ORIGINAL ARTICLES
Comparison of Nurse, System and Quality Patient Care
Outcomes in 8-Hour and 12-Hour Shifts
Patricia W. Stone, PhD, RN,* Yunling Du, PhD, Rhabia Cowell, MS,* Norma Amsterdam, MA, RN,
Thomas A. Helfrich, JD, Robert W. Linn, JD, Amy Gladstein, JD, Mary Walsh, MSN, RN,
and Lorraine A. Mojica, BSN, RNC**
Background: Many nurses desire 12-hour shifts. However, there
are concerns about implementation.
Objective: We sought to compare the effects of 8- and 12-hour
shifts on nurse, system, and quality patient care outcomes.
Methods: We used a cross-sectional design with data collected from
multiple sources in 20032004, including a nurse survey and ad-
ministrative and patient records. We studied hospital nurses and
patients in general adult wards, with outcomes including burnout,
job satisfaction, scheduling satisfaction, preferences, intention to
stay, and employee safety. System outcomes included recruitment
and turnover, staffing, absenteeism, and related costs. A variety of
quality patient care outcomes were measured from the 3 different
types of data.
Results: Thirteen New York City hospitals participated; 805 sur-
veys were examined from 99 nursing units (response rate 42%).
Compared with nurses working 8-hour shifts, those working 12-hour
shifts were on average more satisfied with their jobs, experienced
less emotional exhaustion, 10 times more likely to be satisfied with
schedules, 2 times as likely to perceive 12-hour schedules as
important, and 58% less likely to report missing shifts; units with
12-hour shifts had lower vacancy rates and weeks to fill the position
(all P values 0.05). There were no differences in patient
outcomes.
Conclusions: Nurses working 12-hour shifts were more satisfied.
There were no differences in quality outcomes. Flexibility and
choice in shift length are important elements in a positive nurse
work environment. This study represents an innovative attempt by a
From the *Columbia University School of Nursing, New York City, New
York; Department of Clinical Biostatistics, Albert Einstein College,
New York City, New York; 1199SEIU National Health & Human
Services Union, New York City, New York; League of Voluntary
Hospitals and Homes: Linn & Green Consulting, Inc: New York City,
New York; Beth Israel Hospital, New York City, New York; and
**SVCMC Saint Johns Hospital Queens, Elmhurst, New York.
Supported by the 1199/SEIU League RN Planning and Placement Fund.
This study was conducted as a result of an agreement between the Registered
Nurse Division of 1199 Service Employees International Union (SEIU),
New Yorks Health and Human Service Union (RN Division of 1199),
and the League of Voluntary Hospitals and Homes of New York
(LVHH).
Reprints: Patricia W. Stone, Columbia University School of Nursing, 617 West
168th Street, New York, NY 10032. E-mail: ps2024@columbia.edu.
Copyright 2006 by Lippincott Williams & Wilkins
ISSN: 0025-7079/06/4412-1099
Medical Care Volume 44, Number 12, December 2006
labor-management bargaining group to make an evidence-based
decision. We encourage others to conduct similar studies.
Key Words: nurse staffing, hospital administration, shift length,
patient safety
(Med Care 2006;44: 1099 1106)
T he hospital environment is a 24-hour, 7-day a week
service industry which, by necessity, translates into shift
work for hospital employees. Shift work has been considered
detrimental to workers health, increasing stress-related to
worklife conflict1 and disruptions to circadian rhythms.2 In
healthcare professionals, increased job stress has been found
to be correlated with high levels of burnout3 and increased
incidence of disease.4,5 The majority of nursing personnel
(the hospitals largest labor force) are women, which increases
the likelihood of difficulty balancing work and personal
responsibilities.6 Because 12-hour shifts offer compressed
work weeks (eg, three 12-hour shifts vs. five 8-hour shifts)
many nurses perceive these schedules to be desirable even
7
without salary differentials. However, some managers and
administrators have been concerned about implementation.8
9
Smith and colleagues conducted a comprehensive sys-
tematic review of published evidence on 8- and 12-hour shifts
and concluded that longer shifts increased employee fatigue
but also increased job performance, which was typically
assessed using a survey instrument designed to measure
nurses reasoning ability for critical thinking. They postulated
the reason for these findings may be that employees working
a compressed work week are more motivated, therefore
reducing possible detrimental effects. Results from 6 addi-
tional studies directly comparing hospital nurses working 8-
and 12-hour shifts have been published since Smiths review.
Three research teams surveyed nurses and found they pre-
ferred 12-hour and self-reported wellbeing and performance
were not adversely affected by working longer shifts.10 12
Researchers in the United Kingdom observed nurses working
12- and 8-hour shifts and concluded those working the longer
shifts had less effective total performance score as measured
by an observer rating 5 different domains of nursing care (eg,
care management).13 However, all of these studies were
limited to a single setting with the largest sample size being
1099
Stone et al
FIGURE 1. A diagram of the concep-
tual framework guiding study. Dot-
ted lines and arrows represent the
potential confounding variables and
their relationship with the indepen-
dent and dependent variables.
240 nurses. Hoffman and Scott (2003) conducted a survey of
randomly selected Michigan licensed nurses (50% response
