Safety plays a critical role in the nursing and patient care hence the severe consequences of errors and attention failures (Rheaume & Mullen, 201 7 ; Dorrian et al., 2006). The job description of a nurse var ies from history taking, patient examination, diagnostic test administration, formulation of diagnoses, patient assessment, management of life support, patient admission and discharge decisions, and the design, calculation and administration of treatment regimens (Dorrian et al., 2006). Extended work hour s and working in shifts are occupational and safety hazard s , and the provision of nursing car e inevitably involves both . Subsequently, there is concern for the health of nurses, patient safety and patient outcomes (Rheaume & Mullen, 2017; Caruso, 2014; Dorrian et al., 2006). Fatigue has implications for ensuring safety due to several reasons. These include the role of nurses in remaining vigilant against errors in medication and dispensing orders; miscommunication between nurses, patients and the medical team; changes in patient condition; nosocomial hazards; clinical judgment errors; and failure to intercept errors by others (Dorrian et al., 2006 ).
Adequate sleep is an essential biological need for life similar to other needs such as good nutrition . F or good health and productivity, sleep duration of 7-8 hours is the minimum requirement (Caruso, 2014). Therefore, extended working hours and shift work affects health and well - being due to disruption of circadian rhythms which are key for maintenance of internal body temperature, hormone levels, blood pressure and sleep patterns (Rheaum e & Mullen, 2017). Lack of this minimum sleep duration is associated with the development of conditions such as difficulty with sleep, poor quality sleep, sleep debt, sleepiness during shifts, obesity, diabetes, high blood pressure, myocardial infarction, cerebral vascular incidents, injuries, errors, poor job performance due to increased fatigue , and lack of concentration (Rheaume & Mullen, 2017; Caruso, 2014).
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T he nature of work in health facilities necessitates the provision of patient care around the clock which often requir es shift work and working long hours . As a result, an increasing number of health workers report short sleep duration (≤ 6 hours) and sleepiness during shifts (Rheaume & Mullen, 2017; Caruso, 2014). Also , the competing demands of work - related duties and personal life, the insufficient time between work shifts, economic pressures necessitating the taking on of several jobs or even longer working hours, and a disregard for the importance of sleep result in shorter sleep duration (Caruso, 2014). I n general , t he healthcare sector has the highest number of workers reporting short sleep duration s (Caruso, 2014).
Effect of working long hours on health and social life of nurses
The problem of inadequate sleep is linked to working in shifts, long work hours and sleep disorders . For instance, night shift workers have significantly increased risk of fatigue, insomnia and excessive sleepiness (Rheaume & Mullen, 2017; Caruso, 2014; Dorrian et al., 2006; Muecke, 2005). Sleep deprivation often results in a decline of cognitive functioning and performance which is characterized by reduced alertness , involuntarily falling asleep, and episodes of microsleep , in which the brain does not process information and lapses in attention occur (Rheaume & Mullen, 2017;Caruso, 2014). In the ir study, Rheaume & Mullen ( 2017 ) examin ed sleep quality, quantity, and sleepiness on cognitive outcomes . Results showed that nurses working 12-hour rotations had less sleep time, less sleep efficiency, and exhibited higher rates of sleepiness . H owever, there were no differences in cognitive errors between this group and those undertaking 8-hour days. As a result of this impaired neurocognitive function, injuries and workplace errors are common . Examples include increased incidences of needlestick injuries, missing work, illness and decreased job performance (Rheaume & Mullen, 2017; Caruso, 2014). Poor health behaviours such as short sleep duration, smoking, obesity, low physical activity, and alcoholism as well as prescription and non prescription sleep aids such as alcohol are associated with long working hours and sleep deprivation (Caruso, 2014; Dorrian et al., 2006; Muecke, 2005).
