By Anne Federwisch
Illustration by Malcolm Garris/PhotoDisc
November 30, 1998

Are 12-hour shifts a benefit or burden for health professionals? The answer depends on whom you ask. For some, the longer hours are a morale-boosting perk. For others, they’re merely fatiguing. Yet experts on both sides of the issue believe the success of 12-hour shifts depends on how employers and employees manage the schedule.

"It’s a very controversial issue," said Laura Mahlmeister, PhD, RN, president of Mahlmeister and Associates and a staff nurse in the birthing center at San Francisco General Hospital. "If you’re 23 or 26 or 30 years old, you usually love those 12-hour shifts. They give you so much more personal freedom." Typically, those working 12-hour days get about twice as many days off in a pay period as those on eight-hour cycles.

However, the extended hours are more of a burden for middle-aged nurses, she said. Her unit has consistently voted down 12-hour shifts. "The intensity of care, and the age of some of the nurses, lends itself to eight-hour shifts," said Mahlmeister, who describes herself as "the oldest living labor and delivery nurse still in practice at S.F. General."

Other nurses, like those at Maimonides Medical Center in Brooklyn, N.Y,. would rather fight than give up 12-hour shifts. They went on strike for three weeks to protest management’s proposal to return to eight-hour shifts. In April, the two sides compromised by allowing nurses in critical care units to remain on 12-hour shifts, while the remaining staff reverted to eight-hour shifts.

Not your grandma’s shift

Although striking for the right to work 12-hour shifts may seem ironic in light of the push for eight-hour days by labor unions in the beginning of this century, the issues really are different, said Ed Coburn, publisher at Circadian Information, part of Circadian Technologies Inc. in Cambridge, Mass., a firm that helps managers of 24-hour operations improve safety and performance. Today’s 12-hour shifts are part of a 36- to 48-hour workweek rather than the 72 to 80 hours our greatgrandparents endured. That makes the shifts both more manageable and more desirable, he said. "Once people work on 12-hour shifts, they are overwhelmingly popular," Coburn said. That passion for the 12-hour shift is certainly evident in the pulmonary services department at Baylor University Medical Center in Dallas, according to the manager, Marta Tingdale, RRT, RN. She estimates that 70 percent of respiratory therapists work the longer shift. "I have one employee who’s already told me she’d quit if we ever got rid of 12-hour shifts," Tingdale said. One of the main advantages for employees has been more days off as a result of the condensed schedule, she said.

Resisting temptation

But that free time can be a temptation for some health professionals to moonlight, pushing the workweek to dangerous excesses. "There is a point where we think the fatigue factor over the course of several days will kick in," said Jean Francis, MSN, RN, senior vice president and chief nursing officer at Children’s Medical Center of Dallas. She said that although the medical center has not experienced any unsafe care, the administration knows anecdotally that staff working the weekend option were likely to work elsewhere during the week. (That option required a year’s commitment to work every weekend in return for a bonus every pay period, full benefits, and prorated sick and vacation time.)

Since the administration cannot regulate how many hours someone works at another facility, the medical center no longer offers new employees the weekend option. The center also monitors the number for long shifts of all staff per two-week pay period to ensure that no one works too many hours.

Paying attention to staffing patterns is crucial to the success of a longer workday, according to Martin Moore-Ede, MD, PhD, associate professor of physiology at Harvard Medical School and president and CEO of Circadian Technologies. He recently co-authored the Complete Idiot’s Guide to Getting a Good Night’s Sleep. "You can’t make a blanket approval about 12-hour shifts," he said. They’re not all alike, because there are hundreds of ways to schedule the shifts. Too many shifts a pay period or flip-flopping nights and days can sabotage a 12-hour schedule, he said.

Equally important is what health professionals do when they go home, experts say. Sleep should be a priority. A long day in the emergency department leaves no time for anything at home, said Thomas Bretz, RN, a staff nurse at Valley Presbyterian Hospital in Van Nuys, Calif. "Basically, when you’re at work, you’ve dedicated that day to work," he said. Bretz, a single parent, can now put in a 12-hour day because his 16-year-old son is more independent. But when his son was younger, Bretz took a job in a clinic with an 8 a.m. to 4:30 p.m. schedule so that his career wouldn’t interfere with his child-rearing responsibilities.

Fatigue factor

Although critics of 12-hour shifts question the ability of health professionals to remain alert, Bretz said that he has never had a problem with fatigue. "In my field, in the emergency department, you’re always on a low level of alert," he said. "As soon as something comes in the door, you’re on high alert again."

Tingdale, too, has not noticed any fatigue-related safety problems with her staff. "I think that because you can be off for more days, you’re prepared to do what you need to do to provide good patient care," she said. "Professionals know how to take care of themselves."

The 12-hour shift often gets a bad rap for what is really a staffing difficulty, said Anna Gilmore-Hall, RN, director of labor relations and workplace advocacy for the American Nurses Association. "Patients may be in danger for a lot of reasons, but you can’t say it’s just because a nurse works a 12-hour shift," she said. "If those nurses are understaffed, do not have adequate time off during the week, and the acuity of the patients is so high and the need for additional staff has not been granted, then you run into patient care issues." But that’s really due to understaffing, not the 12-hour shift, she explained.

Research needed

Yet more nursing-related research is needed to determine definitively the effect of longer hours on critical thinking skills, according to Mahlmeister. She said that research on pilots led to a requirement for them to take a nap after 12 hours on overseas flights. "If pilots on long transpacific flights to Asia are required to take naps because research suggests that they are losing mental acuity, what does that say about nurses who are running for 12 hours and are doing more than just looking at a panel of instruments with two other people in the cockpit?"

Mahlmeister said she does not know the answer. Nor is she absolutely opposed to the longer workday. "I think nurses have a right to vote and collectively negotiate for 12-hour shifts if that’s what they want to do," she said. But she would like the unanswered questions studied. "Everybody knows that there’s a finite period of time in which you can work before you start losing your ability to make acute critical judgments," she said. But is that eight hours? 12 hours? Does that change with age? Does it matter how many shifts in a row you work? What about the "second shift" many nurses work at home? "That research has not been done in nursing," Mahlmeister said.

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$ What’s It Worth $

What a 12-hour shift is worth in dollars differs from institution to institution because the equation for paying clinicians for a longer day has many variations.

For instance, nurses at Children’s Medical Center of Dallas are exempt employees, so they get paid overtime only if they work more than 80 hours in a two-week pay period, according to Jean Francis, MSN, RN, senior vice president and chief nursing officer. Respiratory therapists get overtime if they work over 40 hours in a week, but not if they work over eight hours in a day.

Other health professionals, such as ER nurse Thomas Bretz, RN, of Valley Presbyterian Hospital in Van Nuys, Calif., gets a lower base pay than nurses working eight-hour shifts. But he gets time and a half for any hours over eight that he works in a day. Because of the differential, his salary for six 12-hour shifts every two weeks is comparable to other nurses’ pay for 10 eight-hour shifts.

"But if you work less than the 12—if you work part time or flex and go home early—the hospital wins because administrators don’t pay you the overtime, and your base rate is lower," he explained.

He said that the hospital’s new minishift requirement (one four-hour or eight-hour shift per month for 12-hour staff) is not going over well partly because staff would only get paid the lower base rate an hour.

Although he understands that the change allows the hospital more flexibility in scheduling, "for me, I’m really arguing it because I live an hour away."