Nurses make more mistakes when their 12-hour shifts are extended : Planet Money : The Indicator from Planet Money In hospitals, it's standard for nurses to work a 12-hour shift. But research shows that may not be such a good idea for patients — or nurses.

Nurses and the never-ending shifts

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STACEY VANEK SMITH, HOST:

Hey, everybody, Stacey here. I know you have been all waiting with bated breath to figure out who won the indicator of the year. Thank you all for your votes. We have tallied them up, and we have a winner. I'm about to call them now.

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ROBERT SMITH, BYLINE: Stacey Vanek Smith.

VANEK SMITH: Robert Smith, I wanted to officially congratulate you. Your topic of inflation was our indicator of the year.

SMITH: Oh, my gosh - a dream come true.

VANEK SMITH: We got more than a thousand votes, Robert. And...

SMITH: Are you kidding me?

VANEK SMITH: No, I'm not. And you edged out Mary Childs and the labor market by 11 votes.

SMITH: Oh. Listen, I want to thank everyone who paid too much money for their goods and services...

VANEK SMITH: (Laughter).

SMITH: ...Who created inflation and for everyone who voted for me.

VANEK SMITH: Thank you, Robert, and congratulations.

SMITH: Thanks, Stacey.

SYLVIE DOUGLIS, BYLINE: NPR.

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ADRIAN MA, HOST:

So, Stacey, think about your typical workday. Like, how long would you say your typical workday is?

VANEK SMITH: My typical workday? Like, eight-ish, nine-ish hours.

MA: But, like, how many of those hours would you say you're actually work working?

VANEK SMITH: Eight-ish, nine-ish hours (laughter).

MA: Interesting pause.

VANEK SMITH: Every second, Adrian - I'm working every second of my workday.

MA: That's a good answer.

VANEK SMITH: (Laughter).

MA: OK. So, like, you and I work eight-ish or nine-ish hours - at least that's what we're saying on the podcast.

VANEK SMITH: Absolutely.

MA: But, like, imagine if your average workday was more like 12 hours long. And imagine how much more stressful it would be if the whole time, every decision you make is basically a matter of life and death. And maybe you don't have to imagine because maybe you are 1 of 3 million or so people in the U.S. that works as a nurse.

VANEK SMITH: Add a surging wave of COVID, and it is no wonder that so many nurses are saying they are burned out. But the conditions for this burnout did not just start during the pandemic. Some actually go back decades.

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VANEK SMITH: This is THE INDICATOR FROM PLANET MONEY. I'm Stacey Vanek Smith.

MA: And I'm Adrian Ma. Today on the show - one of the foremost researchers in the field of nursing explains the unintended consequences of getting what you want and a fundamental tweak that could prevent more nurses from burning out.

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MA: So as kids, we've all had heroes, right? Maybe Ninja Turtles or Wonder Woman or Black Panther. I don't know about you, Stacey.

VANEK SMITH: Oh, yes. I was a big Wonder Woman woman.

(LAUGHTER)

VANEK SMITH: But Linda Aiken's childhood hero was a little bit different - not a superhero, but a young student nurse named Cherry Ames.

MA: That's right. Cherry Ames was the star of this series of books - think, like, Nancy Drew or, you know, Shelby Woo's "Mystery Files" (ph) on Nickelodeon but in a medical setting.

LINDA AIKEN: They were stories of people's search for cures to things or care after accidents or the birth of their babies or time during death.

MA: And in the middle of all of that was nurse Cherry.

VANEK SMITH: Protecting patients, dealing with doctors, saving lives and solving medical mysteries.

AIKEN: Certainly dedicated, serious but had a sense of humor - I mean, just, like, a person you wanted to be.

MA: And so naturally, Linda grew up, and she became her own Cherry Ames. She became a nurse. And pretty quickly, she realized that real life is not like the storybooks. She says her working conditions were not always great. She often felt overworked and under-supported. And so over time, she started to wonder what she could do to improve the system.

VANEK SMITH: So Linda got into research. For the last three decades, she's been studying nursing at the University of Pennsylvania. And it was through this research that she came to question what is today a pretty standard practice - the 12-hour workday.

AIKEN: So when I started out, shifts were eight hours, and I thought that was a lot. I was really exhausted.

