Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review

Balancing act: exploring work-life balance among nursing home staff working long shifts

BACKGROUND

Nursing home staff often face challenges in achieving a satisfactory work-life balance, particularly because of the nature of shift work. While long shifts offer extended periods off work, their impact on the delicate balance between work and leisure remains understudied in the context of nursing homes. This study investigated the experiences of nursing home staff in Norway working long shifts lasting 12-14 h and their perceptions of the balance between family life and work.

METHODS

Eighteen nursing home staff members were interviewed following a semi-structured qualitative approach. The participants worked in three types of long shifts and provided insights into their experiences, addressing issues such as work hours, shift patterns, and work-family balance.

RESULTS

The study revealed four main categories: (1) impact of long shifts on family life-the highs and lows; (2) maximizing time off with long shifts; (3) reducing job stress with long shifts; and (4) full-time work leads to predictable hours and stable income. The participants emphasised the distinct separation between work and leisure during long shifts, acknowledging limited social life during working periods but appreciating extended periods off. Family life posed challenges, especially with young children, but the participants found benefits in the longer periods of family time during days off. Longer rest periods and reduced commuting time were perceived as advantages of long shifts, contributing to better sleep, reduced stress and overall well-being. Long shifts also allowed for more predictable working hours and income, supporting a stable work-life balance.

CONCLUSION

Balancing work and family life involves more than just the number of hours spent at work; it also encompasses the quality of those hours both at work and at home. Our findings underscore the complex interplay between work and family life for nursing home staff working long shifts. While challenges exist, benefits such as extended time off, improved sleep, reduced stress, and predictable working hours contribute positively to their work-life balance. Long shifts in nursing homes offer a unique perspective on achieving work-life balance, revealing both the challenges and advantages inherent in such schedules. Understanding the experiences of nursing home staff in this context can inform future innovations in shift scheduling, promoting a more balanced and sustainable work environment for healthcare professionals. For some healthcare staff, extended shifts can lead to a better work-life balance.

Sleep quality among emergency nurses and its influencing factors during COVID-19 pandemic: a cross-sectional study

Background

COVID-19 has probably contributed to sleep disturbance among nurses, especially those working at emergency departments (EDs). Sleep disorders in nurse managers can negatively impact their health and impair work performance and decision-making. This study aimed to explore the quality of sleep among nurses working in EDs and its influencing factors during the COVID-19 pandemic.

Method

In this study, a cross-sectional design was employed to assess the sleep quality of nurses working in EDs during the COVID-19 pandemic. The research recruited a convenience sample of emergency nurses, who were selectively sourced from four hospitals in Hail City. This recruitment occurred over the period from April to July 2022. Descriptive data analysis was conducted using SPSS, with the significance level set at 0.05.

Results

Among the 216 participants in the study, the majority (55.6%) were aged between 30 and 39 years, and 73.6% were female. Additionally, 64.4% were married, while 69.4% had a bachelor's degree, 20% held a diploma, and the remaining had a master's degree. Notably, a significant 81.5% of the nurses reported poor sleep quality, as assessed by the Pittsburgh Sleep Quality Index (PSQI), with an overall mean score of 10.55 indicating poor sleep. The study highlighted that poor sleep quality among nurses was linked to being female, being married, and not exercising regularly. Better sleep was associated with nurses who manage fewer patients per shift and have adequate monthly income.

Conclusion

The prevalence of poor sleep quality among Emergency nurses during the COVID-19 pandemic is high. There is a pressing need for targeted interventions to enhance sleep quality among ED nurses. Improving sleep quality is not only essential for the wellbeing of these nurses but is also likely to contribute to better patient care.

Prevalence and factors associated with poor sleep quality among nurses in COVID-19 wards

The COVID-19 pandemic has significantly impacted the working conditions of nurses, leading to a detrimental effect on their sleep quality. This cross-sectional study aimed to investigate the prevalence of poor sleep quality and its associated factors among nurses working in COVID-19 wards in Kermanshah, Iran. A total of 97 nurses were selected through simple random sampling from COVID-19 wards. Data was collected using a demographic information sheet and the Pittsburgh Sleep Quality Index. Descriptive and inferential statistical methods, including chi-square and multiple logistic regression, were used for data analysis. The results showed that 74.2% (n = 72) of the nurses experienced poor sleep quality. Significant associations were found between poor sleep quality and work experience (p = 0.045) as well as the type of work shift (p = 0.001). However, no significant relationships were observed between poor sleep quality and factors such as age, sex, body mass index, overtime hours per month, physical activity, or underlying diseases. The high prevalence of poor sleep quality among nurses working in COVID-19 wards underscores the necessity of implementing targeted interventions to address this issue. In this regard, in addition to periodic shift schedule changes and reductions in working hours, it is necessary to adopt purposeful measures to improve working conditions and enhance the physical and mental health of nurses. These measures may include providing sufficient human resources to reduce the workload and fatigue of nurses, appropriate scheduling of working hours, and the implementation of stress management programs.

Pediatric nurses' fatigue descriptions in occupational injury reports: A descriptive qualitative study1

Background

Despite the high risks associated with occupational fatigue in healthcare, few organizations require nurses to screen and report fatigue symptoms. As a result, little is known about if and how nurses would report fatigue while on the job.

Objective

To determine if hospital-based pediatric nurses reported fatigue as part of an active injury reporting method.

Methods

This secondary analysis of qualitative data used a descriptive design with content analysis. Data from the parent study were collected at a U.S. pediatric hospital where nurses verbally reported on-shift injuries or near misses and pre- and post-shift health status via a digital voice recorder. Researchers used content analysis to independently code data for nurses' references to fatigue. Codes were then analyzed for patterns and themes.

Results

Approximately 30% (n = 104) of participants reported fatigue-related content. Emergent themes were Work Stressors, Individual Risk Factors, Fatigue Descriptors, Adverse Outcomes from Fatigue, Fatigue Buffers, Descriptors for Buffered Fatigue, and Favorable Outcomes from Buffered Fatigue. Fatigue descriptions align with prior literature, demonstrating the accuracy of the voice recorder data collection method. In addition, nurses expressed uncertainty about the appropriateness of reporting fatigue symptoms.

Conclusion

Findings from this study support pediatric nurses will report fatigue, when provided an opportunity. Additional efforts are needed to better understand effective ways to improve fatigue reporting among nurses, including harnessing current technology for real-time reporting and how to change the culture around fatigue reporting.

Assessing the impacts of nurse staffing and work schedules on nurse turnover: A systematic review

AIM

This study aimed to investigate and synthesize the impacts of nurse staffing and work schedules on nurse turnover in acute hospitals.

BACKGROUND

The retention of nurses during the COVID-19 pandemic was critical due to the increased demand for nurses. Among the multifaceted factors contributing to nurse turnover, it is worth examining nurse staffing and work schedules while considering policy intervention.

METHODS

The findings of this systematic literature review were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Using eight databases, including CINAHL and PubMed, research articles published from January 2000 until June 2021 were reviewed. The inclusion criteria were original peer-reviewed research, nonexperimental studies published in English or Korean languages, and studies examining the impacts of nurse staffing and work schedules on nurses' actual turnover.

RESULTS

Fourteen articles were reviewed. Among them, 12 studies investigated the relationship between nurse staffing and turnover, and four examined the impact of work schedules on nurse turnover. Nurse staffing levels are strongly related to nurse turnover in the expected direction. However, few studies have found that work schedules are significantly related to nurse turnover.

CONCLUSION

Inadequate and unsafe nurse staffing leads to increased nurse turnover rates. More studies are needed to investigate the impacts of work schedules on nurse turnover.

