 h shift working (Northrup,
1991). Other strategies included arranging special meetings
at shift handovers, increasing written communication sent
to shift workers’ homes and regular newsletters.
Two studies addressed the issue of costs (Northrup,
1991, 1989). One study (Northrup, 1989) found that, in
most cases, changes to 12 h shifts were instigated by
employees and managers were generally in agreement on
condition that costs were not increased. In some plants,
costs reduced due to less overtime required for staff
absence, but costs also increased in others. In another
study, 12 h shifts were abandoned after a trial period by
some steel companies because managers were concerned
about increased costs due to union negotiated pay rates for
increased daily working hours (Northrup, 1991). Another
study raised the growing recognition of the need for
employers to minimise the risks of 12 h shifts and to
understand the liability of not doing so (Heiler and
Pickersgill, 2001).
3.2.2. Overview of themes – literature reviews
Eight review papers published between 1998 and
2012 were included in the non-nursing review. Most
reviews did include some studies from nursing or
healthcare settings in addition to a wide range of industries
and occupations such as policing, transportation,
manufacturing, mining and air traffic control. As in the
nursing literature, most of the review papers highlight the
methodological weaknesses, varied outcome measures,
629
small sample sizes and lack of longitudinal research into
12 h shifts (Bambra et al., 2008; Bendak, 2003; Driscoll
et al., 2007; Sallinen and Kecklund, 2010; Smith et al.,
1998b; Wagstaff and Sigstad Lie, 2011). Others also
conclude that evaluating shift length alone is insufficient,
as numerous factors associated with working practice
influence the outcome of a shift pattern. For example, the
effects of extended shifts may be exacerbated by scheduling factors, such as start/finish times, fixed versus rotating
schedules, speed of rotation, the amount of consecutive
days and total hours worked, number of rest days and
number of weekends off (Bendak, 2003; Caruso et al., 2004;
Ferguson and Dawson, 2012; Sallinen and Kecklund, 2010;
Wagstaff and Sigstad Lie, 2011). The context in which the
12 h shift is placed is also identified as an important factor
in determining its success or failure (Bendak, 2003; Smith
et al., 1998b). Twelve hour shifts may carry greater risks in
roles that involve night working, high mental or physical
loads, extended commuting time or inadequate staff
resources but may be more appropriate in roles with
low work demands or long rest breaks (Bendak, 2003;
Wagstaff and Sigstad Lie, 2011; Ferguson and Dawson,
2012; Sallinen and Kecklund, 2010). The demographics
of the workforce, including gender, age and domestic
circumstances are additional mediating factors (Ferguson
and Dawson, 2012).
For consistency, themes are presented in the same
order as previous sections.
3.2.2.1. Staff risks (n = 6). Evidence of the impact of 12 h
shifts on sleep and staff fatigue is equivocal, with various
studies finding either improvements, negative effects or no
change (Driscoll et al., 2007; Ferguson and Dawson, 2012;
Smith et al., 1998b; Bambra et al., 2008; Sallinen and
Kecklund, 2010). Evidence of the impact on physical and
psychological health is equally unclear (Bambra et al.,
2008; Ferguson and Dawson, 2012; Caruso et al., 2004;
Smith et al., 1998b).
3.2.2.2. Staff experience (n = 4). Evidence of the impact of
12 h shifts on staff morale and job satisfaction is equivocal
(Ferguson and Dawson, 2012), though one review concludes that work-life balance is generally improved
(Bambra et al., 2008). A trend has also been noted whereby
studies using employee satisfaction measures favour 12 h
shifts, whilst studies using objective measures of performance favour 8 h shifts (Bendak, 2003). One review states
that the popularity of extended shifts may increase
motivation and stimulate greater effort to reduce any
possible detrimental effects (Smith et al., 1998b). It also
notes that staff involvement and support in changing to
12 h shift systems is therefore crucial to its success (Smith
et al., 1998b).
