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NURSING SHIFTS.
Term Paper ID:26757
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Examines professional, economic, medical, labor & personal issues & benefits & strategies related to changing nursing shifts from three 8-hour to two 12-hour shifts.... More...
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Paper Abstract:
Examines professional, economic, medical, labor & personal issues & benefits & strategies related to changing nursing shifts from three 8-hour to two 12-hour shifts.
Paper Introduction:
This research will examine issue fronts relevant to a changing nursing shifts from three eight-hour to two twelve-hour daily periods. The research will set forth the background and context in which such a change might be contemplated and discuss the benefits and strategies associated with instituting this change in a clinical health-care setting.
1. Over the course of the 1990s, as the American unemployment rate has steadily fallen and the level of general prosperity steadily risen, there has emerged a body of cross-industry discourse on the subject of how best to manage workers and retain valued workers. Flexible staffing and scheduling have been one such response.
In its most general sense, flextime, as it is called, changes starting and ending times of a worker's schedule but retai
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(one-half hour lunch plus two 15-minute breaks). Over the long term, physicians and patientsshould experience no limitation of nursing assistance, though it is hopedthat they would experience a significant increase in information transferefficiency. This line of thought has penetratedorganizational and employee staffing structures in clinical settings.However, transformation of traditional work schedules in most clinicalnursing settings does not appear to have taken place universally. As Lancaster (1999, p. American Nurse. Thus it can be argued that having three nonworking 24-hourdays instead of the traditional two could offer the full-time nurse ampletime to reclaim energy for productivity, as well as offer the nurse anongoing opportunity to cope with family or other personal responsibilitiesduring traditional business hours and/or days not just on weekends. In the short term, the quality, efficiency, and extent of patient-information management should be measurably improved. Assuming the clinic-specific objections on the part of institution andstaff to the 12-hour structure had been met, that a general plan forimplementation had been approved, that a sufficient numbers of nurses hadbeen planned for carrying out the pilot program, and that futureimplementation of new shift patterns would take place unit by unit, theprocess would begin as a pilot program for the first unit to be changed. Current contract language. Having to give only two shift reports instead of three allows for more time for patient care, patient education and/or time to catch up on documentation (Levesque, 1998). short-termservice and production goals and to reap the low-cost benefits of acontingent work force (Brown, 1998). Online Journal of Issues in Nursing.Retrieved on the World Wide Web November 23, 1999, fromhttp://www.nursingworld.org/ojin/topic8/topic8_5.htm. 3. Are 12-hour nursing shiftsbeneficial to patient care? Retrieved November 23, 1999, from WorldWide Web: http://www.ed.gov/databases/ERIC_Digests/ed418247.html. L. 1. According to one unionized nurse in this connection: "Today, with all the changes in health care, more nurses are working under conditions that are unsafe for patient care . But in general terms,assuming the pilot program is successful, the adjustments made during thepilot program could be frozen, and new levels of behavior could beinstituted with additional units. Bank of America. The fact that flexible scheduling protocols have become a part ofhospital-nurse contract language is instructive about a rather significantchange in thinking on the issue, at least in some settings. Retrieved from the World Wide WebNovember 23, 1999, at http://www.nursingworld.org/tan/98julaug/kaleid.htm. The American Nurse. Our union has proven to be the way to safeguard nursing practice and patient care by giving staff nurses real power in the workplace. Inbroad outline this would be as follows:The 12-hour option would be voluntary, with nurses in the unit invited tobid for 12x3/4x1 shifts.During the pilot program, nursing managers and administrative staff woulddetermine how best to distribute individual work schedules over the courseof a 4 -hour week. A. Patients know who their nurses