The other diseases associated with working long hours and sleep deprivation include mood disturbances, gastrointestinal disorders such as abdominal pain, gas, diarrhoea, constipation, nausea, vomiting, change in appetite, indigestion and heartburn (Caruso, 2014; Muecke, 2005). It is postulated that the altered circadian rhythms of feeding and digestion, stress response due to sleep deprivation, changes in immunity and type of food available may be the causes of impaired gastrointestinal function (Caruso, 2014; Muecke, 2005). Increased risk of colon cancer also occurs in nurses working night shifts (Caruso, 2014). Shift workers also often report psychological disorders such as depression, bad mood, irritability, anxiety, personality changes, and difficulty with personal relationships (Caruso, 2014; Muecke, 2005). Due to the metabolic changes and smoking , shift workers have been shown to be at higher risk of cardiovascular disorders such as myocardial infarction, chest pain, ischaemic strokes, no-skin cancers, arthritis and high blood pressure (Rajan, 2017; Caruso, 2014). In the study by Burdelak et al. (2012), the most common diseases observed in nurses and midwives doing night work w ere chronic back pain, hypertension and thyroid diseases . For instance, statistically significant association was found between duration of work performed on night shift and relative risk of thyroid diseases and swollen feet. Apart from health - related issues, destructive behavior at work, inability to balance work and family life, dissatisfaction with partner s , and the failure to satisfy needs of partner s were the negative impact s that were frequently cited by nurses working long hours (Rajan, 2017).
The individuals who work for long hours typically have less time to engage in such healthy behavior s as exercise, yoga, and meditation (Rajan, 2017). Working longer hours may lead to work-family conflict (work-life imbalance), work stressors and contribute to lower access to social support . They also influence the development of health conditions that may affect social life since work - life balance and work stressors have impact s on the well-being of famil ies (Rajan, 2017). The most frequently reported w ork - related stressors were unclear role s , inadequate salaries and incentives, paperwork, shift work and work overload (Rajan, 2017). The other reported effects of working long hours are sadness and depression, eye strain, back pain, dissatisfaction with overall life, parenting stress, diminishing vitality, mental health, lack of innovativeness, indulging in unethical behavior such as misuse of assets and authority, sexual harassment, and breaching codes of conduct (Rajan, 2017).
Effect of working long hours on work performance, patient safety, and the community
Fatigue - related impairments occasioned by long working hours , shift work and poor sleep quality are linked to errors in the delivery of patient care . They are also associated with vehicle crashes on the commute (Rheaume & Mullen, 2017; Caruso, 2014; Wu et al., 2013; Dorrian et al., 2006). The overwhelming number of studies conclude that extended working hours and shift work are responsible for decreased work performance by nurses . H owever, on fewer nursing staff working irregular shifts , the increased workload has been shown to increase the risk of error (Rheaume & Mullen, 2017; Muecke, 2005). In the ir study , Dorrian et al. (2006) reported of nurses struggling to remain awake during shifts, and exhibiting moderate to high levels of stress, physical exhaustion, mental exhaustion, extreme drowsiness while driving or cycling home, and near accidents in 36%, 23%, 40%, 36% of shifts, 11.5% of occasions, and 3 cases respectively. O verall, i n th e study , 20 errors, 13 near errors, 22 observed errors were reported , and the consequences for the majority of the errors were minor . H owever, 11 were moderate, and four had potentially severe consequences (Dorrian et al., 2006). Sleep duration was significantly associated with the probability of committing or catching someone else's error with consequences for patient safety (Dorrian et al., 2006; Muecke, 2005).