IMPLICATIONS FOR NURSING, HEALTH, AND SOCIAL POLICY

Several states in the United States have adopted the nurse staffing policy during the COVID-19 pandemic. More hospitals and the government should adopt and implement policies to regulate nurse staffing, reduce nurse turnover, and increase retention. Policy intervention in nurse work schedules should also be considered to prevent nurse turnover.

Effects of working conditions on the perception of night work safety and health effects on nurses

AIM

To examine night working conditions by shift work type and identify the effects of night working conditions on nurses' perceptions of shift work safety and health effects.

BACKGROUND

Night work is the main factor affecting nurses' health. However, the safety of night working conditions has not been sufficiently examined in previous studies.

METHODS

This study used a cross-sectional research design and an online survey using a tool released by the Australian Manufacturing Workers' Union, and the responses of 348 shift work nurses in Korea were analyzed. Logistic regression analysis was used to examine the effects of shift work conditions on the perceived safety of night work and health effects. The STROBE reporting guidelines were utilized, and data were collected from December 1 to December 31, 2021.

RESULTS

The adjusted logistic regression analysis showed that perceived threat to safety and the health effects of shift work were not significant according to shift type. However, night-shift-work nurses who worked alone (P = 0.003), lacked an emergency recovery system (P = 0.026), and had difficulty commuting perceived a threat to their health (P = 0.007). Additionally, nurses who experienced loss of concentration (P = 0.006) and inadequate rest time (P < 0.001) perceived the health effects of shift work.

DISCUSSION

Urgent monitoring of night work conditions is necessary for the 2-shift work type. Nurses must work night shifts together and an emergency system should be established for their safety.

CONCLUSION

Night work conditions should be improved to prevent the hazards of night work and its negative health effects on nurses.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This study suggests the necessity of a policy to enhance night work safety, including emergency coping systems and sufficient inter-shift rest time.

Effect of Mandatory and Voluntary Overtime Hours on Stress Among 9-1-1 Telecommunicators

BACKGROUND

9-1-1 telecommunicators are frequently exposed to indirect traumatic events that impact their mental and physical health and are often required to work overtime with rotating shifts. Previous studies reported various harmful effects of overtime on the health and well-being of workers, such as musculoskeletal injuries, burnout, low job satisfaction, fatigue, and intent to leave. However, there is limited research on the impact of overtime hours on 9-1-1 telecommunicators' stress symptoms, especially mandatory overtime hours. This study aimed to examine the relationship between overtime hours-mandatory and voluntary-and the level of stress symptoms among 9-1-1 telecommunicators.

METHODS

We used secondary data from the surveys of the "Multi-tasking to hyper-tasking: Investigating the impact of Next Generation 9-1-1" study for analysis. Linear mixed-effects regression was applied to examine the association of overtime hours with the stress level.

RESULTS

Of the 403 participants, 47.6% reported that they were required to work mandatory overtime, and the mean mandatory overtime was 7.51 (SD = 12.78) hours in the past month. 58.3% reported working voluntary overtime, and the mean voluntary overtime was 11.63 (SD = 17.48) hours. This study found that mandatory overtime hours were associated with an increase in self-reported stress symptoms (β = 0.30, p = .002), whereas no significant association was found between voluntary overtime and the level of stress symptoms (β = -0.01, p = .885).

CONCLUSION/APPLICATION TO PRACTICE

Study results highlight the importance of reducing mandatory overtime in call centers as one possible strategy for reducing stress levels among this critical workforce.

Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress

BACKGROUND

Incident reports submitted during times of organizational stress may reveal unique insights.

PURPOSE

To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge.

METHODS

We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare.

RESULTS

Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19.

CONCLUSIONS

Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

Modeling wellbeing for U.S. correctional nurses: A cross sectional survey

BACKGROUND

Nurses work in stressful environments, and this stress has negative consequences on health. Correctional nurses experience unique job stress in their roles. However, there has been limited research exploring how the correctional environment impacts nurse health and wellbeing.

OBJECTIVE

This study aimed to evaluate the relationship between the variables of organizational characteristics (i.e., job demands, job control, manager support, peer support, workplace relationships), job stress, and wellbeing levels in a sample of U.S. correctional nurses, while exploring socio-demographic covariates.

METHODS

Using a convenience sampling method, 270 U.S. correctional nurses completed a cross-sectional online survey. Informed by the Job Demands-Resources Theory, a conceptual model was created and tested in this sample. Analysis involved multiple linear regression and structural equation modeling.

RESULTS

The model significantly fit the data (CI: 0.71-0.83, CFI = 0.51, SRMR: 0.37, and RMSEA = 0.08) revealing the direct relationship between job stress, job demands, job control, and workplace relationships and wellbeing. This study also provided evidence that job stress mediates the relationship of job control and job demands with wellbeing.

CONCLUSION

Results underscore the opportunity for correctional organizations to consider targeting job demands, job control, workplace relationships, and job stress in future interventions to improve the correctional nursing work environment and support correctional nurse wellbeing.

TWEETABLE ABSTRACT

A recent study found evidence for a relationship between organizational characteristics & job stress and U.S. correctional nurse wellbeing.

Wake-up Call: Night Shifts Adversely Affect Nurse Health and Retention, Patient and Public Safety, and Costs

The purpose of this mini review is to (1) summarize the findings on the impact of night shift on nurses' health and wellness, patient and public safety, and implications on organizational costs and (2) provide strategies to promote night shift nurses' health and improve organizational costs. The night shift, compared with day shift, results in poorer physical and mental health through its adverse effects on sleep, circadian rhythms, and dietary and beverage consumption, along with impaired cognitive function that increases nurse errors. Nurse administrators and health care organizations have opportunities to improve nurse and patient safety on night shifts. Low-, moderate-, and higher-cost measures that promote night nurses' health and well-being can help mitigate these negative outcomes. The provided individual and organizational recommendations and innovations support night shift nurses' health, patient and public safety, and organizational success.

Factors influencing nurse fatigue during COVID-19: regression vs. fuzzy-set qualitative comparative analysis

Background

Nurses during COVID-19 who face significant stress and high infection risk are prone to fatigue, affecting their health and quality of patient care. A cross- sectional study of 270 nurses who went to epidemic area to support anti-epidemic was carried out via online survey during the COVID-19 pandemic on November 2021.

Methods

A web-based cross-sectional survey of 270 nurses in China who traveled to Heihe City in Heilongjiang Province to combat the novel coronavirus epidemic. The researchers collected information on sociodemographic variables, anxiety, transition shock, professionalism, collaboration, hours of work per day, and fatigue. Regression and fuzzy-set Quality Comparative Analysis (fsQCA) evaluated the factors' impact on the nurses' fatigue.

Results

Regression analysis showed that the psychological variables significant for fatigue, transition shock (β = 0.687, p < 0.001) and anxiety (β = 0.757, p < 0.001) were positively associated with fatigue, professionalism (β = -0.216, p < 0.001) was negatively associated with fatigue, and among the work-related variables, cooperation (β = -0.262, p < 0.001) was negatively related to fatigue. FsQCA analysis showed that combined effects of work hours, anxiety, and nurses' educational status caused most of the fatigue (raw coverage = 0.482, consistency = 0.896).

Conclusion

This study provides two main findings, the one is the greater transition shock experienced during COVID-19 in a new environment, low levels of professionalism, anxiety, and poor nursing teamwork situations lead anti-epidemic nurses to increased fatigue. Second, the fsQCA results showed that anxiety is sufficient for fatigue and that nurses' educational status, daily working hours, and anxiety are the most effective combination of factors.

Impact of the single site order in LTC: exacerbation of an overburdened system

BACKGROUND

The long-term care (LTC) sector has been at the epicentre of COVID-19 in Canada. This study aimed to understand the impact that the Single Site Order (SSO) had on staff and leadership in four LTC homes in the Lower Mainland of British Columbia, Canada.