are" (Levesque, 1998) A key hindrance to implementation of 12-hour shift structures may liewith nurses who resist change from the 8-hour structure: "More than 9 percent of us are over 3 years old. Yes. (1999). (1999c). Retrieved on the World Wide Web November 23, 1999, fromhttp://www.nursingworld.org/dlwa/testing /hotissue/flexschd/flex2.htm. . Retrieved from the World Wide Web, November 23,1999, at http://www.nursingworld.org/tan/98mayjun/nysna.htm. On thisview, employers (health-care organizations) and employees (e.g., caregiverssuch as nurses) alike could benefit from the establishment of a 12-hour/4-hour 4 -hour standard. Stewart, M., and Marx, D. California's new nursestaffing mandate highlights crisis in nurse staffing nationally. A second hindrance to implementation of 12-hour shifts is thehistorical tendency of clinical organizations to prefer the administrativesimplicity of the 8-hour structure. 192, ED418247 98. The researchwill set forth the background and context in which such a change might becontemplated and discuss the benefits and strategies associated withinstituting this change in a clinical health-care setting. . Nursing issues in leading and managing change. Levesque, J. J. (1999, October 19). Article11, Hours: Section 8, 9/2 /97 -- 9/2 / , Lima Memorial Hospital.Retrieved on the World Wide Web November 23, 1999, fromhttp://www.nursingworld.org/dlwa/testing /hotissue/flexschd/flex3.htm. Flexible staffing andscheduling have been one such response. Indeed, changes made to nursing schedulesshould be entirely transparent--when not noticeably improved--to physiciansand patients alike (adapted from American Nurses Association, 1999a, 1999b,& 1999c). 2. Accordingly, it would be useful to phase in the new protocolsgradually, perhaps unit by unit. (1998). (1998, December 31). Trossman, S. c991 3.Center for Entrepreneurial Leadership Clearinghouse on EntrepreneurshipEducation. Staffing numbers and patterns on 12-hour versus 8-hour shifts aredifficult to determine in advance of close analysis of a specificinstitution's dynamics. . The language used by various facilities indicates thatinstitutional, unit, and individual staff considerations have gone into theprocess of implementing shift-structure change, which would be a word tothe wise. More generally, it has been noted that a whole range of ethicalissues, particularly in the managed-care setting, emerge around the issueof who has authority over medical decisions: "Is it the provider, thehealth plan, the insurer, the employer, or the state legislature?" (Maddox,1998). In this regard, consider the background for decisions on the part ofunionized nursing staffs in Joliet, Ill., in 1993, and Brooklyn, N.Y., in1998, to strike: [A]t Maimonides [Brooklyn], roughly 9 percent of nurses there voted to strike. However, what can be embedded into a pilot programof this type are the contingencies that must be accounted for in anyeffective evaluation program, as follows: registered nurses providing direct care; numbers of unlicensed personnel utilized to provide direct patient care; average number of patients per registered nurse providing direct patient care; patient mortality rate; incidence of adverse patient care incidents; and methods used for determining and adjusting staffing levels and patient care needs (Stewart & Marx, 1999). . Retrieved on the World Wide Web November 23,1999, from http://www.nursingworld. American Nurses Association. NewYork: Harcourt Brace. Typically during an eight-hour shift,three sets of nurses must report to their supervisors three times over thecourse of one day. Cost factors,attitudes and fears of long-experienced 8-hour workers who might resist the12-hour structure as something suited only to younger nurses, and a moregeneralized discomfort with disrupting well-established caregivingprocedures are all a part of this mix. The pilot program should be adoptedfor a minimum of six weeks, with adjustments made on an ongoing basis andperformance evaluations made on a weekly basis. Dolan, K. On the other hand,if the 12-hour structure fosters a response to the change in the form ofstaff morale problems or stress, productivity decline or inefficiency, or(in the worst case) patient-care failure, then this should become obviouswithin the same period of time. The state of California, for example, in 1999mandated that patient care units in hospitals "meet fixed minimum nurse-to-patient ratios" (Stewart & Marx, 1999). What it comes down to is the growing desire on the part ofnurses to be perceived and dealt with as full participants in determiningwork rules. The standard nursing shift comprises eight