rate, n 252) and found nurses working 12-hour shifts were
more stressed than those working 8-hour shifts and there were
no differences in job satisfaction or salary. The nurses work-
ing 12-hour shifts were younger and had less work experi-
ence, which may account for the increased stress.10 Con-
versely, in Poland, researchers found that nurses working
12-hour shifts compared with those working 8-hour shifts had
lower physical workload (measured in kilocalories per hour)
and better mood states as measured by fatigue, hostility, and
friendliness.14 In this study, the nurses working 12-hour shifts
also were younger. Based upon this previous research, the
effect of various shift length on nurse health, wellbeing, and
productivity is uncertain.
Currently, many hospitals have implemented 12-hour
shifts for nurses in critical care units.15 However, these longer
shifts often are not widely available. Some nurses seem to
prefer 12-hour shifts; however, there are legitimate concerns
about the safety of the employee and the patient in an
extended work hour environment. This is especially true with
an aging nursing workforce,16 which may not be able to as
easily cope with the physical demands of extended shifts.
Furthermore, with financial pressures put on hospitals and
concerns about patient safety, understanding economic con-
sequences of human resource policy decisions and how best
to improve the nurse work environment is important.17
The availability of 12-hour shifts became a difficult
issue between a union representing nurses and a multiem-
ployer bargaining group. Because of the lack of clear evi-
dence to guide decision-making regarding optimal shift
length, this study was conducted as a result of their negotiated
agreement. The aims of the study were to compare the effects
of 8- and 12-hour shifts on nursing, system and quality
outcomes, while controlling for confounding variables. Dur-
ing the time the study was taking place, based on adminis-
trative policies, preferences, supply and demand of nurses,
different nursing units offered different shift lengths and
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Medical Care Volume 44, Number 12, December 2006
nurses self-selected their place of employment based on
qualifications and seniority within the hospital.
METHODS
Setting
Fourteen hospitals located throughout New York City
were eligible to participate. A cross-sectional research design
was developed and nurse, system, and patient data were
collected from adult general inpatient units. The appendix
lists hospital characteristics such as number of beds and how
the 12-hour shifts were implemented (eg, number of annual
shifts per full-time equivalent). Institutional review board
approval was obtained at all participating hospitals and the
primary investigators home institution.
Conceptual Framework
The study was guided by Donabedians theory of
healthcare quality, which includes the broad concepts of
structure, process and outcomes.18 Previously, investigators
expanded the quality model to include worker outcomes.19 As
illustrated in Figure 1, we further expanded the conceptual
model to include system outcomes. In the model, the structure
of care represents setting specific characteristics (ie, hospital,
nursing unit type, and average organizational climate per
unit) and the nurse characteristics (demographics). These
structural variables may confound the relationship between
our independent variable (shift length) and the outcomes of
interest. For example, the age of the nurse may influence job
satisfaction. The independent variable of interest in this study
is the process of nurse shift length (ie, 8- vs. 12-hour shifts).
Outcomes include those related to the nurse, system and
patient. Because of the contentious nature of the issue and the
conflicting results found in previous research, no a priori
directional hypotheses were postulated. Data collection meth-
ods are described followed by the operational definitions and
psychometric properties of the measures.
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Medical Care Volume 44, Number 12, December 2006
Data Collection
Nurse Survey
Direct care nurses were eligible to be surveyed during
the Fall of 2004. The survey (available from the correspond-
ing author upon request) contained well-developed measures
found in the literature as well as some items developed
specifically for this study. To determine overall clarity, the
survey was piloted in 30 noneligible nurse respondents prior
to distribution.
Using an anonymous self-report questionnaire format,
which was coded to the hospital where it was distributed, the
respondent was asked to indicate the unit in which they
primarily worked. Surveys were distributed on nursing units
in 2 waves. To protect against duplicate responses, nurses
were instructed to respond 1 time. Furthermore, respondents
demographics (ie, age, gender, race, ethnicity, education, and
years of experience) were examined; a survey distributed in
the second wave that directly matched demographics from the
first wave was considered a duplicate and discarded.
Administrative Data
A variety of administrative data were collected for a
12-month study period (July 1, 2003 to June 30, 2004),
including (1) human resource files (ie, payroll files, recruit-
ment and turnover data), (2) nursing management files (ie,
monthly patient census and patient incident reports), and (3)
patient discharge abstract data. All administrative data were
submitted to the research team electronically, compiled into a
database and aggregated at the level of the nursing unit.
Incident report data, which were used in this study as 1
