Search and inclusion/exclusion strategy

We searched CINAHL, Medline and Scopus with terms pertaining to nurses’ experience and preferences around shift patterns. Searches were undertaken up to April 2021. Table 1 provides a detailed list of the key terms that we used for the search. We limited our search to studies with an English language abstract. There was no restriction on the publication date to ensure the review of research was comprehensive.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Search strategy for scoping review on nurses’ experience and preferences around shift pattern.

https://doi.org/10.1371/journal.pone.0256300.t001

Because we were interested in nurses’ experience and preferences around shift patterns from their perspective, we only included papers that contained explicit comments or views as reported by nursing staff, whilst excluding papers that made indirect inferences. Papers that were not specific to nursing, as well as news articles and opinions were excluded from the scoping review.

OE applied the inclusion/exclusion criteria to screen all titles and abstracts, after which CDO and PG reviewed the selections. All authors agreed that the sample of articles selected for full-text review were relevant for the research question. OE extracted data from relevant studies and met regularly with CDO and PE to discuss findings. It was during these meetings that the key concepts were discussed and refined. Any uncertainties about inclusions and exclusions were also discussed between OE, CDO and PG. The Prisma flow diagram describes the literature search and screening process in details (Fig 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Prisma flow diagram of the literature search and screening process for the scoping review on nurses’ experience and preferences around shift patterns.

https://doi.org/10.1371/journal.pone.0256300.g001

Numerical analyses of included studies

Three thousand four hundred and six (N = 3,406) records were retrieved from the database searches (Fig 1). 30 papers published between 1993 and 2021 were judged eligible. Half of the papers (n = 16) were published between 2018 and 2021. The largest group of papers came from the USA (n = 8). The UK (n = 7) and Australia (n = 6) had the second highest output. Other papers came from Asia (Iran, n = 2, China, n = 1, India, n = 1 and Cambodia, n = 1), other European countries (one each from Germany, Norway and Sweden respectively) and Canada (n = 1).

Most studies were undertaken with staff working in Acute Hospital wards (n = 27), 2 studies took place in Acute Mental Health Trusts and one study used staff from multiple settings (i.e. Acute Hospitals, Community Trusts and Care Home). The majority of papers included only registered nurses (RNs) (n = 23), whilst other papers included other nursing staff (healthcare assistant and other staff, n = 2, nursing assistant, n = 2, midwives, n = 1 and student nurse, n = 1). One paper focussed solely on unregistered healthcare staff (n = 1). The number of participants ranged between 10 [24] and 1355 [25], with female participants representing the majority of the sample.

Fifteen papers used semi-structured interviews. Four papers used questionnaire with open-ended questions and another four papers used qualitative interviews. Two papers used mixed-methods with a qualitative component and five papers used focus groups. Each paper included a discussion about nurses’ experiences and preferences around shift work from their perspective.

Overview of themes

The studies we found reported on three aspects of shift work: namely (i) shift work per se (e.g. the mere fact of working shift without referring to its length or time), (ii) shift length, and (iii) time of shift, referring to when shifts were occurring (i.e. morning, evening, or night); and, in some cases, whether these shifts were worked as part of a rotating or fixed schedule.

Discussions on shift work per se were never the focus of a whole study. Rather, nurses were in certain case describing the impact of shift work on their work or life without referring to the length or time. This concerns more than half of the studies (n = 18). When we consider the length of shift, studies focussing on long (12+ hour) shifts were more common (n = 8, including one study investigating 24-hour shifts, Koy, Yunibhand [26]). Seven studies compared 12 hour shifts with other lengths of shift, such as 4, 8 or 10 hours. In these studies, discussion and results were mainly focussed on 12 hours shifts, however. Studies focussing specifically on nurses working short shifts were less common (n = 2).

The third aspect of shift work describes shifts based on their occurrence during the day (n = 11), including studies with night shifts as sole focus (n = 9). The remaining studies (n = 4) described shifts as follows. Epstein, Söderström [27] used a basic shift description, such as ‘morning and evening’ or ‘morning, evening and night’. Gifkins, Loudoun [28] referred to nursing schedule as shift including ‘late night’ or ‘overnight work’. de Cordova, Phibbs [29] used the terminology off-shift (night and weekend), whilst Bauer [30] simply mentioned ‘early shift’ (6 to 7 am start) without indicating the overall number of hours of the shift worked. Table 2 provides a summary of all studies included in the scoping review.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Papers included in the scoping review (arranged by aspect of shift and descending chronological order).

https://doi.org/10.1371/journal.pone.0256300.t002

Findings from the review are summarised and presented according to these three aspects of shift work, namely shift work per se, shift length, and time of shift. Within each aspect of shift work the impacts of shift pattern on experience and preferences are discussed.

Shift work per se

An aspect discussed by nurses when reflecting on shift patterns was shift work per se, meaning the mere fact of working shifts as opposed to a regular “9 to 5” day job.

Nurses often reported detrimental mental and physical health as a result of working shifts, as well as failure to adopt healthy strategies, such as walking or exercising when working shifts [31]. Working shifts could also act as a barrier to healthy eating with nurses reporting unhealthy eating practices [32, 33], such as overconsumption of caffeine and energy drinks, resulting in poor sleep and health outcomes [34]. Such habits could stem from different sources, including exhaustion and job-related stress which further exacerbated circadian rhythm disruption [33]. Notwithstanding the negative effect of shift work on nurses’ health and wellbeing, presenteeism (i.e. going to work when being sick resulting in lower engagement and productivity) was often brought up, in particular by nurses who are mothers. They reported feeling guilty about calling in sick, because staff shortages would mean that their shift would have to be covered by a colleague forced to do overtime [24]. This was amplified by nurses experiencing increased workload as a result of staff shortages during their shifts [25, 26, 35, 36].