Long work shifts have been linked to patient dissatisfaction, specifically due to poor communication and delays in offering patient care (Caruso, 2014; Stimpfel et al., 2012). Besides, nurses doing shifts longer than 13 hours were more likely to suffer burnout, job dissatisfaction and tendency to leave the job (Caruso, 2014; Stimpfel et al., 2012; Muecke, 2005). Similarly, the odds of patient care errors are greater for nurses working longer shifts compared to those doing 8 - hour shifts . Subsequently, s truggling to stay awake is the main predictor of patient-related errors (Rheaume & Mullen, 2017; Caruso, 2014; Muecke, 2005). Consequently, higher patient mortality rates have been linked to higher rates of nurses working long hours, lack of time away from work, working while sick, and a higher burden of work (Caruso, 2014). Fatigue - related accidents, lost productivity, health care expenses, and fatigue-related productivity losses on the part of healthcare organizations are substantial and have been estimated at approximately $2000 per employee in the United States (U.S). T he economic cost is also enormous (Caruso, 2014; Dorrian et al., 2006). Due to disability and inability to work , employers face the risk of losing nurses . This may be accompanied by high insurance rate and even higher compensation rates (Caruso, 2014; Stimpfel et al., 2012).
Long working hours and working in shifts are often cited as reasons for burnout, job dissatisfaction and the reason for leaving the nursing profession . T he major concern s in this regard include acute or chronic effects of stress and being overworked . T he cost s are even higher for healthcare organizations due to failure to retain nurses (Caruso, 2014; Stimpfel et al., 2012). Burnout often manifests as emotional exhaustion, depersonalization of patients, and the feeling of lack of personal accomplishment by caregivers (Stimpfel et al., 2012). The long working hours and extensive shifts affect the wellbeing and safety of nurses, negatively impacts on patient care and safety, and often result s in the feeling of being overworked and under - valued . This is associated with expensive turnover of nurses and retention difficulties (Caruso, 2014; Stimpfel et al., 2012; Dorrian et al., 2006). Decision-making ability as well as patient outcomes are affected by fatigue occasioned by long working hours and disrupted sleep (Rheaume & Mullen, 2017). In the ir study , Wu et al. (2013) sought to determine nurse working hours on ‘patient safety culture’ (PSC) . The study established that th e patient safety grade deteriorated and the number of adverse events reported increased with longer working hours (Wu et al., 2013). Among the 12 sub-dimensions of PSC observed, long working hours impacted staffing and teamwork (Wu et al., 2013). Patient safety culture was defined as the product of individual and group values, attitudes, perceptions, competencies, and pattern of behavior that determine commitment to, style, and proficiency of an organizations health and safety management (Wu et al., 2013) .
Factors and driving forces for extended working hours among nurses
Traditionally, the eight hour working shifts were the norm for hospital nurses . T his has now been replaced with 12 - hour shifts that correspond to a three day work week for nurses (Stimpfel et al., 2012). On the face of it, this appears better for work - life balance and individual flexibility . H owever, when the fact that shift lengths are often unpredictable due to patient needs and changes in staffing are factored in, unintended overtime may creep in (Stimpfel et al., 2012). The effect of unplanned overtime at the end of a long work shift combined with the fact that shifts are often on a rotation basis increases the risk of burnout and fatigue , subsequently compromising patient care (Stimpfel et al., 2012). V arious factors are responsible for long working hours and shifts for nurses . These include the fact that most often than not nurses are not subject to strict policies regulating work hours such as those set for resident physicians (Stimpfel et al., 2012). If policies exist, they are often characterized with ambiguities and double standards (Stimpfel et al., 2012). W orkplace cultures that respect vacation time and days off for nurses, prompt swift departure of nurses at the end of work days and shifts, as well as allowing nurses to decline overtime work without attracting negative consequences rarely exist, hence perpetuating long working hours and extended shifts (Stimpfel et al ., 2012).
Rigid rules of the hospital, long and unsocial work schedules, and inability to leave duty on time were the main factors associated with extended working hours (Rajan, 2017). In their s tudy , Stimpfel et al. (2012) established that a majority of the nurses that worked 12-13 - hour shifts were predominantly male, non-white, and of lower mean age. This category reported higher burnout rates, job dissatisfaction and intention to leave the job and higher odds were calculated . A dditionally, this impacted on patient satisfaction and care as measured by the Hospital Consumer Assessment of healthcare providers and systems survey , which a standardized survey is taken by healthcare institutions (Stimpfel et al., 2012).