METHODS

A mixed method study was conducted by analyzing administrative staffing data. Overtime, turnover, and job vacancy data were extracted and analyzed from four quarters before (April 2019 - March 2020) and four quarters during the pandemic (April 2020 - March 2021) using scatterplots and two-part linear trendlines across total direct care nursing staff and by designation (i.e., registered nurses (RNs), licenced practical nurses (LPNs) and care aids (CAs)). Virtual interviews were conducted with a purposive sample of leadership (10) and staff (18) from each of the four partner care homes (n = 28). Transcripts were analyzed in NVivo 12 using thematic analysis.

RESULTS

Quantitative data indicated that the total overtime rate increased from before to during the pandemic, with RNs demonstrating the steepest rate increase. Additionally, while rates of voluntary turnover showed an upward trend before the pandemic for all direct care nursing staff, the rate for LPNs and, most drastically, for RNs was higher during the pandemic, while this rate decreased for CAs. Qualitative analysis identified two main themes and sub-themes: (1) overtime (loss of staff, mental health, and sick leave) and (2) staff turnover (the need to train new staff, and gender/race) as the most notable impacts associated with the SSO.

CONCLUSIONS

The results of this study indicate that the outcomes due to COVID-19 and the SSO are not equal across nursing designations, with the RN shortage in the LTC sector highly evident. Quantitative and qualitative data underscore the substantial impact the pandemic and associated policies have on the LTC sector, namely, that staff are over-worked and care homes are understaffed.

Overwork Among ICU Nurses: Identification of Risk Factors

OBJECTIVE

This study aimed to describe the current situation and explore overwork predictors among ICU nurses in China.

BACKGROUND

Overwork is a comprehensive condition of labor where employees work for extended periods with high intensity and high pressure, which can negatively affect their health. Limited literature exists regarding the prevalence, characteristics, professional identity, and environment of overwork among ICU nurses.

METHODS

A cross-sectional design study was conducted. The Professional Identification Scale for Nurses, the Practice Environment Scale of the Nursing Work Index, and the Overwork Related Fatigue Scale (ORFS) were used. To explore relationships between variables, univariate analysis or bivariate correlations were used. Multiple regression was used to identify predictors of overwork.

RESULTS

Almost 85% of nurses were categorized as overworked, of which, 30% were moderately to severely overworked. Gender, form of employment, stress related to ICU nursing technology and equipment updates, nurses' professional identity, and nurse working environment accounted for 36.6% in the ORFS.

CONCLUSIONS

Overwork is common among ICU nurses. Nurse managers need to develop and implement strategies to better support nurses to prevent overwork.

Health Professionals' Chronotype Association with Salivary Cortisol and Occupational Stress in Neonatal Intensive Care Units

Burnout syndrome has been reported among health workers, particularly those working in critical areas, and is considered a significant public health problem. This study aimed to investigate the relationship between chronotype and work-related stress, as measured by salivary cortisol levels and burnout, among health professionals working in neonatal intensive care units. A cross-sectional study was conducted across four public hospitals in Fortaleza, Ceará, Brazil. Two hundred and fifty-six health professionals were administered the brazilian version of the Burnout Characterization Scale, the morningness-eveningness questionnaire, for chronotype, a sociodemographic questionnaire that included lifestyle habits and a salivary cortisol test. The results indicated that morning chronotype workers were significantly associated with the following: advanced age (p < 0.001), female gender (p = 0.032), married status (p = 0.014), and having children (p = 0.030) compared to those with evening and intermediate chronotypes. However, no significant association was found between signs of burnout syndrome and chronotype (p = 0.316). Participants whose work shift did not match their chronotype had significantly higher initial salivary cortisol levels (p = 0.013). The findings suggest that adapting working hours to an individual's biological rhythm can help mitigate potential negative effects on physical and mental health. Thus, it is recommended that professionals' working hours be adjusted accordingly.

Effects of nurses' schedule characteristics on fatigue: An integrative review

An integrative review of 21 studies found mixed results on the associations of work schedule and nurse fatigue. Suggestions for nurse leaders include monitoring fatigue in shift workers, ensuring supportive work design, promoting a healthy lifestyle, and implementing scheduling interventions.

The variables in the rationing of nursing care in cardiology departments

BACKGROUND

The rationing of nursing care is a complex process that affects the quality of medical services.

PURPOSE

An assessment of the impact of nursing care rationing on burnout and life satisfaction in cardiology departments.

METHODS

The study included 217 nurses working in the cardiology department. The Perceived Implicit Rationing of Nursing Care, the Maslach Burnout Inventory, and the Satisfaction with Life Scale were used.

RESULTS

A greater emotional exhaustion, the more frequently the rationing of nursing care (r = 0.309, p < 0.061) and the lower the job satisfaction (r=-0.128, p = 0.061). Higher life satisfaction was associated with less frequent rationing of nursing care (r=-0.177, p = 0.01), better quality of care provided (r = 0.285, p < 0.001), and higher job satisfaction (r = 0.348, p < 0.01).

CONCLUSION

Higher levels of burnout contribute to more frequent rationing of nursing care, poorer evaluation of the quality of care provided, and lower job satisfaction. Life satisfaction is associated with less frequent rationing of care, better evaluation of the quality of care provided, and greater job satisfaction.

Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

BACKGROUND

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

AIM

To assess the nursing workload in a Portuguese ICU using the NAS.

STUDY DESIGN

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June-31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

RESULTS

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

CONCLUSIONS

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

RELEVANCE TO CLINICAL PRACTICE

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the 'administrative and management activities' related to the 'patient discharge procedures', the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.

Comprehensive assessment of factors contributing to the actual turnover of newly licensed registered nurses working in acute care hospitals: a systematic review

BACKGROUND

During the COVID-19 pandemic, the demand for nursing care increased, making the retention of nurses even more important. Among staff nurses, it is reported that the turnover rate of newly licensed registered nurses is higher. However, no systematic reviews have focused on the factors that influence newly licensed registered nurses' turnover. Additionally, because newly licensed registered nurses are a major source of the supply of nurses, it is critical to retain them to meet patient needs. Therefore, this study aimed to systematically synthesize the factors contributing to the actual turnover of newly licensed registered nurses working in acute care hospitals.

METHODS

CINAHL, Cochrane Library, DBpia, EBSCO, PubMed, PsycINFO, RISS, and Web of Science were searched for studies published between January 2000 and June 2021. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Ten articles from 9029 were included in this review. All studies used a longitudinal design. The annual turnover rates of newly licensed registered nurses ranged from 12 to 25%. Health status, including sleep and healthy lifestyles, were significant factors affecting turnover. Most studies focused on work environment factors, and emotional exhaustion, job satisfaction, peer support, and intent to leave, were significantly associated with newly licensed registered nurses' turnover. Small hospitals located in nonmetropolitan areas were at risk of high turnover of newly licensed registered nurses.

CONCLUSIONS

Turnover is inevitable in the process of employment, but high turnover can be prevented. Through reviewing ten articles, significant contributing factors for newly licensed registered nurses' turnover included personal factors of health status; work environment factors of physical exhaustion, emotional exhaustion, depersonalization, occupational injuries, income, intent to stay, job satisfaction, and peer support; and hospital factors of hospital size, location, and unionization. Most existing studies focus on work environment factors, which reflects the significance of fostering healthy work conditions to prevent high turnover. These findings can be used to develop strategies and policies for work environment to reduce high turnover of newly licensed registered nurses, and support high-risk groups, such as small hospitals located in nonmetropolitan areas with high levels of nurses' turnover.

The effect of full-time culture on quality and safety of care – a literature review

Purpose

The purpose of this study is to increase knowledge and understanding of the relationship between full-time-culture and the outcome for quality and safety of care.

