If you have ever been in a hospital, you are probably familiar with what seems like a continuously revolving door of staff members providing care. With nurses making up the largest occupation in healthcare and the largest segment of hospital staff, continuity of nursing care for hospitalized patients is an important factor in the delivery of quality healthcare.
A Medical Care article published ahead-of-print last month, Patients Negatively Impacted by Discontinuity of Nursing Care during Acute Hospitalizations, examined the impact of nursing care discontinuity on patient outcomes. Yakusheva and colleagues, from the University of Michigan and Marquette University, conducted a retrospective analysis of electronic health record (EHR) data from an urban academic medical center, reviewing the records of 3,892 adult medical-surgical inpatients. Discontinuity was measured through new nurse assessment entries into the EHR, and patient outcomes were evaluated using the Rothman Index [PDF], a summary metric that reviews multiple clinical parameters to generate a score reflective of the patient’s overall status. Yakusheva and colleagues found a high rate of nursing care discontinuity that ultimately had a negative impact on patient’s clinical condition. Discontinuity was associated with a decline in patients’ Rothman Index, with an even worse effect on elderly patients and those at highest risk.
Continuity of care has been shown to reduce healthcare costs, lead to higher patient satisfaction, and prevent continued hospitalizations. Yet, Yakusheva and colleagues acknowledge multiple factors that influence the occurrence of nursing care continuity, such as budgetary restrictions, patient acuity, nurse skill sets, and nurse-to-patient ratios. Given all that, this study prompts an important question: Does the benefit of continuity outweigh the drawbacks of longer nursing shifts?
In a prior post, I compared the pros and cons of 12-hour nursing shifts to 8-hour shifts. Yes, 12-hour shifts do offer improved continuity of care, since they only require 2 nursing staff handoffs every 24 hours. But longer shifts may result in worsening care quality and patient safety issues when compared to shorter shifts. In comparison, 8-hour shifts could result in less nurse burnout, but require 3 handoffs every 24 hours.
The number of handoffs required for shorter shifts might be the deciding factor. The Joint Commission estimates that “80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.” Furthermore, a prior AHRQ survey on the culture of patient safety found that 53% of the responding hospitals indicated “important patient care information is often lost during shift changes.” Yes, 12-hour shifts do offer their own set of disadvantages–but in the fast-paced field of healthcare, handoffs might be more detrimental to the well-being of patients. Handoffs increase the risk of errors and allow for important information to fall through the cracks.
The benefits of continuity, and fewer handoffs, would appear to outweigh the drawbacks of longer nursing shifts. While longer shifts may make nurses more prone to fatigue-related errors, the risk of errors and missed information during patient handoffs is likely the more pressing issue. Furthermore, nurses might not be unhappy working longer shifts. Prior research published in the Journal of Nursing Care Quality found that 65% of nurses were working 12-hour shifts. Longer nurse shifts (10 hours or more) were associated with more nurse-reported patient safety issues and worse quality, but nurses were largely satisfied with their work schedule. Ultimately, if nurse continuity leads to improved patient outcomes and nurses are content working longer shifts, I think it might be better to potentially have a tired nurse than one who doesn’t have all the necessary information.