VANEK SMITH: But in the 1970s, that started to change. There was this nurse-led push for longer days. And the thinking was, same number of hours per week but fewer days equals more flexibility. And hospital managers said fewer shifts to coordinate - that would actually make our jobs easier. Sure. It seemed like a win-win. And eventually, the 12-hour workday became an industry standard.

MA: But in the mid-2000s, Linda and her colleagues started to wonder, could this have some unintended consequences? So they combed through surveys from hundreds of nurses at different hospitals, and they found something surprising. This longer workday, this thing that was supposed to be a win-win...

AIKEN: We found, no, it's really not good for the nurses, that nurses that worked 12-hour shifts were more likely to experience high nurse burnout, job dissatisfaction and intend to leave their job. I think they weren't really even aware of it.

MA: But apparently, the patients were aware of it because patient satisfaction went down the longer nurses worked. And then there was arguably the most important finding from that study involving medical errors. That might mean a nurse mixing up medication or administering a treatment at the wrong time.

AIKEN: What we found was that anytime after 12 hours, the medical errors that nurses were involved in started to escalate dramatically. And the reason that this was important is we found in our study that most nurses that were scheduled to work 12 hours really were there 13 or 14 hours.

VANEK SMITH: Nursing is just not one of those jobs where you can clock in and clock out when you want to. A lot of times, there isn't a nurse to take over or there's some kind of all-hands-on-deck situation or you're in the middle of something and you can't leave. And that has been especially true during COVID.

AIKEN: And so that's the kind of thing - you've just got to be on your toes constantly. And everybody has experienced a time in their life when they're just a little fuzzy because they just have worked too long or have been up too long.

MA: I feel like I experience that every day.

AIKEN: Yes (laughter).

MA: Yeah. But unlike mistakes I make in my job, mistakes in a medical setting have life-and-death consequences. A recent meta-study published in the Journal of General Internal Medicine estimates 22,000 people a year die in U.S. hospitals because of medical errors.

VANEK SMITH: So one big idea from Linda's research is that it's time to rethink the standard 12-hour shift. Shortening the day or being better at preventing overtime would lead to fewer errors and less burnout.

MA: Of course, if you want to prevent overtime and burnout, Linda says there is a better way for hospitals to do that - hire more nurses.

AIKEN: The major things that have contributed to burnout during the pandemic is we've never had enough nurses to take care of the patients because we didn't have enough in the hospitals when it started. That is the single biggest explanation for why we're in so much trouble now during COVID. We added the COVID emergency on top of what was already a terrible situation.

MA: In a recent survey by the American Nurses Foundation, half of respondents said they're considering leaving their job in the coming months or they plan to. And a lot of those people said short staffing is the reason.

VANEK SMITH: So short staffing leads to burnout, which leads to more people leaving. Is there a way out of this vicious cycle? Linda says there might be, and she points to California as a model. So about 20 years ago, California passed a statewide mandate setting the maximum ratio of patients to nurses for various medical settings.

MA: For example, in a surgical unit, the law required a minimum of one nurse for every five patients. And this requirement - it forced hospitals to rethink how they spend money. Some ended up cutting support positions, like housekeeping and clerks, to make it work so they could hire more nurses.

AIKEN: It was what was called an unfunded mandate, which means the state passed the law. The hospitals didn't get any more money because of it. They invested it in their nurses, and everything is better.

MA: And what she means is - Linda studied this. She compared hospitals in California to states that didn't have this staffing mandate. And she found that California nurses had lighter workloads, and their patients were significantly less likely to die. And not just that - they were happier with their jobs and less likely to say they're burned out.

VANEK SMITH: This, of course, doesn't mean that things aren't hard, especially as the pandemic stretches on and on. And yet here is a surprising indicator - the American Association of Colleges of Nursing says enrollment in programs for new nurses increased about 5% in 2020. So despite COVID and all the hours of stress, interest in nursing is up.

MA: So a lot of future Cherry Ameses.

VANEK SMITH: Fingers crossed.

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MA: This episode was produced by Nicky Ouellet and engineered by Isaac Rodrigues. It was fact-checked by Taylor Washington. Our senior producer is Viet Le. Our editor is Kate Concannon. And THE INDICATOR is a production of NPR.

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