Design/methodology/approach

The paper is a literature review with a qualitatively oriented thematic analysis concerning quality or safety outcomes for patients, or patients and staff when introducing a full-time culture.

Findings

Identified factors that could have a positive or negative impact on quality and patient safety when introducing full-time culture were length of shift, fatigue/burnout, autonomy/empowerment and system/structure. Working shifts over 12 h or more than 40 h a week is associated with increased adverse events and errors, lower quality patient care, less attention to safety concerns and more care left undone. Long shifts give healthcare personnel more flexibility and better quality-time off, but there is also an association between long shifts and fatigue or burnout. Having a choice and flexibility around shift patterns is a predictor of increased wellbeing and health.

Originality/value

A major challenge across healthcare services is having enough qualified personnel to handle the increasing number of patients. One of the measures to get enough qualified personnel for the expected tasks is to increase the number of full-time employees and move towards a full-time culture. It is argued that full-time culture will have a positive effect on work environment, efficiency and quality due to a better allocation of work tasks, predictable work schedule, reduced sick leave, and continuity in treatment and care. There is limited research on how the introduction of full-time culture will affect the quality and safety for patients and staff, and few studies have been focusing on the relationship between longer shift, work schedule, and quality and safety of care.

Overtime and alertness of rotating-shift nurses: An observational study using ecological momentary assessment

AIMS AND OBJECTIVES

This study aimed to determine the effect of overtime on alertness at work among rotating-shift nurses in South Korea and to investigate whether these effects of overtime vary across the different types of shifts.

BACKGROUND

Nurse overtime is prevalent in healthcare settings to manage nursing shortages and staffing needs; however, it negatively affects patient and nurse outcomes. Furthermore, little attention has been paid to the effects of previous overtime shifts and overtime for consecutive shifts on alertness during work.

DESIGN

A prospective observational study was employed. The study followed STROBE checklist for observational studies.

METHODS

Data were collected between June 2019 and February 2020 from 82 nurses who worked in acute care hospitals. An ecological momentary assessment was used to capture real-time data of overtime and alertness. Alertness scores were estimated using the sleep/wake data measured by an actigraph. Mixed-effect models were employed to investigate the association between overtime and alertness.

RESULTS

A majority of the shift nurses worked overtime. Episodes of a decline in alertness scores to the level of increased accident or serious error risk (alertness score ≤80) were most frequently seen during night shifts (98.9%), followed by day (59.8%) and evening shifts (10.1%). Previous-day overtime hours and consecutive overtime days were associated with decreased alertness scores during work. A significantly positive correlation was observed between alertness scores ≤80 and previous-day overtime hours and consecutive overtime days in all shifts.

CONCLUSIONS

The study findings indicate that a majority of nurses who work overtime experience decreased alertness while on duty.

RELEVANCE TO CLINICAL PRACTICE

Policy development at the government, organisational and unit level is needed to guarantee adequate rest for shift nurses by adjusting work schedules and assignments and limiting overtime.

Data-Driven Analysis of Employee Churn in the Home Care Industry

Annual turnover of home care workers represents a huge loss of revenue and is a key source of inefficiency in the home health care industry. In this article, we propose a data-driven approach to monitor employee churn and to capture the evolution of employee intent to leave. Unlike most papers in the literature, we use machine learning techniques to analyze over 2 million visits in the US, Canada, and Australia between 2016 and 2019. Results show that the gap between the number of hours worked and in the contract is the most important factor to predict employee intent to leave, which means an employee should be given as many hours as requested in the contract to improve retention. Secondary results show that having diverse shift lengths and continuity in services and patients seem to be associated with less turnover.

Nurse scheduling in COVID-19-designated hospitals in China: A nationwide cross-sectional survey

AIM

This study aimed to investigate scheduling in COVID-19-designated hospitals, including working hours, rest days, adverse nursing outcomes and their relationship.

BACKGROUND

Hospitals are at the forefront of COVID-19 prevention and control, and nurses are the main force on the frontline of the epidemic. Nursing shift is one of the most relevant and pressing issues for frontline nurses. However, there is a lack of national, large-sample surveys on scheduling and adverse nursing outcomes in COVID-19-designated hospitals.

METHODS

Using a cross-sectional online survey, we used nurse-reported data to measure the characteristics of the work setting, samples and work schedule. A descriptive analysis was performed to assess the shift status and adverse outcomes of designated hospitals and frontline nurses. Logistic regression analysis was performed to determine the association between them.

RESULTS

Basic data were collected from 217 departments of 69 COVID-19-designated hospitals in 31 provinces in China. Nurses in the severe isolation ward worked mainly for 4 h per shift, whereas those in the fever clinic and observation ward worked mainly for 6-8 h. Half of the nurses had only 1 day of rest per week. Long working hours, lack of adequate rest time and overtime can seriously affect the quality and safety of nurses' work, resulting in adverse outcomes. Frontline nurses hope that scheduling guarantees the time to rest while ensuring fairness.

CONCLUSIONS

The current evidence showed that frontline nurses were faced with long working hours, insufficient rest and overtime, which has a negative impact on nurse satisfaction, physical and mental health and quality of care. The government, hospitals and administrators still face many problems to overcome in their nursing schedules.

IMPLICATIONS FOR NURSING MANAGEMENT

Governments and hospitals should take these factors, such as the work setting characteristics and demographic features of the frontline nurses, into account when selecting nurses to fight COVID-19. Nurses have different working hours in different types of coronavirus unit; therefore, nursing managers should consider the working environment and nursing schedule needs, and in the future, we should pay attention to the fairness of nurses while ensuring their rest.

Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector

BACKGROUND

The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public.

METHODS

This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum.

RESULTS

The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified.

CONCLUSION

Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.

A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care

We have limited understanding of the organisational issues at the health facility-level that impact providers and care as it relates to mistreatment in childbirth, especially in low- and middle-income countries (LMICs). By extension, it is not clear what types of facility-level organisational changes or changes in working environments in LMICs could support and enable respectful maternity care (RMC). While there has been relatively more attention to health system pressures related to shortages of staff and other resources as key barriers, other organisational challenges may be less explored in the context of RMC. This scoping review aims to consolidate evidence to address these gaps. We searched literature published in English between 2000-2021 within Scopus, PubMed, Google Scholar and ScienceDirect databases. Study selection was two-fold. Maternal health articles articulating an organisational issue at the facility- level and impact on providers and/or care in an LMIC setting were included. We also searched for literature on interventions but due to the limited number of related intervention studies in maternity care specifically, we expanded intervention study criteria to include all medical disciplines. Organisational issues captured from the non-intervention, maternal health studies, and solutions offered by intervention studies across disciplines were organised thematically and to establish linkages between problems and solutions. Of 5677 hits, 54 articles were included: 41 non-intervention maternal healthcare studies and 13 intervention studies across all medical disciplines. Key organisational challenges relate to high workload, unbalanced division of work, lack of professional autonomy, low pay, inadequate training, poor feedback and supervision, and workplace violence, and these were differentially influenced by resource shortages. Interventions that respond to these challenges focus on leadership, supportive supervision, peer support, mitigating workplace violence, and planning for shortages. While many of these issues were worsened by resource shortages, medical and professional hierarchies also strongly underpinned a number of organisational problems. Frontline providers, particularly midwives and nurses, suffer disproportionately and need greater attention. Transforming institutional leadership and approaches to supervision may be particularly useful to tackle existing power hierarchies that could in turn support a culture of respectful care.

Ambulatory Oncology Nurses Weigh in About 12-Hour Shifts

BACKGROUND

Studies conducted in hospital settings have associated negative clinical outcomes with 12-hour shifts. Despite this, 12-hour shifts are common in nursing and popular among nurses. Little is known about outcomes associated with 12-hour shifts in ambulatory care settings.