consecutive hours, butbeneficial change could occur were the shift to last twelve hours.Proposals and/or policies that change eight-hour shift structures do appearto be in the works in a variety of settings (American Nurses Association,1999a, 1999b, 1999c). Trossman, S. (1998). . Retrieved from the World Wide Web, November23, 1999, at http://www.nursingworld.org/search/ vfp_search.cfm. The AmericanNurses Association (ANA) (e.g., 1999a) lists flexible-schedule contractlanguage for nurses current in ten health-care facilities (nine in Ohio,one in New York). References American Nurses Association. (1999b). (1998, July-August). In order to arrive at a 4 -hour standard for full-time nurses, full-time work weeks have been based on three 12-hour shifts and one 4-hourshift or four 1 -hour shifts, with two 12-hour and two 8-hour shift optionsavailable, chiefly to accommodate professional development and education(ANA, 1999c). Increased communication withless repetition of information between the nurse and the patient/familymembers occurs. Brown (1998) points out that flexible staffing, often initiated byemployers, may appeal to many workers but is mainly "designed to satisfythe needs of the employer." Flexible scheduling, of which the 3x12/4x1clinical-care model is representative, may be established to accommodateemployee's needs, "although the employers are reaping benefits as well."Flexible scheduling, however, has been interpreted across industries, notexcluding health care, as a morale booster and a check on high employeeturnover: "All over the country, smart employers large and small are wooingtheir workers with nonmonetary rewards that add convenience to their dailylives and render them more fulfilling" (Dolan, 1996). In no case will 12-hour-shift participants be entitledto use additional shifts within a weekly employment period to achieveovertime hours at the institution's expense.Preferential assignments would be made based on seniority and managementlevel; three consecutive 12-hour shifts are meant to be avoided. Columbus, Ohio: ERIC Clearinghouse on Adult,Career, and Vocational Education. Administrators wanted to force all RNs to work eight-hour shifts, instead of 12, without considering the effect it would have on nurses' lives, such as the financial drain of increased child care, and without guaranteeing they wouldn't cut RN positions (Trossman, 1998). American Nurses Association. 5. Thus, the project would involve unfreezingexisting behavior (i.e., the 8-hour tradition), moving to a new level ofbehavior (i.e., 12-hour shift options and scheduling protocols), andrefreeezing new behavior (i.e., enforcing the new protocols contractually).Particularly in a large organization this process could be extremelydisruptive. . Nurses describe a concern for patient care as a driving force for the12-hour shift structure. However, thebenefit of maintaining continuity and integrity of data during transfer hasbeen thought to outweigh this risk: Having only two nurses care for the same patient in a 24-hour period allows for more concise and complete evaluation of the patient's outcomes, which expedites the shift report. Tendency toward understaffing on the part of health-care facilities,in the context of a tendency in recent years toward cost-effective health-care delivery by bureaucracies such as HMOs, also hinders implementation of12-hour shift structures. The benefits of change can be inferred from thestructure of the standard shift. and from 7 p.m. Thus one driving force for flexible scheduling is the evidence ofdesire on the part of employees to balance their personal and professionallives. (1996, November 18). Under that structure, nursesreceive overtime for 12-hour shifts whether or not they work 8 hours intwo weeks. history that such tactics have had some success, notably in thecontext of cross-industry economic downturns of the 198 s, plant closings,union give-backs, the air-traffic-controller union demise engineered byRonald Reagan, and so on. Another driving force for the 3x12/4x1 shift structure is related tothe first. Unforeseen circumstancesinvolving a nurse on the 12-hour schedule would be reviewed on anindividual basis.Adjustments to details of this general system would take place based onevidence of the quality and efficiency of patient care as determined byperformance evaluations of nurse managers and administrators.Physician satisfaction with nursing performance and delivery would be acritical feature of evaluation. (1998, May-June). to 7:3 p.m. Brown, B. Retrieved from theWorld Wide Web November 23, 1999, athttp://www.nursingworld.org/tan/98julaug/kaleid.htm. Maddox, P. The