Abstract
The 12-hour shift schedule of nurses is one of the hospitals’ response to the shortage of nurses in the United States. Having this type of schedule practised among nurses, some studies have shown deleterious effects on the provision of care and providing safety for patients. The focus of the research paper is to identify the perceptions of nurses from the emergency room and critical care units on the effects of the 12-hour staffing schedule on patient’s safety. The nurses’ perception will be surveyed and analysed to contribute to the improvement of patient care in practice.
Introduction
It is a fact that nurses have an important role of being primary caregivers in the healthcare field. They are tasked to provide quality care and assure patient safety in any condition. The roles and responsibilities of nurses have a wide range, it includes monitoring of patients’ status, coordinating care, providing health education to patients as well as their relatives and giving competent and essential therapeutic care. However, there are several factors that might affect the performance of nurses in relation to assuring patient safety. Some of the factors identified by the Committee on the Work Environment of Nurses and Patient Safety were work processes, workload, work hours and workspaces of nursing staff (Page 2004: xi). In 2000, a report from the Institute of Medicine (IOM) documented an alarming rate of medical errors in the United States that caused mortality and morbidity to patients.
As what have been established, nurses are important members of the healthcare team. They provide direct care and spend the longest time at the bedside. Thus, nurses’ overall condition has a significant impact on the quality of patient care. According to Kovner et al., there is a definite link between nursing and patient safety (2002: 611-619). Factors that govern the safety of patients involve leadership and evidenced-based management structures and processes, effective nursing leadership and adequate staffing.
Background of the Study
The total care and safety of patients are dependent on the nursing staff. It is important that there is an existing effective nursing management in the healthcare setting. One criterion of a well-managed staff is a conducive and effective work shift for the nursing staff. Work shifts is a common prevalence in the nursing profession. There are numerous studies about the effects of working condition such as shift works. It was claimed that shift work and associated sleep disturbances can greatly affect human health conditions and can produce injuries as well as medical consequences (Berger & Hobbs 2006: 465-471). However, Dwyer et al. (2007: 711-720) mentioned in Bloodworth study , several advantages were identified by nurses regarding a longer work shift (two 12-hour and two 6-hour shift). The advantages of this shift work include better nurse-client interaction, better transition of communicated information including documentation within the ward, same privileges and work duties and responsibilities. Dwyer et al. (2007: 711-720) also identified other studies that revealed that 12-hour shifts produce benefits such as increased work concentration and satisfaction for nurses and enhanced direct nursing care for patients. Several studies have focused on the advantages and disadvantages of the 12-hour shift. This study aims to emphasise the effect of this work shift on patient safety.
Significance of the Study
Although healthcare professionals, such as nurses, are trained and knowledgeable, they can still make detrimental errors that may result to death or injury. Leape (1994: 15-25) stated that about 1.3 million patients are injured from healthcare errors. Kohn et al. (2000) stated that more than 100,000 deaths resulted from preventable adverse events that occur.
Patient safety is an important aspect of nursing care. One should be assured that the patient’s condition will benefit from the interventions provided by the healthcare team. It is important to recognise risk factors that may potentially produce mortality and morbidity to the patients. The presence of shift work in the nursing profession presents several threats to the well-being of nurses that can affect their performance. It is essential to develop better nursing management structures and processes that would decrease healthcare errors. Coordination between nurse managers and staff nurse must exist to develop an evidence-based system that would ensure patient safety .
Review of Related Literature
In many institutions like the the healthcare industry, it is imperative that staff or workers must circulate for 24 hours. It is impossible for an individual to work straight 24 hours without affecting the quality of the service he or she is rendering. Therefore, staffing schedules are utilised by hospitals and other similar industries to increase the efficiency and effectiveness of their manpower. Some of the staffing schedules would include the eight-hour shift, five-day work week; ten-hour workday, four-day work week; and 12-hour shift, three days on and four days off schedules. Each of them has its own advantages and disadvantages, and each is utilised depending on the situation the institution is experiencing. However, greater emphasis will be stressed on the 12-hour shift, three days on and four days off schedule.
The 12-hour shift, three days on and four days off schedule is utilised by some institutions. This pattern allows better continuity of the shift over the course without compromising the week (Marrelli and Hilary 2004). It also permits employees to have safe traveling hours; decreased traveling time to and from work; increased time to perform patient care, patient teaching, and staff education; and more effective reporting about changes in patients and effectiveness of treatment. Nevertheless, there are drawbacks in this kind of shift that makes it impractical to use by some institutions. The long hours of work makes the staff more fatigued compared to the eight-hour shift. The 30 minutes alloted for change-of-shift report may also be insufficient to accomplish everything. At the same time, attendance for staff meetings, in-service education programmes, and nursing care conferences may be reduced because nurses work for fewer days compared to other shift schedules (Rowland and Rowland 1997).
