Hospitals cutting nurses' long shifts

A growing number of hospitals, including Massachusetts General, have stopped scheduling nurses for extra-long shifts -- those of up to 16 hours -- amid growing national concern that exhausted healthcare workers are more prone to errors.

In an industry where long hours have been the norm, new research and a recent government report have motivated hospitals to scrutinize nurses' hours, especially since patients are sicker than they used to be and demand more of nurses.

The Hospital of the University of Pennsylvania recently prohibited 16-hour shifts, and Congress has directed Veterans Administration hospitals to develop a plan by the end of this year that would cap nurses' shifts at 12 hours. The Massachusetts Nurses Association says that in some cases hospitals order nurses to work 16-hour shifts and that it has negotiated contracts with a number of facilities, including UMass Memorial Medical Center in Worcester and Caritas St. Elizabeth's Medical Center in Brighton, that prevent them from requiring nurses to stay beyond 12 hours.

At Mass. General, nurses said that many of their colleagues have chosen to work extra-long shifts. Last year executives reviewed payroll records and found that 550 of the hospital's 3,000 nurses had worked at least one extended shift of up to 16 hours during a four-month period. Of the 103,000 nursing shifts during that period, 1,355 were for roughly 16 hours. A small number of nurses, 89, accounted for most of these shifts. A normal shift is eight or 12 hours.

Jeanette Ives Erickson, the hospital's chief nurse, said Mass. General has not studied the connection between long hours and errors. But when an error occurs, she said, one of the first questions she asks is how long had the nurse been working.

''We have not found any errors directly attributable to long hours," she said. ''But experts say it's very hard to find a causal relationship, because there are so many different things going on."

Erickson said that during the spring and summer, managers at Mass. General stopped scheduling nurses for 16-hour shifts, although nurses may work 16 hours straight in emergencies.

On Ellison 16, the hospital's largest medical floor, with 36 beds, Sandra Palladino regularly worked back-to-back eight-hour shifts. Typically, she worked from 3 p.m. Monday to 7 a.m. Tuesday, then she would return for two 12-hour shifts on Wednesday and Thursday, giving her Friday to work a second nursing job. Other nurses worked extra-long shifts because it meant fewer commutes: One nurse drove in from northern New Hampshire, stayed with relatives, and worked two 16-hour shifts over several days.

Palladino, 53, said she has not made a medical error that she is aware of; she would sleep extra hours the night before a 16-hour shift and never had trouble staying awake. But she realizes now that the mental strain was significant.

''There were surely times when instead of counting the patient's medications three times, I counted them five times. Even when I walked out of that room, I'd be double-checking myself again. Then you get home and you start saying, 'Did I do this?' Then you start making phone calls," she said. ''I am very fortunate for all the hours I worked that I never found myself in any sort of trouble."

Susan Gordon, who became nurse manager of Ellison 16 a year ago, said she was shocked to learn that six nurses regularly worked 16-hour shifts on the floor, where patients with heart and liver failure and multiple medical problems are treated.

''I was surprised that anyone would have the stamina to do that," Gordon said. ''The work here is very hard. Our patients are very sick. I don't see how anyone can give that level of focus for 16 hours in a row."

Gordon said she didn't know whether the error rate was higher on 16-hour shifts than on shorter ones. But she said the nurses now seem less irritable, although ''some nurses are very unhappy about the change" because they preferred to squeeze their hours into fewer days.

The medical profession has been slow to address the problem of fatigue among its workers. Several years ago, however, researchers and policy makers began to focus on the work hours of hospital residents, doctors in training who staff teaching hospitals and who routinely worked 36 hours straight. Research showed that residents who worked long hours made more errors; one recent study found that tired residents driving after their shifts were as impaired as drunk drivers. In 2003, the board that oversees doctor training established the first national limits on the work hours of residents, restricting them generally to 24 hours at a stretch. More recently, researchers have turned their attention to nurses, who provide the bulk of the hands-on care.

A study from the University of Pennsylvania School of Nursing published last summer found that nurses who worked 12.5 hours or longer were three times more likely to give a patient the wrong medicine or the wrong dose, or commit some other type of error, than nurses who worked fewer than 8.5 hours.

In Massachusetts, state Senator Richard T. Moore, an Uxbridge Democrat, is planning to revise nursing legislation he previously filed to include standards or guidelines on hours.

Erickson said she will not be sure whether all nonemergency 16-hour shifts have been eliminated at Mass. General until the hospital completes a follow-up survey this year, especially since some nurses work in units where they schedule themselves.

Other hospital executives in Massachusetts said they do not routinely schedule nurses for 16-hour shifts, but that it happens. In some cases, nurses can stay an extra four hours after a 12-hour shift to pick up overtime, and in other instances hospitals will ask nurses to stay longer when colleagues call in sick or there is an unexpected surge in patients.

Ann Rogers, a nurse and professor who conducted the Pennsylvania study, said eliminating 16-hour shifts is progress, but will not end excessive tiredness among nurses. Part of the problem is that many nurses who work 12-hour shifts almost never leave on time.

''We need to figure out why nurses almost always stay later than scheduled and how to reorganize the work flow," she said. ''Nurses are just beginning to be studied."