Challenging shiftwork: a review of common rostering practices in UK hospitals

Contents.
Introduction.
Night shifts - permanent rota or internal rotation?
8 v 12 hour shifts.
Self rostering and flexible rostering.
Conclusion and recommendations.
References.

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For many nurses, shift work is a way of life. As Buchan states, 'As a service which is essentially 24-hour in nature, with often unpredictable fluctuations in workload, the NHS requires the majority of clinical nurses it employs to work some form of shift pattern'.(1) Historically, shift patterns in hospital wards were rigid and inflexible with little regard for either the actual workload or the individual nurse. There are many nurses in practice today who can remember split shifts and split days off which were endured because the vast majority of nurses lived on the hospital premises and were single. Today very few nurses live in hospital accommodation for any significant length of time and many have responsibilities and commitments outside work. It is therefore not surprising that there has been considerable interest in the last few years in tackling the problem of shift patterns.

The need for managers to review shift patterns has primarily arisen because of the recent problems of recruitment and retention of staff. (2), (3), (4)  Traditionally nurses with family commitments who no longer felt able to work a full time fixed rota could work on the hospital 'bank', transfer to a '9-5' area such as out-patients or opt for permanent night duty.(2) All of these options considerably disadvantaged the nurse in terms of continuing education and promotional opportunities. With many hospitals phasing out permanent night duty and some out-patient departments offering an extended service nurse managers are faced with the challenge of offering a flexible shift system which meets the requirements of the patient workload while also meeting the needs of the nurses. This paper sets out to review some of the recent literature and discuss the various models of shift working in hospitals in the UK. For the purposes of this discussion the American literature is not included. While some of the articles are very interesting, they are context bound to the U.S. healthcare system. (5), (6) This paper concludes by  making recommendations for those considering a review of their current working practices.

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The problem with night working is that as a species, the human race is diurnal, that is one which functions during the daytime. Night workers report a number of health problems including cardiovascular and gastro-intestinal disorders and circadian disruption has also been linked to depressive illness. (7) For many Night workers the worst time is just before dawn when they can barely stay awake to do their work yet often have to make important decisions. Lorry and train drivers are 15 times more likely to crash at dawn than at dusk and many of the world's major disasters - such as the Three Mile Island nuclear incident and the grounding of the Exxon Valdez have occurred in the early hours of the morning. (8) Such is the problem of night working that a U.S. company called Shift work systems has been coming into workplaces where night work is essential and 'resetting Night workers clocks' which fools the body that day is night and night is day.

Night shifts in hospitals are an essential part of a twenty four hour service yet a review of shift work by Harrington (cited by Humm) revealed that 10% of people enjoyed night work, the majority put up with it and between 20 and 30 percent were forced to give up nights because of health considerations.(7) Whether a hospital chooses to operate a permanent night shift system or by internal rotation both can be problematic to individual nurses. Nurses who choose to work permanent nights often do so because it fits in with their family commitments. However, in many hospitals permanent night rotas are being phased out because, apart from high technology areas such as Intensive Care and Accident and Emergency, a 'them and us' culture has developed between day and night staff with night staff rarely being considered much more than a maintenance service and, as mentioned earlier, restricted access to continuing education opportunities. This segregation has been further compounded in some city hospitals by a large presence on night duty of enrolled nurses who believe they are overlooked for first level registration conversion. Many hospitals have attempted to resolve these problems by introducing compulsory internal rotation. While this has certainly eradicated for the most part the 'them and us culture many individual nurses find the system problematic. Internal rotation plays havoc with childcare arrangements and some nurses find it physically impossible to cope with nights because of difficulty sleeping during the day.(7) However some managers believe the system to be fairer if everyone is required to work a set number of nights in a rota. Indeed Norfolk and Norwich Health Care Trust hit the headlines at the end of 1996 by making seventeen night shifts a year mandatory for all their surgical nursing staff with a one off payment of £800 despite opposition from the nurses. (9)

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But is it fairer? Given the reasons why many nurses work nights in the first place suggests that internal rotation suits very few nurses. In fact the evidence seems to indicate that in the current climate of recruitment and retention difficulties if nurses don't want to work nights they will simply leave. (3) Some of the solutions put forward have been to change the start and finish time of the night shift (10) and introducing a twilight shift which some staff are very happy to work. (11) However more enlightened managers are allowing their staff to decide for themselves how to cover the night shift.(7) Night shifts are voluntary, (as long as the ward was covered) and if staff opt for a period of permanent nights steps are taken to include them in care planning and ward activities. It is anticipated that enough nurses will volunteer for night shifts partly because a period of permanent nights may fit in with family life but also because in most hospitals night work still attracts more money.

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Recent publications have concentrated primarily on the advantages and disadvantages of 8 versus 12 hour shifts. (1), (12), (13), (14)  However, as Buchan points out, most of the evidence supporting the advantages and disadvantages of the two shift patterns is anecdotal with only one systematic study having been carried out in the UK this decade.(1) Todd, Reid and Robinson were commissioned by a health board to evaluate the 12 hour shift being introduced into all inpatient units in the boards' area.(15) The study was the first full-scale evaluation of the shift in the UK and comprised repeat measures (before and six months after) on 10 inpatient wards in two hospitals situated in the county town of a rural area. The hospitals chosen were currently using the traditional 8 hour shift allowing direct comparisons to be made. The researchers took a multi-focussed approach to the study by observing and measuring the effect on patient care, education of students, patient satisfaction and nurse satisfaction.