method to measure patient outcomes, are formal systems
developed to collect and analyze information about unusual
events.20 Risk adjusted patient safety indicators were devel-
oped from 17 data elements from the patient discharge
abstract (eg, age, sex, admission type, diagnosis related
group, major diagnostic category, the unit the patient was
discharged from, admit and discharge date).
Operational Definitions and Psychometric
Properties of Variables
Structural Variables
Nursing demographics and organizational climate mea-
sures were collected in the nurse survey. Organizational
climate was measured using a 30-item modified version of the
Perception of Nurse Work Environment (PNWE) scale.21 The
PNWE has 7 dimensions (eg, Nurse/Physician Collaboration
and Support for Professional Practice), in which respondents
are asked to indicate the extent the factor is present in their
work environment using a 5-point Likert scale. Internal
consistency of the composite scale, which was used in the
analysis, was excellent ( 0.95). Indicator variables for the
hospital and unit type (medical/surgical or general specialty
wards such as oncology or orthopedics) were developed.
Independent Variable
Each nursing unit was identified based on the type of
staffing in place (12- or 8-hour shifts).
2006 Lippincott Williams & Wilkins
8-Hour Versus 12-Hour Shifts
Nursing Outcomes
Data for nurse outcomes came from the survey; variables
included burnout, job satisfaction, scheduling satisfaction,
scheduling preferences, intention to stay, employee health and
safety. The Maslach Burnout Inventory (MBI) was the measure
of burnout and includes 3 subscales: emotional exhaustion (9
items, 0.91), depersonalization (5 items, 0.77), and
personal accomplishment (8 items, 0.89).22 Job satisfaction
was measured using the Job Enjoyment Scale,23 which asks
respondents to rate job satisfaction on a 5-point Likert-type scale
(7 items, 0.88) with scores ranging from 7 to 35.
Scheduling satisfaction, preferences, and intention to
stay in current position were 1-item self-report measures. In
previous research of physicians, self-report intention to stay
had a sensitivity of 73.3%24 and is a frequently used in
research assessing the nursing workforce.25 Employee health
and safety was measured by absenteeism and injuries. It is
well documented that employee reporting of occupational
injury using institutional mechanisms is low26,27 and self-
report of employee occupational health outcomes using sur-
28
vey methods has been validated. Therefore, we directly
asked respondents their history of occupational injury and
absences in the last 4 months. This recall period was chosen
because these are somewhat rare events, but the longer the
period, the more likely a respondent is to underestimate the
occurrence.29
System Outcomes
System outcomes included measures of recruitment and
turnover, staffing and related costs, as well as absenteeism
and related costs. Recruitment measures included (1) average
vacancy rate for the year and (2) average number of weeks to
fill a position. Turnover was defined as the number of nurses
leaving their position per full-time equivalents per unit.
Payroll and census data were used to calculate: (1) 3 staffing
variables (ie, total care hours per patient days TCHPPD ,
registered nursing hours per patient days RNHPPD and
skillmix ratio of RNHPPD to TCHPPD ); (2) overall and
registered nurse specific staffing costs per patient day; and 3)
absenteeism rates and costs per patient day.30 Staffing costs
included all payroll expenditures such as regular time, differ-
entials, sick time, overtime, and agency personnel costs. To
account for fringe rates, nonagency payroll cost data were
multiplied by the mean factor representing these particular
costs for this group (1.36).
Quality of Patient Care Outcomes
Previous researchers have found patient adverse events
to be under reported using administrative mechanisms.31
Therefore, nursing sensitive quality of patient care outcomes
were measured using 3 different types of data including
12-months of administrative incident reports, 12-months of
patient discharge abstracts, and nurses perceptions of quality
obtained from the survey.
Unit level measures of quality from incident report data
included (1) medication events per patient bed, (2) patient
falls per patient bed (defined as any unplanned descent to the
floor), and (3) decubitus ulcer prevalence per patient bed.
These patient outcomes were chosen because similar mea-
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Stone et al
sures to the latter 2 have been endorsed by the National
Quality Forum as nursing sensitive outcomes30; and, medi-
cation errors have been found to be related to nurse staffing.27
However, although most hospitals monitored these incidents,
definitions were not always similar. In all instances, original
data were examined and, if needed, recoded to meet study
definitions. For example, 1 hospital separated witnessed and
unwitnessed falls and these categories were collapsed. If
usable data were not available the unit was dropped from that
analysis.
In a comprehensive review of literature conducted by
the developers of the Patient Safety Indicators (PSI), 4 of 20
measures were categorized as staffing sensitive (decubitus
ulcer, failure to rescue, postoperative pulmonary emboli or
deep vein thrombosis, and postoperative respiratory fail-
ure).32 Therefore, these 4 PSIs were chosen for analysis and
developed from the electronic patient discharge data using the
publicly available software. All data were aggregated to the