The staffing schedules have some correlation with patient safety. It is found out that nurses, who participated on shifts lasting for more than 12 hours, are three times higher to commit an error. A total of 199 errors and 213 near-errors were reported among the 393 members of the American Nurses Association who were working for 12.5 hours or more. About 50% of these errors involved medication administration, while the remaining half was comprised of charting, transcription, and procedural errors (American Health Consultants, Inc. 2004).
Patient Safety
Providing safety for patients is continuously declining with various human errors. Reports have shown a great number of patients who experienced various casualties from errors committed by physicians, nurses, and healthcare members providing care. One of the researches which discussed the deleterious effects of medical errors on patients is the one conducted in Colorado and Utah hospitals which demonstrated that 6.6% of adverse events led to the patients’ deaths (Brennan et al. 1991). Aside from that, the study conducted in Colorado and Utah hospitals revealed that around 44,000 Americans die annually due to medical errors (Thomas et al. 1999). The number of deaths due to medical errors exceeded the number of people dying from those who experienced motor vehicular accidents (43, 458), or even those patients who are experiencing breast cancer (42, 297) (Center for Disease Control and Prevention 1999). The healthcare providers’ inability to ensure patient safety and to guarantee protection from human errors has resulted in increased opportunity costs and lives affected by diseases.
The critical and initial step in order to provide progress in the quality of care is the safety of the patients. According to Kohn, Corrigan and Donaldson (2000), quality is referred to as one’s freedom from injury from accidents that occur inside or even outside the hospital premises. The safety of the patients is further driven by the intrinsic motivation of the health professionals, which is molded by their values and attitudes. Kohn et al. (2000) further stated that in order to keep the safety of the patient, then worker safety must also be promoted. Some of the ways that protect the healthcare professionals and are also beneficial to patients are the procedures for avoiding needle sticks and limiting long work hours of workers. These are some of the factors that have an impact on the quality of care being provided for patient safety.
In providing healthcare among patients, various hindrances could occur placing the patient’s safety at stake. Numerous kinds of patient safety problems can occur at any situation, these include transfusion errors and adverse drug events; surgical injuries and inappropriate site of surgery; restraint-related deaths or injuries; preventable suicides; nosocomial infections; and burns, falls, pressure ulcers, and mistaken identity (Kohn et al. 2000). Patient safety is completely acquired by keeping one’s patient free from all of these safety problems all throughout the course of providing care. In addition, a group of researchers grouped the patient safety problems in types identified as diagnostic errors, treatment errors, preventive errors, and other forms of errors (Leape et al. 1993). These are the currently being used criteria of the patient safety problems that often occur in hospitals, home care settings, and even at patient’s home. In order to control these preventable accidents, regulation modification must be enhanced, better information be disseminated, and explicit standards for patient safety must be set.
Research Question
What are the nurses’ perceptions of the impact of the 12-hour roster on patient safety?
Research Design
This study is considered as a qualitative type of research. According to Polit and Beck (2004), qualitative research is the investigation of a phenomenon, typically in an in-depth and holistic fashion through the collection of rich, narrative materials using a flexible research design from focused samples. Qualitative researches are one of the type of researches that increases and develops ways on understanding and explaining nursing knowledge for the nursing practice. With the purpose to explore, describe and explain a certain phenomenon, this type of research responds to answer an array of queries related to nursing concerns with respect to the responses of an individual to an actual or potential health problem. The study to be conducted will explain and describe the perception of 12-hour shift nurses from the emergency room department and intensive care unit department regarding the impact of the 12-hour shift schedule on patient safety. This phenomenon will be investigated and researched thoroughly by utilising the responses from a focused sample of nurse respondents.
This qualitative research is also considered as descriptive and exploratory. Descriptive qualitative research provides a comprehensive summary of events or phenomena in everyday life. In this research, the researchers do not interpret or penetrate deeply on the data itself; rather, they are collected and are based on the general premises of naturalistic inquiry. On the other hand, exploratory qualitative research explores the dimension of a certain phenomenon, or refines or develops hypotheses to explain the relationship between phenomena. It aims to answer questions regarding the full nature of the phenomenon; the process by which the phenomenon has experienced or evolved; or the real state or condition of the phenomenon in the present (Polit and Beck 2004). With the utilisation of the descriptive and exploratory research designs, this study will then provide a clearer view about the impact of the 12-hour shift schedule with consideration to patient safety.