One principal factor that is driving the progression to extended and unpredictable working hours and shifts that lack regular breaks is the worldwide shortage of nurses . This is exacerbated by t he overwhelming increase in demand for healthcare . When combined , these two factors result in increased workload for existing nursing staff (Dorrian et al., 2006). The other notable factor is the changing nature of the nursing profession . Currently, the profession emphasizes fast patient turnover , which often demands that nurses care for acute illness patients for shorter durations . This leads to increased associated stress, and the lack of personal satisfaction that is gained from knowing a patient and seeing them recover (Dorrian et al., 2006). The increasing introduction of technology in nursing and patient care often and ironically results in the increased demand for the cognitive processes of nurses (Dorrian et al ., 2006).
Recommendations of countermeasures reducing the adverse effects of long working hours on nurses
To reduce the adverse effects of long working hours, one possible countermeasure is the implementation of fatigue management programs. These programs are aimed at reduc ing sleepiness-based errors and include an educational component and schedule alterations (Rogers, 2008). Employees are given information about circadian rhythms, sleep hygiene measures, the adverse effects of shift work, and strategies to reduce fatigue . Notable strategies include judicious caffeine use and napping during night shifts (Rogers, 2008). Shift schedule alterations may include changes in shift starting times to match circadian rhythms, alternating night shifts, providing adequate recovery time between shifts and considering hours of service regulations where applicable (Rogers, 2008). The other recommended safety practices include rest breaks, napping, exercise, bright lights, and pharmacologic measures (Rogers, 2008). Due to the observation that nurses working on rotational shifts tended to nod off more during shifts than their day - to - evening counterparts, napping or provision of quiet time during the day is one of the most successful countermeasures for decreas ing the effects of sleepiness and fatigue during shifts (Rheaume & Mullen, 2017). This has the effect of reduc ing the risk of work injury, increas ing patient safety, decreas ing attention related failures, reduc ing errors at work and improv ing job performance (Rheaume & Mullen, 2017). On average , nurses report having only 27.5 minutes break in a shift, with those working longest hours less likely to receive appropriate breaks . S hort breaks improve performance and subjective fatigue (Rogers, 2008). These breaks are particularly effective in lowering the accumulated risk associated with prolonged task performance (2 hours of sustained work) . However, short breaks do not necessarily decrease accident risk and errors (Rogers, 2008). Some of the self-reported strategies for coping include praying, consulting and vacationing (Rajan, 2017) .
References
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Dorrian, J., Lamond, N., van den Heuvel, C., Pincombe, J., Rogers, A. E., & Dawson, D. (2006). A pilot study of the safety implications of Australian nurses' sleep and work hours. Chronobiology international , 23 (6), 1149-1163. doi: https://doi.org/10.1080/07420520601059615
Muecke, S. (2005). Effects of rotating night shifts: Literature review. Journal of advanced nursing , 50 (4), 433-439.
Rajan, D. (2017). Negative Impacts of Long Working Hours: A Comparative Study among Nurses. MOJ App Bio Biomech . 1(2) : 00010. doi: 10.15406/mojabb.2017.01.00010
Rhéaume, A., & Mullen, J. (201 7 ). The impact of long work hours and shift work on cognitive errors in nurses. Journal of nursing management , 26 (1), 26-32. doi: https://doi.org/10.1111/jonm.12513
Rogers, A. E. (2008). The effects of fatigue and sleepiness on nurse performance and patient safety.
Stimpfel, A. W., Sloane, D. M., & Aiken, L. H. (2012). The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs , 31 (11), 2501-2509. doi: https://doi.org/10.1377/hlthaff.2011.1377
Wu, Y., Fujita, S., Seto, K., Ito, S., Matsumoto, K., Huang, C. C., & Hasegawa, T. (2013). The impact of nurse working hours on patient safety culture: a cross-national survey including Japan, the United States and Chinese Taiwan using the Hospital Survey on Patient Safety Culture. BMC health services research , 13 (1), 394 . doi: https://doi.org/10.1186/1472-6963-13-394