unit the patient was discharged from. The software allowed
for risk adjustment to control for differing patient popula-
tions by adjusting for age, sex, diagnostic-related groups, and
comorbidity distribution of data compared with national
norms. Furthermore, patient populations were standardized
by computing the event rate based on the number of patients
that are at risk for the event. Because postoperative compli-
cations were so rare in this population, they were dropped and
failure to rescue (ie, deaths per 1000 patients having devel-
oped specified complications of care during hospitalizations)
and decubitus ulcers (ie, cases of decubitus ulcers per 1000
discharges with a length of stay greater than 4 days) were
analyzed.
Three questions on the nurse survey were directed at
obtaining the nurses perception of quality of patient care and
included statements about quality (1) on the last shift worked,
(2) in general, and (3) changes over the last year. The
responses for the first 2 items included categorical choices
ranging from excellent to poor. Responses to changes over
the last year included improved, stayed the same, and dete-
riorated. Single-item questions assessing the clinicians per-
ception of quality of care provided have been used in a
number of studies.33,34
Data Analysis
Distributions and descriptive statistics of all variables
were reviewed. If a continuous variable was not normally
distributed, it was either transformed using logarithmic tech-
niques (ie, job satisfaction) or dichotomized at the median (ie,
depersonalization, personal accomplishment, satisfied with
current scheduling). Missing value analyses were conduct-
ed.35 Because of the relatively low amount of missing data
( 5%) for responses in the Likert type scales, a mean
substitution approach was taken imputing the missing score
with individual mean response for each scale.36 There was no
attempt to impute missing nurse demographic data or items
related to nurses perceptions of quality.
Response bias is always a potential limitation in sur-
veys. The usual way of checking for this bias is comparing
those that responded to those who didnt on key variables.
Because the survey was anonymous, there was no way to
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Medical Care Volume 44, Number 12, December 2006
accurately check for this potential bias. To understand how
the respondents may be similar and or different from the
population of interest, the demographics of those who re-
sponded to the study were compared with demographic data
based on each hospitals Healthcare Employee Pension files
for the same time period. The Pension data included basic
demographic data by personnel category at the hospital level of
analysis. In addition, the response rate for each unit was calcu-
lated; relationships between response rate and scheduling type as
well as nurse outcomes were examined (see below).
Multivariate general estimating equations (GEE) were
developed for each outcome variable.37 The GEE method was
chosen as the primary data analytic technique because re-
sponses may be correlated (ie, not independent). The GEE
inference is based on the sandwich estimators of standard
errors. Although other methods, such as hierarchical linear
modeling, increasingly are being used to handle correlated
continuous data, the GEE method has been shown to be
robust when outcomes are categorical.37 To evaluate the
effects of 8- versus 12-hour shifts on nursing outcomes and
nurses perceptions of quality, responses from all useable
surveys were included, the nurse was the unit of analysis,
structural variables were entered into the models as covariates
and analyses were clustered by the unit in which the nurse
was employed. The effect of entering unit-level response rate
as a covariate in these models was examined. For the quality
of patient care outcomes (except nurse perceptions) the sam-
ple was limited to medical/surgical nursing units, the unit was
the level of analysis, and the analyses were clustered by the
hospital. Differences in adjusted means were determined by
the beta coefficient for continuous data. Logistic regressions
and odds ratios were computed for dichotomous outcomes.
Statistical significance was examined with P values and 95%
confidence intervals.
RESULTS
Thirteen of the 14 eligible hospitals (93%) enrolled in
the study. The median bed size was 300 (range, 212780). All
participating institutions were affiliated with an academic
institution, nonprofit status and considered nonspecialty hos-
pitals. A total of 99 units (8-hour shifts, n 63; 12-hour
shifts, n 36) were analyzed.
Fifteen nurse surveys were discarded as duplicates; this
left a total of 805 useable surveys with an overall response
rate of 42% (range, 2270%). The majority (76%) of the
responses came from the first wave of distribution (n 612).
There were no differences in the respondents demographic
profile compared with the Pension data; and response rate did
not differ between 12- and 8-hour units (data not shown). The
majority of the nurses (n 504, 63%) worked 8-hour
schedules. Comparisons of nursing demographics by sched-
ule and unit type are reported in Table 1. The only significant
difference (P 0.05) in nurses demographics between shift
length was related to race, with a greater proportion of those
working 8-hour shifts being black.
Table 2 displays the summary statistics and results of
the multivariate regressions with nursing outcomes as the
dependent variables. Compared with nurses working 8-hour
2006 Lippincott Williams & Wilkins
Medical Care Volume 44, Number 12, December 2006 8-Hour Versus 12-Hour Shifts