Setting of Participants
The subjects in this study are registered nurses who have 12-hour shifts in the healthcare setting, represented by the staff nurses in a hospital. Staff nurses from the intensive care unit and emergency room of the chosen hospital are to be the target population for determining the perception of nurses regarding the impact of the 12-hour shift on patient safety. The number of subjects is set to 15 nurses for each area (intensive care and emergency room). The areas of intensive care units and emergency room are chosen because nurses from these areas experience a more challenging and stressful atmosphere.
The researcher is to utilise purposive sampling technique in obtaining the sample group. In purposive sampling, the samples, usually one or more specific predefined groups, are chosen to achieve a purpose. In this sampling technique, Polit and Beck (2004) suggested that the researcher sets eligibility criteria for population selection but their samples are not equal – they are not the same in some of the characteristics – and they are not randomly picked.
The researcher considered a set of criteria in the selection of the samples of the study. The set of criteria are as follows:
1 Staff nurses who have 12-hour shift in the hospital
2 Staff nurses who are assigned in the intensive care units and emergency room of the hospital
Only staff nurses who have consented to be respondents in the study are to be utilised.
Methods and Procedures
The main instrument that the researcher intends to use in this study is a self-made two-part questionnaire mainly composed by the nurses’ demographic profile and nurses’ perception and experience with patient safety during the 12-hour roster. This questionnaire will be a form of descriptive survey which will provide the necessary information that the study needs from the respondents.
The questionnaire will be customised to determine the nurses’ perceptions of the 12-hour roster on patient safety. The questionnaire that will be utilised is a self-made questionnaire patterned to the kinds of patient safety problems as identified by Kohn, Corrigan and Donaldson (2000). The first part of the questionnaire will be filled out by the nurse respondents and the second part of the questionnaire will employ the 5-point Likert Rating Scale to identify the degree of positivity or negativity of the perception of the participants. This scale will be utilised to measure the number of times that the participants from the ER and from the ICU encounter patient safety problems in a week with 5 as very often (9-10 patient safety problems occurred out of 10), 4 as often (7-8 patient safety problems occurred out of 10), 3 as sometimes (4-6 patient safety problems occurred out of 10), 2 as seldom (1-3 patient safety problems occurred out of 10), and 1 as never (no patient safety problem).
The researcher will validate the items in the questionnaire by doing a pilot study to the ICU and ER nurses of another hospital. Also, the tool will also be validated by three professors with master’s degree in related fields. Upon approval of the questionnaire, letters will be sent to the hospital informing it that the researcher wants to conduct the survey. Then, upon gaining entry to the hospital, the questionnaire will be multiplied and be distributed to 15 critical care nurses and 15 emergency care nurses with 12-hour roster. The accomplished questionnaires will be retrieved after 10 minutes.
The responses gathered will be tabulated, analysed and interpreted. The researcher will utilise the weighted mean value of the responses per item and will be computed by acquiring the sum of all the scores divided by the total number of scores. Mean is the most stable index of central tendency (Polit and Beck 2004: 460). This is utilised to acquire the general perception of the nurses with each occurrence of patient safety problems. A rank order rating scale will be used and the set of items will be ranked according to 5 as the highest and 1 as the lowest.
Ethical Implications
Before the participation of the respondents, an informed consent would be presented as a sign of their willingness to be part of the study. The researcher would inform the respondents about the nature and purpose of the research study. The research materials such as questionnaires would be kept by the researcher and confidentiality would be guaranteed. The identification of the respondents would not be mentioned, only their responses would be documented. Respondents have the right to withdraw any time during the study.
Summary
The researchers identified the increasing number of patients losing their lives from the preventable safety problems in the hospital. From this gathered fact, the researcher wishes to conduct this exploratory and descriptive study regarding the perceptions of nurses on the how 12 hour shifting type of schedule impacts the safety of the patients. Nurses from the emergency unit and from the critical care unit will be surveyed on the perceptions that each one has on the 12 hours shift ‘s impact on the safety of patients. The researchers believe that this study will definitely guarantee a leap in the advances of patient safety issues and a help in the decreasing the number of preventable deaths of patients throughout the treatment course.
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