typical American work week is 4 hours in length, which means thata 12-hour shift structure in a clinical health-care setting that werespread over three days would amount to a three-day work week comprising 36hours. Failure to trumpet the former is as foolish as attempting toconceal (and remedy) the latter.Written communication, reinforced by in-person training and orientation ofaffected staffers, so that everyone involved in the innovation will becomfortable with the new schedule and work rules, will adapt their patient-care and information-transfer protocols properly, and will be committed togiving timely reports to nurse managers.Committing to paper the new schedule--whether on a grid or a computer isless important than the certain knowledge that it is a schedule transparentto all.MBWA--Management By Walking Around, in the famous phrase of managementexpert Tom Peters (In Search of Excellence)--personal contact undertaken bynurse managers for the purpose of getting a realistic picture of theprogram in the trenches and at the level of physicians. How much more professional can a nurse get?" (Trossman, 1998). Twelve-hour shifts are just too long.After eight hours, our mental acuity, tolerance level and ability to carestarts fading" (Creagan, 1998). Should you be getting overtime? Administrative ethics and theallocation of scarce resources. ANAWorkplace Issues Homepage. Are 12-hour nursing shifts beneficialto patient care? Article28: Flexible Hours, 5/ 1/98- 4/3 /99, Western Reserve Care System/ForumHealth. Retrieved from the World Wide Web, November 23, 1999, athttp://www.celcee.edu/SpecInt/c991 3.html. A rather unusual hindrance to 12-hour shift structures can be seen inthe fact that access to such structures seems to be increasingly a creatureof legislation and not of internal institutional policy discourse,analysis, and debate. Lancaster, J. Emotions run high on this aspect of theissue, but the core concern appears to be that the physical wear and tearon the nurses who must adjust to 12-hour shifts would be excessive. 152ff) suggests ona theoretical level and as the experience of collective bargainingsituations of recent years confirms, this would involve a preliminary stepof identifying what is driving and restraining change in a giveninstitution and attacking the issues systematically. Some version of formal or informalflextime is offered by an estimated 85% of all larger organizations. A 1998 strike at Maimonides Hospital in Brooklynwas driven by the position of the New York State Nursing Association's viewthat "12-hour shifts are better for patient care--providing greatercontinuity and fewer 'hand-offs' between shifts" (Trossman, 1998b). In either case, the work week as a whole for an individualnurse spreads across four days, not the five of the standard 8-hour-day, 4 -hour work week. NY nurses' strike stops hospital cost-cutting. to 7:3 a.m. ERICDigest No. Article14, Hours: Section 7, 4/ 1/97 -- 7/ 1/99, The Ohio State University.Retrieved on the World Wide Web November 23, 1999, fromhttp://www.nursingworld.org/dlwa/testing/ hotissue/flexschd/flex11.htm. In its most general sense, flextime, as it is called, changes startingand ending times of a worker's schedule but retains the same total hours ofregular employment (Bank, 1998). 4. The character of driving and restraining forces affecting 12-hourshift structures for nurses suggests that anyone who is committed to thebenefits of change from the 8-hour structure really cannot shrink from theneed to as it were fish or cut bait. Those working 8-hour shifts only would not receive overtime forworking more than 4 hours the first week (American Nurses Association,1996). American Nurse. Not employing workers on a part-time basis butrather as contract workers, temporary workers, or part-timers allowsemployers, including clinical organizations, "to realize . At a time when team-based, interdisciplinary health care has emergedas a standard of practice in larger clinical settings, the 12-hour shiftstructure has been advocated as a mechanism for improving communicationbetween physicians and support personnel: "Physicians aren't asked twiceabout the same concerns nurses might have. The American Nurse. This is so especially in the context ofhealth-care organization mergers and acquisitions, and it is in thebackground of labor disputes cited earlier, which reveal the costconsciousness of institutions seeking economies of scale. There is aview that productivity may slip, especially for persons older than 5 , whohave been on duty for more than eight hours (Creagan, 1998). This obliges the institutional