TABLE 1. Descriptive Statistics of Respondents Unit and from 12 to 14 units). Units staffed by nurses working 12-hour
Scheduling Type shifts had lower vacancy rates and weeks to fill the position
(P 0.05). Turnover, staffing, absenteeism, and related costs
12-Hr 8-Hr were not statistically significantly different between units.
(n 301), (n 504),
Variables n (%) n (%) P
Table 4 displays the quality patient care outcomes
results. There were no differences in any of the quality of
General nursing ward type 0.001
patient care variables. The incident report data came from 9
Specialty unit 167 (55.5) 349 (69.2)
(70%) participating hospitals and 13 (92%) hospitals pro-
Medical/surgical unit 134 (44.5) 155 (30.8)
vided the patient discharge abstracts (n 68,034). The mean
Nursing demographics
numerators and denominators across nursing units for the
Gender 0.111
PSIs were decubitus ulcer 32 of 1053 and failure to rescue 11
Female 279 (93.3) 452 (90.6)
of 149.
Male 20 (6.7) 47 (9.4)
Education 0.136
Diploma 25 (8.5) 44 (9.0) DISCUSSION
Associate degree 101 (34.2) 181 (37.2) Controlling for structural variables related to nurse
Baccalaureate degree 157 (53.2) 226 (46.4) demographics and employment settings, most nurses working
Masters degree 12 (4.1) 36 (7.45) 12-hour shifts in this sample reported higher job satisfaction
Race 0.002 and less emotional exhaustion, they preferred and were more
American. Indian 3 (1.1) 3 (0.6) satisfied with their schedules, and missed less shifts. The
Asian 104 (36.7) 124 (26.1) finding that nurses working 12-hour shifts report missing
Hawaiian, Pacific 7 (2.5) 7 (1.5) fewer shifts is not surprising, since they are scheduled to
Islander
work less shifts. Nurses working 12-hour shifts reporting
Black 104 (36.7) 243 (51.2)
that these shifts were important may indicate ability for
White 65 (23.0) 98 (20.6)
self-selection to units that provide these schedules. It is
Ethnicity 0.559
important to note, a minority preferred conventional 8-hour
Hispanic 9 (3.4) 20 (4.5)
shifts. These results support calls for flexibility and choice in
Non-Hispanic 256 (96.6) 426 (95.5)
shift length as important elements in positive nurse work
Mean (SD) Mean (SD) environments.38
Age 42.45 (10.82) 43.75 (9.70) 0.108
We did not find statistically significant differences
Years in healthcare 17.26 (10.12) 17.50 (10.33) 0.752
between groups in actual absenteeism or staffing costs. How-
Years in hospital 11.29 (7.87) 11.68 (8.38) 0.545
ever, small sample sizes due to lack of useable data were an
Years on unit 7.95 (6.68) 8.26 (7.00) 0.568
issue and may have prevented detection of important trends
that exist. Further larger scale research is needed to help
Specialty unit was defined as oncology, orthopedics, or detox. 2 analyses con- understand the extent and characteristics of absenteeism as
ducted for categorical data, t tests conducted for continuous data. Sample sizes of nurse
demographics vary because of missing data. Sample sizes are gender (n 798), well as other staffing related expenses, such as use of tem-
education (n 782), race (n 758), ethnicity (n 711), age (n 683), years in porary staff.39 In the meantime, we encourage policymakers
healthcare (n 783), years in hospital (n 704), and years on unit (n 663).
to analyze data from their own institutions to inform their
human resource management decisions. Although the best
shifts, those working 12-hour shifts were, on average, more data would come from a randomized controlled trial, that is
satisfied with their jobs, experienced less emotional exhaus- probably not feasible. Analyzing longitudinal data pre and
tion, were more than 10 times more satisfied with schedules, 2 post changes would be the next best choice.39
times as likely to perceive 12-hour schedules as important, and In 8-hour units, vacancy rates and weeks to fill posi-
58% less likely to report missing shifts (all P values 0.05). tions were significantly higher than the 12-hour units. Expen-
Although most respondents thought 12-hour shifts were impor- ditures related to vacancy have been found to be the single
tant, approximately 15% of the respondents working 12-hour largest component in estimating costs of nurse turnover,
shifts and 35% of those working 8-hour shifts did not. which ranges from $62,000 to $67,000 per nurse depending
Greater unit response rate was significantly related to on the service line.40 Vacancies may be related to the pref-
younger age (P 0.009), positive organizational climate (P erences of the nurses and internal transfers to units offering
0.001), lower emotional exhaustion (P 0.040), lower de- 12-hour shifts; however, we did not have data to test this
personalization (P 0.001), and higher personal achieve- hypothesis.
ment (P 0.001); however, results from the multivariate A strength of this study is the multiple ways quality of
regressions were similar to Table 2 when the unit response patient care was measured. We did not have sufficient power
rate was entered as a covariate (data not shown). to detect differences of incident reports or the PSIs; however,
The results of the system outcomes analyses are dis- the point estimates of all quality measures were similar by
played in Table 3. Four hospitals (29%) provided the recruit- shift length and do not provide any consistent evidence that
ment and turnover data, and 5 (36%) hospitals provided there were differences by shift length. To our knowledge, this
payroll data, which limited sample sizes (12-hour units is the first study that has examined administrative data, incident
ranged from 14 to 17 units, 8-hour units sample sizes ranged report data and nursing perceptions of quality in 1 study. Con-