3.2.2.3. Productivity/quality of work (n = 4). Contradictory
evidence is provided on the impact of 12 h shifts on safety
aspects such as accidents and error. One review states that
long hours present a substantial risk to safety, with risk of
accidents on 12 h shifts being twice that on 8 h shifts
(Wagstaff and Sigstad Lie, 2011). However, another review
states there is no conclusive evidence that 12 h shifts
630
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
compromise safety in terms of increased accident rates,
reduced performance or increased errors (Smith et al.,
1998b), though it notes that this may be due to increased
emphasis on preventative safety measures, limited commute time, sufficient breaks between shifts and reorientation after breaks of more than 4 days. Other reviews
conclude that evidence around the impact of 12 h shifts on
staff alertness (often used as a predictor for safety and
performance measures) is inconsistent (Driscoll et al.,
2007; Ferguson and Dawson, 2012). One review states
there is some evidence that staff working 12 h shifts are
less productive (Ferguson and Dawson, 2012).
3.2.2.4. Impact on work (n = 2). One review concludes that
most studies demonstrate no evidence of benefit or
detriment of 12 h shifts in terms of organisational
outcomes (Bambra et al., 2008). Another states there is
little difference in absenteeism according to shift length
but notes that older workers may find 12 h shifts more
difficult (Smith et al., 1998b).
4. Discussion
This scoping review has provided the most comprehensive, rigorous overview of the key concepts and
evidence of the impact and effectiveness of 12 h shifts in
the international nursing literature to date. Furthermore,
this new understanding is supplemented by a review of
evidence of 12 h shifts in other non-nursing related
industries. The main findings of the review demonstrate
that, despite a reasonable number of included studies,
there is inconclusive evidence of the effects of 12 h shift
patterns in nursing, with some studies demonstrating
positive impacts and others negative impacts. This also
mirrors the evidence in other industries. The majority of
the available evidence focuses on the risks, experience or
work/life balance for staff and far fewer have addressed the
impact on patient outcome and experience of care and
work productivity. Most studies are conducted in acute
hospitals and few in community health or social care
settings where 12 h shift working may be prevalent and
this is a concerning gap in the evidence. Furthermore, few
studies in nursing have included an analysis of costs, which
is surprising since cost saving is considered an important
driver for the implementation of 12 h shifts.
Systematic appraisal of the quality of studies is not
undertaken as part of a scoping review (Arksey and
O’Malley, 2005) and this can limit the conclusions about
the strength of evidence of the intervention under review.
However, it provides a useful overview of the whole field
including the gaps in the literature and as such provides a
valuable perspective. The quality of the research reviewed
here is generally weak although it is a developing field. Few
of the papers reviewed took into account or reported in
sufficient detail the context in which the studies were
conducted. These contextual factors are likely to be
important determinants of the impact of different shift
patterns e.g. the nature of work, features of shift pattern
undertaken (start time, number of sequential work days,
number of days off, rotation onto night duty, rest break
length and frequency, etc.), staff skill mix and patient-to-
nurse ratio, which further weakens our understanding of the
studies’ findings. Furthermore, it is likely that differences in
workplace context and organisation explain, in part, the
variation in findings and different conclusions between the
included studies. It is also important to acknowledge that
the healthcare context has changed considerably since the
early studies in 1970s and 1980s with increased technology,
increased patient acuity and decreased length of hospital
stay and therefore the findings of these studies may have
reduced relevance to the care delivery context today. Most
studies did not use existing validated tools as part of their
research designs and therefore the usefulness of a systematic review is likely to be limited. Only one study addressed
the impact of 12 h shifts beyond one year, although the
follow-up duration was unspecified (Niemeier and Healy,
1984) and therefore the long term consequences on patient
care and the nursing workforce and sustainability of 12 h
shifts is unknown.