OBJECTIVE

A mixed-methods, quality improvement project was conducted in a large, ambulatory cancer center to evaluate oncology nursing staff perspectives on 12-hour shift work.

METHODS

One hundred ambulatory oncology nurses completed surveys and 11 participated in focus group interviews.

FINDINGS

Nurses expressed predominately positive perspectives about 12-hour shift work in ambulatory oncology care.

CONCLUSIONS

Ambulatory oncology nurses perceived benefits to quality, safety, and satisfaction for both nurses and patients related to 12-hour shifts. Further evaluation of patient, nurse, and organizational outcomes unique to ambulatory settings is essential for nurse executives in formulating data-driven staffing plans. The incorporation of 12-hour shifts should be considered.

Missed nursing care in the COVID-19 pandemic in Iran

Background

Quality of care is one of the most critical issues in nursing care today. Moreover, all health care employees are responsible for providing support and high‐quality, safe care. However, nurses caring for COVID‐19 patients face problems such as unfamiliar work environments, exposure to the disease, lack of experience in their new positions, and close public and media attention. This study aimed to investigate missed nursing care and the reasons for missed nursing care during the coronavirus disease 2019 (COVID‐19) pandemic in Iran.

Methods

This cross‐sectional study included 135 nurses working in COVID‐19 units. Data were collected using the MISSCARE Survey. The significance level for the statistical tests was set at p < 0.05.

Results

Most of the participants were women and had a bachelor's degree in nursing. There was a lack of supportive and necessary care more than any other form of care. According to nurses, the most common reasons for missed care were urgent patient situations, inadequate staff, and an unexpected rise in patient volume and/or patient acuity on the unit.

Conclusion

Generally, the results showed that being positioned in a new situation and unfamiliarity with the disease had a significant impact—among nurses—on the amount of care provided. Managers can use this information to solve existing missed‐nursing‐care problems and contribute to improving the quality of care.

These results can be helpful in controlling missed nursing care and finding a more optimal solution for this problem; thus, we can improve the quality of care delivery and increase the satisfaction of nurses and patients. Additionally, an understanding of the kind of missing nursing care during a pandemic can positively enhance the management of similar situations in the future.

Effects of 90 Min Napping on Fatigue and Associated Environmental Factors among Nurses Working Long Night Shifts: A Longitudinal Observational Study

For nurses working long night shifts, it is imperative that they have the ability to take naps to reduce fatigue, and that an appropriate environment is prepared where such naps can be taken. We verified the effects of 90 min napping on fatigue and the associated factors among nurses working 16-h night shifts. We investigated 196-night shifts among 49 nurses for one month. Wearable devices, data logging devices, and questionnaires were used to assess nap parameters, fatigue, and environmental factors such as the napping environment, ways of spending breaks, and working environment. Nurses who nap at least 90 min on most night shifts had more nursing experience. Multivariable logistic regression analysis showed that the environmental factors significantly associated with total nap duration (TND) ≥ 90 min were noise, time spent on electronic devices such as cellphones and tablets during breaks, and nap break duration. The night shifts with TND ≥ 90 min showed lower drowsiness after nap breaks and less fatigue at the end of night shift compared to those with TND < 90 min. Nurses and nursing managers should recognize the importance of napping and make adjustments to nap for at least 90 min during long night shifts.

Work schedule characteristics associated with sleep disturbance among healthcare professionals in Europe and South Korea: a report from two cross-sectional surveys

Background

Healthcare professionals worldwide are prone to sleep disturbance. Such sleep disturbance is associated with lower patient safety and quality of care. Therefore, this study aimed to identify the prevalence of sleep disturbance and determine the effect of work schedule characteristics on sleep disturbance among healthcare professionals in Europe and South Korea.

Methods

We used the sixth European Working Conditions Survey and the fifth Korean Working Conditions Survey for analyses. The study included 2285 healthcare professionals aged 18–65 years. Work schedule characteristics included shift work, night work, working hours per week, long work hours (i.e., more than 10 hours per shift), quick return to work, having to come to work on short notice, and changes in work schedules. A multiple logistic regression analysis was performed.

Results

The overall prevalence of sleep disturbance was 37.7%. The multivariate logistic regression model indicated that long work hours, quick return to, having to come to work on short notice, and changes in work schedules were significant factors associated with sleep disturbance among healthcare professionals.

Conclusion

The findings revealed that several work schedule-related factors were associated with sleep disturbances in healthcare professionals in Europe and Korea. Institutions and policymakers should implement strategies and policies to reduce the unpredictability of work schedules to ensure an adequate rest period between shifts and to reduce sleep disturbances.

Investigation of the Level and Factors Influencing Emergency Department Nurses Fatigue: A Case Study of the Saudi Arabian Context

Background: Work-related fatigue is a common health problem among nurses which can affect their performance and decision making. Significance and Aim: The study explores the levels of fatigue and its associated factors among emergency department (ED) nurses in Saudi Arabia. Methods: The study was developed through a cross-sectional quantitative study design. This included the collection of primary quantitative data with a questionnaire prepared and published on REDCap. The study questionnaire was adapted from two tools, namely the OFER 15 and the Copenhagen II tools, respectively. Results: The study established that the Saudi Arabian ED nurses have high acute fatigue (OFER 15 score = 81.11), moderate-high chronic fatigue (OFER 15 score = 74.17), and a high inter-shift recovery index (OFER 15 score = 78.01). In terms of the predictor factors, the study established that for the demographic factors, gender has an impact on chronic and acute fatigue, while work experience impacted acute fatigue and the number of dependents impacted on inter-shift recovery index. On the psycho-social factors, chronic fatigue is influenced by emotional demand (which is a variable used to evaluate the levels to which the nurse is invested, gaining education/skills thus increases job satisfaction) (−0.289), influence at work (−0.310), commitment at the workplace (0.376), rewards (−0.187), stress (0.420), and burnout (0.293), respectively. Acute fatigue is influenced by the emotional demands (0.336), role clarity (−0.128), and the nurses’ well-being and health (−0.034). Finally, the inter-shift recovery index is influenced by the ED nurses’ burnout levels (−0.877). Conclusions: The study indicates a high level of nursing fatigue among the Saudi Arabian ED nurses.

Infections, accidents and nursing overtime in a neonatal intensive care unit

The paper investigates the effects of nursing overtime on nosocomial infections and medical accidents in a neonatal intensive care unit (NICU). The literature lacks clear evidence on this issue and we conjecture that this may be due to empirical and methodological factors. We model the occurrences of both events using a sample of 3979 neonates who represents over 84,846 observations (infant/days). We exploit an important change in workforce arrangement that was implemented in June 2012, and which aimed at reducing overtime hours to identify a causal impact between the latter and the two outcomes of interest. We contrast the results using a standard mixed-effects logit model with those of a semiparametric mixed-effects logit model. Contrary to the mixed-effects logit model, the semiparametric model unequivocally shows that both adverse events are impacted by nursing overtime as well as being highly sensitive to infant and NICU-related characteristics. Furthermore, the mixed-effects logit model is rejected in favour of the semiparametric one.

Effect of Shift Work on Cognitive Function in Chinese Coal Mine Workers: A Resting-State fNIRS Study

Aim: Pilot study to examine the impact of shift work on cognitive function in Chinese coal mine workers. Background: Shift work is commonly used in modern industries such as the coal industry, and there is growing concern over the impact that shift work has on miners’ work performance and personal well-being. Method: A total of 54 miners working three shifts (17 in morning shift, 18 in afternoon, and 19 in night shift) participated in this exploratory study. A resting-state fNIRS functional connectivity method was conducted to assess the cognitive ability before and after the work shift. Results: Results showed significant differences in cognitive ability between before and after the work shifts among the three-shift workers. The brain functional connectivity was reduced ranking as the night, afternoon, and morning shifts. Decreased brain functional connectivity at the end of the working shift was found compared with before in the morning and afternoon shifts. Opposite results were obtained during the night shift. The resting-state functional brain networks in the prefrontal cortex of all groups exhibited small-world properties. Significant differences in betweenness centrality and nodal local efficiency were found in the prefrontal cortex in the morning and night shifts. Conclusions: The current findings provide new insights regarding the effect of shift work on the cognitive ability of Chinese coal mine workers from the view of brain science.