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Stone et al Medical Care Volume 44, Number 12, December 2006

TABLE 2. Comparison of Nursing Outcomes by Shift Length

12-Hr Mean (SD), 8-Hr Mean (SD),
Variables n 301 n 504 Beta (95% CI) P
Job satisfaction 21.2 (4.3) 20.3 (4.3) 1.05 (0.13, 1.96) 0.025
Emotional exhaustion 21.4 (12.4) 25.9 (12.7) 5.86 ( 8.62, 3.10) 0.001

n (%) n (%) OR (95% CI)

Depersonalization 124 (41.2) 239 (47.4) 0.72 (0.471.09) 0.121
Personal accomplishment 140 (46.5) 223 (44.3) 1.11 (0.781.57) 0.56
Satisfied with current scheduling 232 (77.1) 260 (51.6) 10.44 (5.7418.99) 0.001
12-hr shifts are important 257 (85.4) 326 (64.5) 2.37 (1.413.98) 0.001
No intention to stay 83 (28.7) 152 (31.3) 0.83 (0.501.37) 0.47
Missed shifts 101 (33.6) 276 (54.8) 0.42 (0.290.60) 0.001
Injury 175 (58.1) 285 (56.6) 1.12 (0.791.61) 0.52
Results are from Generalized Estimating Equations models with responses clustered by nursing unit and structural variables entered into all to
control for potential confounding.
CI indicates confidence interval.