Therefore, there is insufficient evidence on which to
support the widespread implementation of 12 h shifts or to
return to 8 h shifts. It is not clearly understood where there
are real benefits of 12 h shifts and where there are real and
unacceptable risks to patients and staff. There are also a
number of potential impacts of 12 h shifts that have not
been considered, for example, patients’ psychological
safety in terms of maintaining their dignity and meeting
needs for compassion. The health risks and risk of burnout
of any form of shiftwork for staff are well known
(Matheson et al., 2014) and it is important to understand
whether working 12 h shifts exacerbates or ameliorates
these risks, especially as recent research has demonstrated
that staff morale has an impact on patient experience
(Maben et al., 2012). Furthermore, the nursing workforce is
increasingly growing older; in the US the median age of
nurses is 46 and more than 50% of the nursing workforce is
close to retirement (American Nurses Association, 2014)
and in Europe the average age in many countries such as
Denmark, France, Iceland, Norway and Sweden is 41–45
years (World Health Organisation Regional Office for
Europe, 2014). There is little evidence available about
whether older nurses have more difficulty working 12 h
shifts, although there is some evidence in other industries
that this may be the case. This raises questions about the
long term sustainability of 12 h shifts should these
demographic trends continue, particularly as stress and
heavy physical workloads have been identified as factors
that influence older workers’ continued participation in
the workforce (Andrews et al., 2005; Harris et al., 2010).
Furthermore, the studies did demonstrate that nurses
working 12 h shifts tended to receive less in-service
education and continuing professional development than
those working an 8 h shift pattern, where there was an
overlap between morning and evening shifts which
facilitated release of staff for educational activities and
team meetings. The non-nursing literature highlighted the
importance of managers being more creative in scheduling
meetings and staff training for times when shift workers
were available, although this was not addressed in the
nursing studies.
Although the evidence for the impact of 12 h shifts is
inconclusive, there is stronger evidence for a detrimental
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
impact of shifts lasting more than 12 h on the quality and
safety of patient care and this does give cause for concern.
In the UK, where a large proportion of nurses and midwives
work 12 h shifts, the recent annual NHS staff survey (NHS,
2013) found that 33% of registered nurses and midwives
worked paid overtime in an average week (up to 5 h – 16%,
6–10 h – 10%, 11 or more hours – 7%) and 72% worked
unpaid overtime (up to 5 h – 52%, 6–10 h – 14%, 11 or more
hours – 6%). With this level of regular overtime it is likely
that a large number of nurses are working longer than 12 h
in a day at increased risk to patients and themselves.
Furthermore, there are anecdotal accounts of nurses being
unable to take breaks due to high workload (Calkin, 2012),
which, if widespread, would increase the risks associated
with long working hours.
Nursing forms a significant part of the hospital
workforce as a whole and the impact of 12 h shifts in
nursing on nursing teams and interprofessional teams and
how they work together was very rarely addressed in the
papers reviewed. Although 12 h shifts were thought to
increase continuity within a 24 h period, there was
evidence in the non-nursing literature that continuity of
staff throughout the week/month was reduced, as a large
proportion of the workforce did not meet regularly due to
longer periods away from work. There have also been
concurrent changes in working arrangements for other
health disciplines, especially medicine, in response to the
European Working Time Directive (European Parliament
and Council, 2000) which has mandated significant
reductions in the working hours of junior doctors. It is
likely that reduced contact between team members will
influence the quality of interprofessional team working
(Harris et al., 2013) and may reduce opportunities for peer
support, practice development and innovation, and reduce
opportunities for the team to review how they work
together. This has been referred to as ‘reflexivity’ and has
been found to be an important predictor of team outcomes,
especially innovation, and is believed to be particularly
helpful for teams with high workload and demands
(Schippers et al., 2012).
Following the Francis Inquiry in England, increasing
attention has been given to the quality of care on wards
with directors of nursing (executive chief nurses) expected
to provide assurance to their executive boards that there is
safe staffing in place (National Quality Board, 2013;
Department of Health, 2013). Assurance needs to be given
that not only are there sufficient numbers of nurses but
that the shift patterns deployed afford safe care. This
scoping review highlights that there is inconclusive or
insufficient evidence for directors of nursing to either
endorse or refute the effectiveness of 12 h shift systems.