Assessing Preferences and Perceived Restorative Qualities of Break Spaces for Nurses in China

OBJECTIVE

This study investigated Chinese nurses' preferences for (a) proximity of break areas, (b) functionality of break areas, (c) amenities, and (d) nature-related environmental features.

BACKGROUND

While nurses in China need support to adequately perform their jobs, little is known about how restorative spaces impact their mental and physical health.

METHODS

Data were collected through interviews (N = 12), survey questionnaires (N = 88), and visual assessments (N = 88) from nurses who worked in inpatient settings in China.

RESULTS

Nurses preferred the break room to be close to nursing stations; to have visual privacy from patients; and to provide space and facilities for drinking, taking naps, dining, and chatting with colleagues. Balconies and windows were shown to have a significant restorative effect. Well-designed break areas were perceived to have positive impacts on nurse perceived levels of well-being and increase nurses' satisfaction levels with their work environment.

CONCLUSION

The study outcomes emphasize the importance of restorative spaces for inpatient nurses and recommend including natural elements in the break rooms.

Nurse Staffing Practices and Postoperative Atrial Fibrillation Among Cardiac Surgery Patients: A Multisite Cohort Study

BACKGROUND

Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery that is associated with increased morbidity, mortality, and costs. Recent studies suggest that nurse staffing practices are associated with adverse postoperative events, but whether these practices are also related to POAF occurrence is unknown.

METHODS

To fill this knowledge gap, a cohort of 6401 cardiac surgery patients admitted to 2 Canadian university health centres (UHC A and UHC B) between 2014 and 2018 was studied. Patients' cumulative exposure to 4 staffing practices (registered nurse [RN] understaffing, education, experience, and non-RN skill mix) was measured every shift over the first 6 postoperative days, during which 96% of POAF cases occur. The associations of these exposures with in-hospital POAF occurrence were estimated using site-specific multivariable logistic regression models and a mixed-effect model combining data from both sites.

RESULTS

Overall, 563 (27.2%) and 1336 (30.8%) cases of POAF occurred at UHC A and UHC B, respectively. In site-specific models, every 5% increase in the cumulative proportion of understaffed shifts over the first 6 postoperative days was associated with a 3.5% increase in the odds of POAF (adjusted odds ratio [aOR] for UHC A: 1.035; 95% confidence interval [CI]: 1.000-1.070, P = 0.0472; aOR for UHC B: 1.035; 95% CI: 1.013-1.057, P = 0.0019). In the mixed-effect model combining data from both sites, RN understaffing remained significant and was associated with a 3.1% increase in the odds of POAF (aOR: 1.031; 95% CI: 1.014-1.048, P = 0.0003). No other staffing practices were significantly associated with POAF occurrence.

CONCLUSION

Higher RN understaffing postoperatively is associated with increased POAF occurrence among cardiac surgery patients.

Nursing home nurses' turnover intention: A systematic review

Aim

This review aimed to examine and describe the published research on nursing home (NH) nurses' turnover intentions in their workplace.

Design

This study is a systematic review following PRISMA guidelines.

Methods

An electronic search was conducted for English and Korean articles to identify research studies published between 2009–2019 using CINAHL, PubMed, Cochrane Library, PsycINFO, RISS, and DBpia.

Results

A total of six studies met the inclusion criteria and revealed NH nurses' turnover intentions. The factors influencing NH nurses' turnover intentions were identified and classified as individual and organizational factors. Among the various factors above, this study found that job satisfaction was the most influential factor in nurses' turnover intentions. Therefore, further efforts are required to increase NH nurses' job satisfaction to decrease turnover intention.

Work schedule characteristics and occupational fatigue/recovery among rotating-shift nurses: A cross-sectional study

AIMS

To determine the effects of work schedule characteristics on occupational fatigue and recovery among rotating-shift nurses in South Korea.

BACKGROUND

Understanding the effects of work schedule characteristics on occupational fatigue is important to prevent adverse nurse outcomes and to ensure patient safety.

METHODS

This study used secondary data analysis with a cross-sectional design. Data were collected on 436 rotating-shift nurses in 2018. Nurses' occupational fatigue and recovery were measured using the Occupational Fatigue Exhaustion/Recovery Scale. We used quantile regression models.

RESULTS

The scores for acute and chronic fatigue and intershift recovery were 70.40, 73.39, and 29.82, respectively. Overtime hours, number of night shifts, number of consecutive days off, and breaks were significant influential factors in some quantiles of acute fatigue, chronic fatigue, and intershift recovery, while total working hours was only associated with chronic fatigue in the 25th quantile.

CONCLUSIONS

The quantile and linear regression models revealed different results for work schedule factors that affect occupational fatigue and intershift recovery among rotating-shift nurses.

IMPLICATION FOR NURSING MANAGEMENT

These findings have important implications for developing targeted strategies and policies to reduce occupational fatigue and improve intershift recovery for rotating-shift nurses with different levels of occupational fatigue and recovery.

Work hours and overtime of nurses working in Cambodian hospitals

Aim

To examine the nature and prevalence of Cambodian nurses’ work hours and overtime and related factors

Background

The chronic shortage of nursing workforce is a major cause of overtime among nurses.

Introduction

Nursing shortage and working overtime among nurses negatively affect nurse and patient outcomes, but nurses’ work hours and overtime in Cambodia have not been comprehensively examined.

Methods

A multicenter cross‐sectional study was conducted in four Cambodian hospitals. Data were collected from 253 nurses providing direct nursing care using a questionnaire. The STROBE checklist was used for reporting this study.

Results

More than a fifth of staff nurses worked more than 48 h, which is the legal work hour limit in Cambodia. Two major reasons for working mandatory or voluntary overtime, on‐call or 24‐h on‐call were (a) not wanting to let down colleagues and (b) able to get all work done. The number of patients cared for was related to whether or not nurses worked 48 h or more.

Conclusion

Overtime work and adverse nurse scheduling are common in Cambodia.

Implications for nursing and health policy

Nurse managers and healthcare institutes in Cambodia need to monitor Cambodian nurses’ work hours, which are often beyond the legal work hour limit. Moreover, it is important to understand why nurses work overtime and develop health policies, strategies, and programs that can help promote patient and nurse safety and retain qualified nursing staff. The 24‐h on‐call practice needs to be regulated according to the labor policy in healthcare institutes to prevent adverse nurse and patient outcomes.

Behaviours and experiences of nurses during the COVID-19 pandemic in Turkey: A mixed methods study

AIM

The aim of this work is to present behaviours and experiences of nurses in Turkey during the current coronavirus pandemic.

BACKGROUND

The coronavirus pandemic leads to difficulties for most health care workers, especially for nurses who mostly accompany patients and are on the front line.

METHODS

In the study, a parallel mixed pattern converging quantitative and qualitative research methods was used.

RESULTS

The model revealed that 41 years old or older, diabetic, female, single professionals, working in the pandemic department took more personal measures. Five main themes appeared regarding the experiences of the nurses during the pandemic period: (1) psychological and mental strain; (2) personal protective equipment; (3) organizational, physical, and social strains; (4) change in professional values; (5) turning the crisis into an opportunity.