TABLE 3. Comparison of System Outcomes by Shift Lengths

Variables 12-Hr, Mean (SD) 8-Hr, Mean (SD) Beta (95% CI) P
Recruitment and turnover n 17 n 12
RN vacancy 5.0 (3.3) 13.5 (7.9) 10.00 ( 12.20, 7.90) 0.04
Weeks to fill RN position 5.3 (3.6) 10 (2.6) 4.39 ( 7.71, 1.08) 0.001
RN turnover 0.28 (0.30) 0.05 (0.05) 0.03 ( 0.10, 0.16) 0.63
Staffing and costs n 14 n 14
TC HPPD 6.00 (2.96) 7.96 (2.50) 1.74 ( 3.84, 0.36) 0.36
RN HPPD 3.21 (1.51) 3.25 (4.16) 0.05 ( 1.17, 1.08) 0.94
Skillmix 0.50 (0.09) 0.49 (0.07) 0.02 ( 0.05, 0.08) 0.61
Total staffing cost 285 (126) 353 (107) 41.2 ( 49.4, 131.6) 0.37
RN staffing cost 188 (77) 237 (78) 9.08 ( 77.4, 59.3) 0.79
Absenteeism and costs n 14 n 14
RN sick hour per patient day 0.224 (0.10) 0.313 (0.13) 0.07 ( 0.02, 0.01) 0.59
RN sick wage per patient day 5.82 (2.61) 8.00 (3.64) 1.69 ( 3.77, 0.38) 0.49
Recruitment and turnover data came from 4 hospitals. Staffing, staffing costs, and absenteeism data came from 5 hospitals. All 99 nursing units
were eligible to provide data. Results are from Generalized Estimating Equations models with data clustered by hospital.
RN indicates registered nurse; TC, total care; HPPD, hours per patient day; OR, odds ratio; CI, confidence interval.

tinued research is needed to determine the most accurate and
feasible measurement of the quality of nursing care.
There are a number of potential limitations to this
study. Because our analysis was in 1 geographical region,
which is known for long commute times, these results may
not be generalizable to other locales.41 Future research inves-
tigating the staffing preferences of nurses and recruitment and
retention issues across locales would better inform these
issues. The PSIs were the only variables for which patient
underlying risk was controlled for. To limit this potential bias
for other patient outcomes, we limited our analysis to similar
types of units (ie, medical/surgical units). Whenever survey-
ing is conducted, response bias must be considered. Our
survey response rate is favorable to the 38% to 53% response
rates recently found in other anonymous multisite surveys of
hospital-based nursing personnel.42 The lack of differences
between the demographics of the Pension data and the survey
respondents gave us confidence that we had a representative
sample from the participating hospitals. Response rates were
higher in units with better nursing outcomes. However, the
response rate did not affect the results of the multivariate
models.
Most of the previous literature examining effects of
shift length in hospitals is limited to 1 study site. Studying
multiple hospitals is a definite improvement. However, this
was a convenience sample of limited size and the hospitals
were part of multiemployer bargaining group with 1 union
located in New York City. Although these hospitals are likely
to be representative of many urban environments, they may
not reflect hospitals in rural regions or nonunion environ-
ments. Consistent with concentrations of minority popula-
tions in urban regions, these hospitals employee a higher
proportion of minorities than are found in nationally, which
may limit the generalizability.43
One of the problems encountered was that many of the
participating hospitals were not equipped to efficiently pro-

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Medical Care Volume 44, Number 12, December 2006 8-Hour Versus 12-Hour Shifts