However, the review does suggest that where 12 h shifts
are in place, risk reduction strategies, as endorsed by
recent RCN guidance (Royal College of Nursing, 2012), are
needed. It is perhaps to these areas that directors of
nursing/chief nurses should currently give their attention,
for example, ensuring safe systems are in place for
medication rounds, and that such safety critical activities
are not scheduled to take place near the end of shifts;
ensuring nurses take the rest breaks they need; and
eliminating or significantly reducing overtime at the end of
631
12 h shifts. In addition to reducing the risk of harm when
the shifts are in place, directors of nursing also need to be
mindful and point others towards evidence that does exist
from other disciplines and good practice in other professions. For example, learning from sectors such as the police
force, where shift patterns seek to minimise the disturbance to normal circadian rhythms, or being open to the
suggestion for ‘‘power naps’’ on night duty, as endorsed by
the Royal College of Physicians (2006).
Another important finding in this review has been the
positive impact of staff collaboration. The studies where
the implementation of 12 h shifts have been successful
point to local engagement with regular review and
evaluation. It is therefore questionable whether whole
hospital changes to 12 h shift working can be implemented
successfully. As discussed previously, very few studies
have assessed the financial costs or benefits of 12 h shifts
adequately and national Quality, Innovation, Productivity
and Prevention (QIPP) case study guidance (NHS Evidence,
2010) endorsing a move to 12 h shifts extrapolates large
savings based on ‘old’ shift systems which most hospitals
eliminated in the early 1990s as part of initiatives to reduce
handover times. Directors of nursing need to be mindful of
the full costs of maintaining or moving to 12 h shift
systems, taking into account nursing personnel factors
(such as sickness, absence, turnover/retention, temporary
staffing costs) alongside direct and indirect patient costs
associated with either minimising error or treating the
consequences of harm.
A particularly important finding of this scoping review
is the urgent need for more research that focuses on
patient safety and experience of care. Research is also
needed to address the longer-term impact on staff and
work organisation. The nursing and non-nursing studies
reviewed tended to focus on one aspect of the work pattern
(i.e. shift length) without addressing the complexity of
other factors that would influence the outcomes measured.
It has been suggested that shift systems are better
understood as a ‘complex ecology of interdependent
factors’ where a range of mediating factors influence the
experience of working 12 h shifts and the outcomes
(Ferguson and Dawson, 2012). These mediating factors
include type of work, age and gender of the worker,
domestic circumstances and responsibilities and commuting arrangements. It is argued that ‘system risk’ should be
assessed with the understanding that some workers will be
at greater risk of adverse outcomes than others. Managing
this risk may involve identifying a system, which presents
the fewest risks to the workforce or implementing
protective strategies for staff at risk (Ferguson and
Dawson, 2012). The non-nursing studies reviewed demonstrated additional strategies implemented to reduce
risks from longer shifts (e.g. extra breaks, cooling rooms,
etc.). Therefore, it is recommended that future research
about 12 h shifts in nursing should take a ‘complex system’
approach to fully understand the risks of 12 h shifts and the
intended and unintended consequences of working in this
way.
In conclusion, there has been a widespread change to
12 h shift patterns in many countries driven in the main by
the need to make savings to healthcare budgets. Many
632
R. Harris et al. / International Journal of Nursing Studies 52 (2015) 605–634
nurses like working 12 h shifts although there is inconclusive evidence of the benefits and risks to staff overall and
considerably less but still inconclusive evidence of the
impact on patients. This uncertainty is uncomfortable and
although there is much that can be done to reduce the
potential risks, there is an urgent need for more research
that focuses on patient safety and experience of care.
Research is also needed to address the longer term impact
on staff and work organisation and the complex factors
that influence the impact of 12 h shifts and compressed
working week schedules.
Acknowledgement
We thank David Foster for his very helpful comments
on an earlier draft of this paper.
Conflicts of interest: None declared.
Funding: None.
Ethical approval: Not applicable.
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