Working patterns and patient loads: the influence on good nursing practice

Introduction

Previous health workforce research has explored how components of nursing work may be affected when different staffing and scheduling configurations are used. A large body of evidence shows the potentially harmful effects that long shifts (≥12 hours), working beyond contracted hours (overtime) and low staffing levels have on outcomes like care quality, missed care and nurses’ wellbeing (Shin et al, 2018; Bae and Fabry, 2014; Ball et al, 2014; Griffiths et al, 2014; Stimpfel et al, 2012; Needleman et al, 2002).

In addition to direct care, nurses are also responsible for doing work that indirectly supports good nursing practice. This can include fostering care continuity, ensuring good communication with colleagues, and maintaining/updating skills and knowledge. Although not part of face-to-face care, these activities are critical to the delivery of safe and continuous care, and to building workforce capacity (Manley et al, 2011).

Nurses’ ability to complete these supportive activities may also change when they are operating under strained working conditions. To explore this idea further, we looked at the influence of long shifts, overtime and higher patient load on nurses’ opportunity for completing work that supports good nursing practice.

Data collection and analysis

We analysed survey data from 2,990 nurses working on general medical and surgical wards across 48 hospitals in England. These surveys were originally collected as part of Sermeus et al’s (2011) Nurse Forecasting in Europe (RN4CAST) study. We selected four survey questions to examine activities that support good practice:

• Taking part in staff development/continuing education programmes;
• Having time to discuss patient care problems with other nurses;
• Observing care assignments that foster continuity of care;
• Observing loss of patient care information during shift changes;

Nurses were asked to rate on a 4- or 5-point scale the extent to which each factor was present in their jobs.

We looked at respondents’ demographic profiles and the percentage of nurses agreeing with each statement, according to the length of shift worked, whether they worked overtime and patient load (measured as average patient:nurse ratios). We tested relationships between workforce configurations and responses using multilevel logistic mixed models, which allowed us to account for other factors that may influence nurses’ responses, such as age, gender, full/part-time status and shift timing (day, afternoon/evening, night). Odds ratios were used to estimate the relative likelihood of a particular outcome (such as undertaking professional development) by comparing two sets of people: one group of nurses who were exposed to something (such as working long shifts) and another group of nurses who were not.

Who was surveyed?

Nurses were aged ~40 years old on average, with 92{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} being female and 77{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} working full time. In terms of the length of last shift worked: 33{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} of nurses worked eight hours or less; 14{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} worked between eight and 10 hours; 19{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} worked between 10 and 12 hours; and 34{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} worked ≥12 hours.

The average patient load was calculated as 8.6 patients per nurse, and 51{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} reported working overtime during their last shift.

Effects of working long shifts

When compared with nurses who had worked eight hours or less on their last shift, those who worked for ≥12 hours were:

• 42{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} less likely to report having time for professional development;
• 28{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} less likely to report having time to discuss care problems.

Shift length did not appear to make a difference to nurses’ reports of continuity of care or information loss during handovers.

Effects of working overtime

When compared with nurses who kept to their contracted hours, those who worked overtime on their last shift were:

• Less likely to report having time for professional development;
• Considerably less likely to report being able to discuss care problems with other nurses;
• Less likely to see patient care assignments that foster continuity;
• More likely to report loss of care information during shift changes.

Effects of higher patient loads

For each additional patient per nurse (that is, an increase in patient load), there was a:

• 4{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} decrease in the likelihood of having time for professional development;
• 9{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} decrease in likelihood of having time to discuss patient care problems with other nurses;
• 5{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} decrease in the likelihood of observing care assignments that foster continuity of care;
• 3{33c86113bcc32821f63c6372852a0f501e07fff55ce3ce61b15b246c5f8c531c} increase in the likelihood of observing loss of care information during shift changes.

What do these results tell us?

Nurses are statistically significantly less likely to have the time and opportunity to complete activities that support good nursing practice when working long shifts and overtime, and when they have higher patient loads. Opportunity for contining professional development was most negatively affected when nurses worked long shifts. Discussing care problems with colleagues, observing continuity of care assignments and observing loss of care information during handovers were most negatively affected when nurses worked overtime. All four outcomes worsened when nurses had higher patient loads.

Other studies specifically exploring incomplete/missed care – namely, Dall’ora et al (2019) and Griffiths et al (2018) – have found associations between these workforce configurations and worsened patient outcomes. Yet, despite these associated problems, long shifts, overtime and high patient loads are often seen as unavoidable responses to system-wide pressures due to nursing shortages (Buchan et al, 2020).

To counter potential consequences, support for staff must be strengthened so nurses have enough time to complete all aspects of their work. General solutions – such as protecting time for team discussion/debriefing and administrative paperwork, streamlining charting and data-entry processes, and incentivising professional development – can be introduced or revitalised. However, more local solutions (that is, on the ward, or at hospital or trust level) are also necessary to address different staff needs and priorities.

Conclusion

As well as doing direct care work, nurses need adequate time/opportunity to complete activities that support good practice –but opportunities to do so may be reduced for those working long shifts or overtime, or with heavier patient loads. Decision makers and managers must carefully consider the implications of using these workforce configurations, as they have short- and long-term consequences for care quality. Completing this supportive work is likely to improve nurses’ capacity to manage workloads, team collaboration and career satisfaction – all of which are important for staff recruitment and retention.

• This article is reproduced from: Ball J, Emmanuel T (2022) How do long shifts, overtime, and higher patient load influence activities that support good nursing practice? Evidence Brief; University of Southampton. Sept 2022. Available from: eprints.soton.ac.uk/id/eprint/469204 (accessed 15 November 2022). Reproduced under the terms of a creative commons attribution CC-BY (4.0) licence. The RN4CAST study was funded by the EU 7th Framework Programme (FP7/2007–2013, grant agreement no: 223468). Members of the research team were supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex. The views expressed are those of the authors and not necessarily those of NIHR, Department of Health and Social Care, arm’s-length bodies or other government departments.