TABLE 4. Comparison of Quality Patient Care Outcomes by Shift Length

Summary Statistics
Variables 12-Hour, Mean (SD) 8-Hour, Mean (SD) Beta (95% CI) P
Incident reports n 15 n 11
Medication events 0.05 (0.02) 0.05 (0.02) 0.001 ( 0.027, 0.028) 0.95
Falls 0.10 (0.03) 0.09 (0.03) 0.006 ( 0.020, 0.032) 0.64
Decubitus ulcers 0.09 (0.10) 0.09 (0.03) 0.005 ( 0.016, 0.025) 0.66
Risk-adjusted patient safety indicators n 13 n 21
Decubitus ulcer 0.03 (0.02) 0.03 (0.04) 0.002 ( 0.029, 0.026) 0.61
Failure to rescue 0.06 (0.03) 0.08 (0.06) 0.006 ( 0.040, 0.027) 0.94

n (%) n (%) OR (95% CI)

Nurse perceptions of quality n 289 n 491
Quality of nurse care last shift
Excellent/good 229 (79%) 358 (73%) 1.35 (0.795, 2.293) 0.27
Overall quality of nursing unit
Excellent/good 220 (76%) 352 (72%) 1.03 (0.625, 1.699) 0.90
Overall quality of nursing unit/past year
Improved 93 (32%) 113 (23%) 1.26 (0.843, 1.916) 0.25
The unit of analysis for incident reports and risk-adjusted patient safety indicators is medical surgical nursing units. The target sample size for these
outcomes was 34 units. The incident report data came from 9 hospitals and the patient discharge abstracts for use in the patient safety indicators came from
13 hospitals. For incident report and patient safety indicators, data were clustered by hospital in all Generalized Estimating Equations models. For the nurse
perceptions of quality, the unit of analysis of is the nurse respondents, data came from all 14 hospitals and in the GEE models data are clustered by the nursing unit.
OR indicates odds ratio; CI, confidence interval.

vide needed administrative data elements, such as aggregate
payroll and unit-based recruitment and turnover data. This
limited the power for the system outcome analyses and may
have caused some selection bias. Lack of investment in
management support to help evaluate best practices has been
noted elsewhere.44 There are many new electronic and web-
based technology applications becoming available to assist
administration, nurse managers and clinical nurses more
effectively and efficiently provide quality care. As informat-
ics infrastructure rapidly increases in hospitals, the burden of
participating in multisite research and reviewing data to make
evidence-based management decisions may be reduced.45
We controlled for organizational climate and other
potential confounding variables to determine the independent
effect of shift length on the outcomes of interest. However,
shift length may positively affect organizational climate.
Further research examining the relationship between these
variables is warranted.
This study represents an innovative attempt by a labor-
management bargaining group to make an evidence-based
decision. Leadership from labor and management were com-
mitted to participating in an objective study conducted by a
nonpartisan outside research team. In this context, conduct-
ing this study offered unique challenges and opportunities
related to design and analysis. For example, the population of
interest was a limited sample size; and, the choice of depen-
dent variables was based not only on previous research, but
also important concerns from both constituencies. Impor-
tantly, the knowledge gained from this study had the unique
opportunity of being implemented into practice quickly,
which increased the interest of all stakeholders (researchers,
labor and management) to ensure appropriate interpretation
of results. Data from this study are being used to inform
negotiations for individual participating hospitals. The largest
hospital in this study has converted multiple medical/surgical
units to 12-hour scheduling since the results have been
reported. We encourage others to conduct similar rigorous
studies with the ultimate goal of implementing evidence-
based management practices to improve nurse work environ-
ment while improving quality of care.
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APPENDIX

APPENDIX. Characteristics of Each Hospital

Hospital
1 2 3 4 5 6 7 8 9 10 11 12 13
Hospital size
Beds 212 780 530 387 235 200 222 300 461 250 332 358 279
No. medical/surgical units
8-hr 4 2 2 1 7 2 1
12-hr 1 4 3 3 3 1
No. adult general specialty units
8-hr 5 11 5 9 4 3 1 5 1
12-hr 1 4 1 2 1 6 2 1 3
No. eligible nurses for survey 181 388 221 171 139 68 123 150 134 41 150 117 52
Survey response rate (%) 31 33 52 70 48 25 33 26 40 22 62 48 58
Annual shifts by schedule type
8-hr 260 260 260 260 260 260 208 260 260
12-hr 169* 169 169 169 156 164 163 169 169 156 169
*One 12-hr unit scheduled nurses only 164 shifts.

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