CONCLUSIONS

Personal measures are associated with the risk status. There is a need to protect nurses with significant measures by providing psychosocial support, meeting their basic needs, and preventing all complications likely to occur due to increasing workload.

IMPLICATIONS FOR NURSING MANAGEMENT

More efforts should be made to ensure good work, fair treatment, no tolerance for discrimination, and equal compensation conditions.

The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: A quasi-experimental study

BACKGROUND

Healthcare systems have widely adopted consecutive 12 h day and night shifts for nurses, but the effects of these shifts on cognition, sleepiness, and nursing performance remains understudied.

OBJECTIVE

To determine the extent of changes in cognition and sleepiness in nurses working three consecutive 12 h shifts, quantify the respective impacts of these changes on different aspects of nursing performance, and investigate individual differences in all measures.

DESIGN

A quasi-experimental, between-within design collected data from nurses between November 2018 and March 2020. The between-groups component was comprised of day shift nurses vs. night shift nurses, while the within-groups component was comprised of two separate test sessions for each nurse: one immediately following a third consecutive shift (fatigued) and one after three consecutive days off work (rested).

SETTING

Participants were tested in a northwestern US university's nursing simulation laboratory.

PARTICIPANTS

A volunteer sample of 94 registered nurses involved in direct patient care working 12 h shifts were recruited from two local hospitals.

METHODS

Simulated nursing performance was measured in seven separate domains and an aggregate score from the Creighton Competence and Evaluation Inventory, covering both lower- and higher-level constructs like procedural skills, assessment, decision-making, etc. Cognition and sleepiness were assessed through measures of sustained attention, predicted cognitive effectiveness, and subjective sleepiness.

RESULTS

In our 94 nurses, individual differences in all our measures varied from trivial to extensive. For six domains of performance and the aggregate score there were no significant differences in means across groups or conditions. For the seventh, Communication skills were lower for night nurses than day nurses, but this effect was small. After three consecutive shifts, sustained attention and predicted cognitive effectiveness decreased, and subjective sleepiness increased. Predicted cognitive effectiveness was particularly low for fatigued night nurses relative to other conditions and was positively correlated with Communication while controlling for other predictors.

CONCLUSIONS AND RELEVANCE

Nurses maintained their levels of performance for all domains after three consecutive shifts. Individual differences in predicted cognitive effectiveness could account for variation in performance by shift type for Communication skills but for no other domain of performance. Communication skills and predicted cognitive effectiveness may interest researchers in the development of fatigue-mitigation strategies for night nurses, but our findings also suggest that more sensitive measures of performance may be necessary to capture other meaningful effects of long, consecutive shifts-if any-on patient care. Tweetable abstract: The effects of three consecutive 12 h shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: A quasi-experimental study.

Acute and chronic fatigue in nurses providing direct patient care and in non-direct care roles: A cross-sectional analysis

Nurses are at risk for work-related fatigue, which can impact their health, well-being, and job readiness. The purpose of this study was to examine the levels, types, and factors associated with fatigue in registered nurses (RNs) in direct patient care (DCRNs) and in non-direct patient care (non-DCRNs) roles. A cross-sectional survey was administered to 313 RNs. Measures included: Multidimensional Fatigue Symptom Inventory, Occupational Fatigue Exhaustion Recovery, Brief COPE, PROMIS® Global Sleep Disturbance, and Job Content Questionnaire. Acute fatigue levels in RNs were similar to those in diseased populations, and nearly 50% reported moderate/high levels of chronic fatigue. DCRNs reported higher levels of acute and chronic fatigue than non-DCRNs, but the differences were small and disappeared when accounting for other factors associated with fatigue including sleep disturbance, job strain, workplace support, maladaptive coping, and especially intershift recovery, which accounted for 20%-41% of fatigue variability. This study suggests that it may not be only nurses providing direct patient care who are at risk for acute and chronic fatigue. Intershift recovery may be particularly important in alleviating acute and chronic fatigue in nurses.

Comparison of Fatigue, Quality of Life, Turnover Intention, and Safety Incident Frequency between 2-Shift and 3-Shift Korean Nurses

This study aimed to compare the fatigue, quality of life, turnover intention, and safety incident frequency between 2- and 3-shift nurses, and analyze their perceptions of the 2-shift system. Participants were 227 nurses working for one year or more in a tertiary hospital in Seoul, South Korea (113 were 2-shift nurses for two months or longer, and 114 were 3-shift nurses with no experience of 2-shift work). The Occupational Fatigue Exhaustion Recovery Scale (OFER) and Quality of Life Scale were used. Turnover intention, safety incident frequency, and perceptions of the 2-shift system were surveyed by questionnaires developed by the researchers. Results showed that 2-shift nurses had lower chronic fatigue (t = -2.38, p = 0.018) and higher recovery between shifts (t = 3.90, p < 0.001) and quality of life scores than 3-shift nurses (t = 3.69, p < 0.001). There were no significant differences for turnover intention (t = -1.48, p = 0.140), frequency of needlestick accidents (t = 0.30, p = 0.763), medication errors (t = -1.46, p = 0.146), or near-miss medication errors (t = 0.78, p = 0.437). Two-shift nurses found it easier to secure rest and personal leisure time, and their shift system was shown to improve work satisfaction by increasing the continuity of care. Additional research is necessary to examine how nurses' health status and emotional satisfaction vary by shift type.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review

OBJECTIVE

The objective of this review was to determine the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings within low- and middle-income countries.

INTRODUCTION

Health care systems in low- and middle-income countries experience a high proportion of the global burden of disease, which is aggravated by several health care constraints. The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging in low- and middle-income countries. Health care systems in low- and middle-income countries, however, are still expected to address universal health care access and provide high-quality health care. Systematic reviews examining nurse staffing and its effect on patient and nurse workforce outcomes are largely from the perspective of high-income countries. There is a need to understand the evidence on nurse staffing and its impact in the context of low- and middle-income countries.

INCLUSION CRITERIA

Empirical studies that addressed acute care nurse staffing levels, such as nurse-to-patient ratio or nurses' qualifications, experience, and skill mix, and their influence on patient and nurse workforce outcomes were included in the review. Studies conducted in a low- or middle-income country were included. Outcomes must have been measured objectively using validated tools.

METHODS

Studies published until July 2019 were identified from CINAHL, PubMed, Scopus, Embase, PsycINFO, Cochrane Library, Web of Science, and ProQuest Dissertations and Theses. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. Narrative synthesis was conducted due to high heterogeneity of included studies. The level of evidence was determined using GRADEpro.

RESULTS

Twenty-seven studies were included in this review and the level of evidence was low, mainly due to the design of included studies. Low nurse-to-patient ratio or high nurse workload was associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls, and abandonment of treatment. Findings on the effect of nurse staffing on length of hospital stay and incidence of pressure ulcers were inconsistent. Extended work hours, less experience, and working night or weekend shifts all significantly increased medication errors. Higher nurse workload was linked to higher levels of nurses' burnout, needlestick and sharps injuries, intent to leave, and absenteeism.

CONCLUSIONS

Lower nurse-to-patient ratios and higher nurse workload are linked to in-hospital mortality, hospital-acquired infections, and medication errors among patients, and high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave their job among nurses in low- and middle-income countries. The results of this review show similarities with the evidence from high-income countries regarding poor outcomes for patients and nurses. These findings should be considered in light of the lower nurse-to-patient ratios in most low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018119428.

Predictors of actual turnover among nurses working in Korean hospitals: A nationwide longitudinal survey study

AIM

To examine the factors affecting actual turnover among nurses working in hospitals using the Brewer-Kovner synthesis model.

BACKGROUND

To increase retention of nurses, it is important to understand factors contributing to actual turnover among nurses.

