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Med Care. 2014 Nov;52(11):975-81. doi: 10.1097/MLR.0000000000000233.

Nurses' shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety.

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*Centre for Innovation and Leadership in Health Sciences, University of Southampton, Southampton, UK †Università degli Studi di Milano Bicocca, Milan, Italy ‡Inselspital Berne University Hospital and Institute of Nursing Science, University of Basel, Bernoullistrasse, Basel, Switzerland §King's College London, National Nursing Research Unit, London, UK ∥Karolinska Institutet, Medical Management Centre, Tomtebodavägen, Stockholm, Sweden ¶Radboud University Medical Centre, the Netherlands and University of Southampton, Centre for Innovation and Leadership in Health Sciences, Southampton, UK #Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA.



Despite concerns as to whether nurses can perform reliably and effectively when working longer shifts, a pattern of two 12- to 13-hour shifts per day is becoming common in many hospitals to reduce shift to shift handovers, staffing overlap, and hence costs.


To describe shift patterns of European nurses and investigate whether shift length and working beyond contracted hours (overtime) is associated with nurse-reported care quality, safety, and care left undone.


Cross-sectional survey of 31,627 registered nurses in general medical/surgical units within 488 hospitals across 12 European countries.


A total of 50% of nurses worked shifts of ≤ 8 hours, but 15% worked ≥ 12 hours. Typical shift length varied between countries and within some countries. Nurses working for ≥ 12 hours were more likely to report poor or failing patient safety [odds ratio (OR)=1.41; 95% confidence interval (CI), 1.13-1.76], poor/fair quality of care (OR=1.30; 95% CI, 1.10-1.53), and more care activities left undone (RR=1.13; 95% CI, 1.09-1.16). Working overtime was also associated with reports of poor or failing patient safety (OR=1.67; 95% CI, 1.51-1.86), poor/fair quality of care (OR=1.32; 95% CI, 1.23-1.42), and more care left undone (RR=1.29; 95% CI, 1.27-1.31).


European registered nurses working shifts of ≥ 12 hours and those working overtime report lower quality and safety and more care left undone. Policies to adopt a 12-hour nursing shift pattern should proceed with caution. Use of overtime working to mitigate staffing shortages or increase flexibility may also incur additional risk to quality.

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