The use of extended work shifts and overtime has escalated as hospitals cope with a shortage of registered nurses (RNs). Little is known, however, about the prevalence of these extended work periods and their effects on patient safety. Logbooks completed by 393 hospital staff nurses revealed that participants usually worked longer than scheduled and that approximately 40 percent of the 5,317 work shifts they logged exceeded twelve hours. The risks of making an error were significantly increased when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week. Se v e r a l t r e n d s i n h o s pi ta l use and staffing patterns have converged to create potentially hazardous conditions for patient safety. High patient acuity levels, coupled with rapid admission and discharge cycles and a shortage of nurses, pose serious challenges for the delivery of safe and effective nursing care for hospitalized patients.1 While systematic national data on trends in the number of hours worked per day by nurses are lacking, anecdotal reports suggest that hospital staff nurses are working longer hours with few breaks and often little time for recovery between shifts.2 Scheduled shifts may be eight, twelve, or even sixteen hours long and may not follow the traditional pattern of day, evening, and night shifts. Although twelve-hour shifts usually start at 7 p.m. and end at 7 a.m., some start at 3 a.m. and end at 3 p.m. Nurses working on specialized units such as 2 0 2 J u l y /A u g u s t 2 0 0 4 D a t a W a t c h

• Background To minimize the occurrence of adverse events among patients, critical care nurses must be alert to subtle changes in patients’ conditions, perform accurate clinical assessments, and respond expediently. However, little is known about the effects of the nurses’ work hours on vigilance and patients’ safety. • Objectives To describe the work patterns of critical care nurses, determine if an association exists between the occurrence of errors and the hours worked by the nurses, and explore whether these work hours have adverse effects on the nurses’ vigilance. • Methods Data were obtained from a random sample of critical care nurses in the United States. Nurses eligible for the study were mailed two 14-day logbooks to fill out. Information collected included the hours worked, the time of day worked, overtime hours, days off, and sleep-wake patterns. On days worked, the respondents completed all work-related questions and questions about difficulties in remaining awake while on duty. Space was provided for descriptions of any errors or near errors that might have occurred. On days off, the nurses completed only those questions about sleep-wake patterns, mood, and caffeine intake. • Results The 502 respondents consistently worked longer than scheduled and for extended periods. Longer work duration increased the risk of errors and near errors and decreased nurses’ vigilance. • Conclusions The findings support the Institute of Medicine recommendations to minimize the use of 12-hour shifts and to limit nurses’ work hours to no more than 12 consecutive hours during a 24-hour period.

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Given the large numbers of nurses who reported struggling to stay awake when driving home from work and the frequency with which nurses reported drowsy driving, greater attention should be paid to increasing nurse awareness of the risks and to implementing strategies to prevent drowsy driving episodes to ensure public safety. Without mitigation, fatigued nurses will continue to put the public and themselves at risk.

These findings underscore the importance of restorative sleep interventions and fatigue countermeasures for hospital staff nurses involved in dual care giving roles. Limiting overtime and applying circadian principles to hospital scheduling processes would ensure a more alert workforce, minimize health risks for nurses, and maximize the safety of those in their care.