METHODS

A longitudinal study design was utilized with 2,633 of 20,613 eligible female hospital nurses who participated in Korea Nurses' Health Study. We created two age groups: a younger group (20-35 years) and an older group (36-49 years). Multivariate logistic regression was used to identify the factors influencing turnover by age group.

RESULTS

Pregnancy and childbirth increased young nurses' turnover. When we excluded intent to leave, depression and burnout were significant factors affecting young nurses' turnover. Salary and hospital size were factors predicting nurse turnover among nurses older than 36 years.

CONCLUSIONS

It is essential to develop prevention strategies of female nurse turnover based on the age group in Korea.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers and health care institutes need to develop new managerial and policy strategies to reduce nurse turnover in each age group.

Risk factors for incorrect surgical count during surgery: An observational study

BACKGROUND

Incorrect surgical counts are closely related to retained surgical items, which pose a threat to patients. However, the risk factors for incorrect surgical counts have not been identified yet.

AIM

To identify the risk factors associated with incorrect surgical counts during surgery in a tertiary hospital.

DESIGN

An observational case-control study.

METHODS

Seventy cases of incorrect surgical counts were reviewed in this study. Data were collected from January 1, 2014, to April 4, 2019. For each case, we included four randomly selected control cases involving the same surgical procedures by the same surgeon within a 6-month period for comparison. The medical data of these cases were extracted for further statistical analysis.

RESULTS

A higher incidence of incorrect surgical counts was observed among surgical counts performed between 8:00 a.m. to 12:00 a.m., emergency operations, prolonged procedures, and/or after addition of surgical items.

CONCLUSION

Prolonged surgical procedures, emergency operations, time of occurrence, and addition of surgical items were the risk factors related to incorrect surgical counts during surgery.

Nurses reports of actual work hours and preferred work hours per shift among frontline nurses during coronavirus disease 2019 (COVID-19) epidemic: A cross-sectional survey

Background

The Coronavirus disease (COVID-19) pandemic is an ongoing pandemic all over the world, leading to 126, 372, 442 people diagnosed and 2, 769, 696 deaths globally as of March 28, 2021. Nurses are providing care to patients with COVID-19 who require hospitalization. To ensure adequate response capacity and to maintain the health of nurses, it is important to analyse the actual work hours and the nurses reported preferred work hours per shift among frontline nurses.

Objective

To analyse the actual work hours and preferred work hours per shift of nurses reports among frontline nurses fighting the COVID-19 epidemic and to explore the influencing factors on the nurses reported preferred work hours.

Design

Cross-sectional survey.

Settings

This study was conducted in 10 designated hospitals providing treatments to patients with COVID-19 in China.

Participants

Nurses providing care to patients with COVID-19 in designated hospitals in China.

Methods

A questionnaire with open-ended questions was used to assess frontline nurses caring for COVID-19 cases in 10 designated hospitals. Quantitative and qualitative methods were used to analyse the actual work hours, the nurses reported preferred work hours and factors influencing nurses reported preferred work hours among the frontline nurses.

Results

A total of 109 nurses responded to the survey. The shift length exceeded the nurses' preferred work hours [Median (interquartile range): 5.00 (2.00) h vs 4.00 (2.00) h; Minimum-Maximum: 4-12 h vs 4-8 h], and 60.55% (66/109) of the nurses regarded 4 h as the preferred number of work hours per shift. Five key themes associated with the influencing factors emerged, including circumstances; personal preventable equipment; the nurses' physical and emotional needs of nurse; and the nurses' safety needs and work intensity.

Conclusions

These findings suggest that there is a gap between the actual work hours and the nurses preferred work hours among frontline nurses in different units and different posts. The main influencing factors were circumstances, personal protective equipment, the nurses' physical and emotional needs, and the nurses' safety needs and work intensity.

Telecommuting, Off-Time Work, and Intrusive Leadership in Workers' Well-Being

Telecommuting is a flexible form of work that has progressively spread over the last 40 years and which has been strongly encouraged by the measures to limit the COVID-19 pandemic. There is still limited evidence on the effects it has on workers’ health. In this survey we invited 905 workers of companies that made a limited use of telecommuting to fill out a questionnaire to evaluate intrusive leadership of managers (IL), the request for work outside traditional hours (OFF-TAJD), workaholism (Bergen Work Addiction Scale (BWAS)), effort/reward imbalance (ERI), happiness, and common mental issues (CMIs), anxiety and depression, assessed by the Goldberg scale (GADS). The interaction between these variables has been studied by structural equation modeling (SEM). Intrusive leadership and working after hours were significantly associated with occupational stress. Workaholism is a relevant moderator of this interaction: intrusive leadership significantly increased the stress of workaholic workers. Intrusive leadership and overtime work were associated with reduced happiness, anxiety, and depression. These results indicate the need to guarantee the right to disconnect to limit the effect of the OFF-TAJD. In addition to this, companies should implement policies to prevent intrusive leadership and workaholism.

Staffing levels and nursing-sensitive patient outcomes: Umbrella review and qualitative study

Objective

To derive a comprehensive list of nursing‐sensitive patient outcomes (NSPOs) from published research on nurse staffing levels and from expert opinion.

Data Sources/Study Setting

Published literature reviews and their primary studies analyzing the link between nurse staffing levels and NSPOs and interviews with 16 experts on nursing care.

Study Design

Umbrella review and expert interviews.

Data Collection/Extraction Methods

We screened three electronic databases for literature reviews on the association between nurse staffing levels and NSPOs. After screening 430 potentially relevant records, we included 15 literature reviews, derived a list of 22 unique NSPOs from them, and ranked these in a systematic fashion according to the strength of evidence existing for their association with nurse staffing. We extended this list of NSPOs based on data from expert interviews.

Principal Findings

Of the 22 NSPOs discussed in the 15 included literature reviews, we rated the strength of evidence for four as high, for five as moderate, and for 13 outcomes as low. Four additional NSPOs that have not been considered in literature were identified through expert interviews.

Conclusions

We identified strong evidence for a significant association between nurse staffing levels and NSPOs. Our results may guide researchers in selecting NSPOs they might wish to prioritize in future studies. In particular, rarely studied NSPOs as well as NSPOs that were only identified through expert interviews but have not been considered in literature so far should be subject to further research.

Relationships between comprehensive characteristics of nurse work schedules and adverse patient outcomes: A systematic literature review

AIMS

To review the comprehensive characteristics of adverse nurse work schedules and to synthesise the evidence of their relationships with adverse patient outcomes.

BACKGROUND

To manage nurse shortages and fluctuations in patient censuses, nurses often work overtime. This increases nurses' work hours and causes them to have fewer breaks. Such extended work schedules, long shift length, long weekly work hours and insufficient beaks can be considered as adverse nurse work schedules. Understanding how these adverse nurse work schedules affect patient outcomes is important to ensure patient safety.

DESIGN

A systematic review of nursing and healthcare literature was conducted in this study.

METHODS

Eight electronic bibliographic databases (CINAHL, Cochrane Library, DBpia, EBSCO, PubMed, PsycINFO, RISS and Web of Science) were used to search research articles published from 2000 to 2019. The study selection process followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

RESULTS

From the search, 2,366 articles were identified, 22 of which were included in this review. Working more than 12 hours in a day had an adverse effect on patient outcomes, as was working more than 40 hours per week. There were mixed findings in the relationship between nurse overtime and adverse patient outcomes.

CONCLUSIONS

This study found a conclusive relationship between excessive nurse work hours and adverse patient outcomes. This review highlights the importance of managing adverse nurse schedules such as long daily and weekly work hours to improve patient safety and prevent adverse patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Study findings support the importance of monitoring and regulating nurse work schedules and adverse scheduling practices to improve nurse well-being and health and to prevent adverse patient outcomes.