hierarchy to respond toinnovation from below and helps limit nursing's obligation to adhere to top-down structural-change mandates.Documentation of both successes and failures of the pilot program once itis under way. S. Current contract language. Because the advocacy positions are sosharply divergent, it would appear that Lewin's classic theory of change,which is suited to a formalized project of institutional transformation,could be most helpful here. No. Fortunately, there is some help available in the form of contractlanguage that has already been put in place and cited above relative toOhio and New York. But in the late 199 s in particular, withunprecedented strong performance of the U.S. (1998, July-August). When money isn't enough. It is a commonplace of recentU.S. Creagan, M. Forbes.Retrieved from the World Wide Web, November 23, 1999, athttp://www.forbes.com/forbes/111896/5812164a.htm. advocated from workers' point of view as amethod of balancing work and family life, and from employers' point of viewas an strategy that can allow an organization to "realize its short-termservice and production goals and to reap the low-cost benefits of acontingent work force" (Brown, 1998). The ANA cites the tremendous growth inthe number of "institutions [that] have decreased the numbers of registerednurses (RNs) caring for an increasingly acutely ill patient population,cutting corners by substituting unlicensed assistive personnel for RNs"(Stewart & Marx, 1999). (1999a). Contract language reported by ANA for 12-hour shift structures goesinto a great deal of detail about vacation time, professional development,reassignment to standard shift structures, and so on. Your guide to flextime, CELCEE no. Thus the benefit to institutions of the 8-hour structure is readilyapparent. org/dlwa/wages/wp4.htm. American Nurses Association. . Overlapping time would be usedfor patient-information reporting and transfer.Nurses who successfully bid for 12-hour shifts will agree to stay with therotation for a minimum of four weeks. (1998). In a 12-hour shift structure, daily staff rotation occurs twiceonly, thereby creating a lesser chance of losing information. Embedded in this practice is the possibility of losingimportant patient-care information, as staff hand data to the next rotatingshift. Part-time work and other flexible options. Onehealth-care corporation, CIGNA, has nearly one-third of its 37, employees in flexible scheduling arrangements, on the theory that "lettingemployees work part-time or compressed work weeks with full benefits savesmoney in the long run by reducing turnover and lowering training andrecruitment costs" (Brown, 1998). Striking reflections: Why nurses are willing towalk the line. Current contract language. But one need not be an opponent ofthe mandate to see that this could actually foster ratio ceilings, thuspushing 12-hour-shift nurses to excessive overtime, which could depleteenergy and competency stores even more than it is alleged has occurredalready. Retrieved on the World Wide WebNovember 23, 1999, fromhttp://www.nursingworld.org/pressrel/1999/pr1 13.htm. economy, workers (particularlyunionized ones) appear to have reasserted claims to a voice in their workexperience. This research will examine issue fronts relevant to a changing nursingshifts from three eight-hour to two twelve-hour daily periods. Consider the so-called "8 and 8 " structure, often made a part of union agreements and afeature of the Fair Labor Standards Act. . Methods for guaranteeing a nursing voice in workplace changes haveat their core a nursing commitment to written documentation of the schedule-change implementation, as follows:Written documentation associated with the proposal for shift-structurechange itself. (1996). Over the course of the 199 s, as the American unemployment rate hassteadily fallen and the level of general prosperity steadily risen, therehas emerged a body of cross-industry discourse on the subject of how bestto manage workers and retain valued workers. If, as advocates of12-hour shift structures claim, patient evaluations can be improved, thenthe change should be obvious within the first two weeks. PressRelease, American Nurses Association. There is a view among a number of nurses that hospitalorganizations would like nothing so much as to "bust the union" (Trossman,1998) and essentially dictate caregiving, scheduling, and a host of otheron-the-line work rules in a top-down manner. If three12-hour shifts are worked consecutively, a minimum of two consecutive daysoff must follow.Shifts would run from 7 a.m.
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