Their findings have been published from a range of perspectives.  (15), (16), (17), (18) The quality of patient care was evaluated using MONITOR and found a mean decrease of 11% for the total MONITOR score under the 12 hour shift system. While the overall quality of care for all dependency groups dropped, it was high dependency patients who were most adversely affected especially in terms of the physical and psychosocial care provided. The researchers measured the quantity of patient care given using an activity analysis and found that the amount of direct care given by nurses to patients decreased from 46% to 39% on the 12 hour shift. There was also a drop from 50% to 17% in the number of occasions when staff nurses and students were paired for situations which were observed to be overtly educational. Furthermore nurse educators expressed concern over the effect the shifts had on student learning since the 'overlap' period had traditionally been when formal teaching took place.

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This study clearly concluded that 12 hour shifts were detrimental to patients, students, nurses and the organisation. Despite these widely disseminated findings there has been a steady increase in the number of nurses undertaking 12 hour shifts whose experiences are not consistent with the study findings. (1), (2), (12), (19)  Certainly there are some limitations to Todd, Reid and Robinson's study: it was carried out in Northern Ireland therefore the setting is different to many U.K. city hospitals. It was before Project 2000 was implemented and the organisation of care appears to be patient allocation where some may argue primary nursing may have made a difference to the outcome. Indeed, those in favour of twelve hour shifts cite the implementation of the named nurse as much  easier with  twelve  hour shifts.(2), (14), (20)  However the main limitation of the findings is that the introduction of 12 hour shifts in this study was mandatory, not voluntary. Those who have experienced positive gains from the introduction of 12 hour shifts have all been where staff had a choice about whether to take part or not. (12), (14), (19)  Northcott  however, having noted a number of advantages to 12 hour shifts concludes that 'as the clinical leader of the Nursing Development at the John Radcliffe Hospital, Oxford, I could not entertain the 12 hour shift, especially as the benefits such a shift pattern offer are often abused.'(20) It seems a shame the staff were not able to make this decision for themselves.

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The advantages claimed for 12 hour shifts over 8 hour shifts are a small financial gain for the Trust by dispensing with the overlap period, (2), (20)  less time spent travelling for the nurse, more days off and heifer continuity of care. (14) All of these perceived advantages must be seen in the context of the voluntary nature of the introduction of such a shift system. The issue of quality of care is contentious; there appears to be no research that correlates systems of care with 8 and 12 hour shifts and studies the effects on patients and relatives from their perspective. Apart from a few exceptions, (13), (21)  most of the benefits claimed are from the point of view of individual nurses and their managers. (22)

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In a review of shift systems in England and Wales, Jane Barton found that out of 182 hospitals some 122 different shift systems were classified and out of these no two shifts were identical. (10) However, the specific features of the systems did not vary greatly and the main variations were in start and finish times. Given therefore that shift patterns are determined locally and that many hospitals reported shift trials in progress, it is therefore timely that recent emphasis has been on flexible and self rostering and annualised hours.

Two studies have described flexible rostering systems where the starting point was an analysis of the patient workload followed by the staff requirements to meet the workload.(2), (21) Both studies found it was possible to introduce a range of unconventional shift patterns with varying start and finish times that suited both the staff and met the requirements of the ward. An important factor was that staff perceive that they have far more control over their working lives with flexible rostering thus improving staff satisfaction. The two main arguments in favour of flexible rostering are that individual preferences can be taken into account which helps to minimise the conflict often experienced between home life and non standard working hours. Secondly, from an organisational point of view, flexible rostering is believed to reduce problems associated with staff retention and recruitment.(4) Two important developments around flexible rostering are annualised hours, (23) and self rostering. (3), (24)  Annualised hours have the advantage of offering even greater flexibility in that the nurse can work as little or as much as she likes as long as she does her total hours, thus allowing her to take more time off, for example, during school holidays, and the ward can request a high presence of staff for predictable busy times such as operating days or winter months. Many colleges of nursing within universities operate a similar system around annual teacher/student  contact  hours  which  allows  staff maximum flexibility in organising their working year. Annualised hours also offer nurses a full range of part time options rather than the 25 hours traditionally on offer, allowing staff to work anything from 0.1 to 0.9 of a whole time equivalent. Annualised hours in clinical settings have great advantages for the organisation and for staff, (1) but do need initial investment in support systems to ensure they are calculated accurately. Gillespie & Curzio used Time Care a computerised, flexible self-rostering system that enables nurses to match the demands of home and personal commitments with the requirement to provide quality patient care.(13) However, other modern software  packages,  such as the ANSOS application of the MDIS nursing system offer similar functions. In addition to annualised hours, there is a growing interest in self-rostering, (3), (24)  which while time consuming to set up and often beset with teething problems, again gives staff maximum control over their working lives.

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As stated at the beginning of this paper, shift work for most nurses is a way of life, indeed some nurses see positive benefits to working shifts. (25) What is quite striking about the literature reviewed is that within the sub-text of reviewing shift patterns are issues about the organisation of care, the needs of working mothers, recruitment and retention and a shift in the locus of control from managers to workers. Many nurses are juggling complicated lives with responsibilities at home as well as at work and it is clear that employers who are making an effort to accommodate flexible working as recommended by the RCN are more likely to retain motivated staff which must be good for patient care.(26) Recommendations are summarised below.

• New ways of working should be on a voluntary trial basis, not imposed.
• There is no reason why nurses on the same ward should all be working the same shifts.
• Shift patterns should be based on patient dependency and workload, not historical considerations.
• Making internal rotation compulsory is not necessarily in the interests of the nurse or the organisation.
• Wherever possible, flexible rostering should be supported by self-rostering and annualised hours with accompanying l.T. software.
• Employers would be well advised to set up monitoring systems to measure recruitment and retention against shift patterns.
• Future research should also concentrate on patients and carers views.

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1. Buchan J. The shape of things to come. Nursing Standard 1995: 9.26; 22-3.

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Last updated by DEB on 30/4/02

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