Nurses asserted that working shifts could in certain cases not be conducive for rest and napping [34] or restricting access to planned break periods [37–39]. Fatigue was often discussed in relation to shift work, and it was found to be exacerbated by working more than two consecutive long shifts [37, 40]. Noticeably, nurses observed that the reduction in consecutive shifts decreased work absence [38]. Fatigue could be manifested by physical pain [41], difficulty to transition from day to night-time (and vice-versa) [42], reduced concentration [27, 37], difficulty in taking decisions or emotional manifestation, such as being easily annoyed or unengaged during shift [27].

One study revealed that preference for shift work varied depending on the length of time (i.e. experience) in working shift [28]. Experienced nurses (i.e. at least three years of shift work experience) had a preference for shift work because it aided in their work-life balance. They benefited from the support of their family, friends and senior nurses which positively impacted on their domestic and children caring responsibilities. In contrast, inexperienced nurses reported being isolated and missing out on family and social activities, because friends (more often than family) did not always understand the time constraints of working shifts [28]. The ability to request for their own roster also helped nurses to cope with shift work [28]. Relatedly, nurses choosing their own roster were more satisfied with their job [43]. In contrast, nurses were more reluctant to accept, adapt or prefer a particular shift pattern when it was mandatorily imposed [26, 37, 44].

One study by Gao et al. [35] offered a perspective on how the experience of shift work was affected by the COVID-19 pandemic. As a result of the increase in patient numbers and their acuity, and, consequently in workload, nurses highlighted the need to adjust shift patterns dynamically according to the workload. They also emphasised the importance to account for nurses’ knowledge, skills and abilities during shift scheduling, as well as considering their physical and mental experience [35]. Based on their shift experiences during the COVID-19 pandemic, nurses asserted that their perspectives should be taken into consideration to humanise shift patterns. Besides, communication between managers and front-line nurses should be strengthened to understand nurse perspective when scheduling shift schedules [35].

Shift length

Nurses reflected on their experience and preferences around the length of shifts. Our review report on two main lengths of shift, short shifts (<12 hours), including 4-hours [35], 8- or 10-hour shifts; and long shifts (≥ 12 hours and more), including one study focussing on 24-hour shifts [26].

A factor discussed by nurses in relation to different shift lengths was handovers. Studies consistently highlighted how nurses believe the additional handovers resulting from shorter shifts posed a threat to safety in terms of miscommunication of patient information. One study found that nurses were concerned about the additional handover when moving from long to short shifts, such that the information did not always reach the next shifts [36]. Nurses believed the introduction of an additional handover as a result of moving to 8 hour shifts had led to a higher risk of information being miscommunicated, similar to a Chinese Whispers effect [36]. When the length of shifts was reduced from 8 to 4-hour during the COVID-19 pandemic, nurses described how they felt shorter shifts had led to more handover errors [35]. In another study, nurses reported that communication with all levels of senior staff improved, probably as a result of the extra time that long shifts offered [45]. However, not all studies concluded that long shifts were beneficial to improve communication. One study mentioned that implementing long shifts led to a disruption in communication with colleagues [38].

The loss of one handover when implementing 12 hour shifts limited opportunities for clinical education [38]. It also led to a decrease in informal social support, reduced opportunities for sharing good practices and reflection time. Nurses reported being more isolated, because core staff increasingly worked alongside agency staff which worsened collegiality [46]. In contrast, in one study, nurses reported an increased access to professional development education after 12 hour shifts were introduced. The higher rate of professional development leave was supported by organisational data [45]. One study highlighted how the ability to study was affected by the subsequent tiredness after working long shifts [47]. In some instances, the introduction of 12 hour shifts also reduced nurse confidence in their clinical skills and knowledge following extended time away from a dynamic ward environment [44, 46]. Nurses working short shifts also declared having limited access to education, teaching or staff development as a result of work intensity [36].

Nurses believed there had been an increase in staff turnover after 8 hour shifts were imposed, because staff did not like or did not adapt to the new shift pattern [36]. Some nurses feared 12 hour shifts would cause recruitment challenges of adequately trained nurses [47]. In contrast, another study reported that nurses believed 12 hour shifts would improve retention of experienced staff due to the shift flexibility and ability to increase nurses’ morale, possibly because those nurses reported a strong preference for this shift pattern [45]. Relatedly, some nurses believed the implementation of long shifts had improved staffing levels, with more nurses available during the shifts [38].

Across different studies there were contrasting results for nurses’ views about the impact of long shifts on the quality and continuity of care after 12 hour shifts were implemented. Long shifts were perceived by unregistered healthcare staff [37] and nurses to improve patient and continuity of care [38, 41, 42, 45, 46, 48, 49]. The implementation of long shifts rendered possible the full completion of their nursing tasks, as evidenced by fewer interruptions of work tasks and the possibility to focus on their tasks for longer [41, 42]. Nurses perceived improved communication with patients [42], as they were able to care for the same patients throughout their shifts [48]. They also reported achieving more nursing care with their patients resulting from the extra time long shifts offered [37, 41, 42].

However, in a few studies nurses reported a deterioration in the quality of care they were delivering in the last (four) hours of the shifts [47]. Nurses also had mixed views about the effect of short or long shifts on quality of care, stating their uncertainty about which shifts improved patient care [36, 40]. Nurses reported that the introduction of 12 hour shifts amplified their job strain and left some nursing tasks incomplete because of the intensity of work over an extended period of time [46]. Another study revealed that frequent changes in assignments during long shifts could negatively impact continuity of care, as nurses could not complete their nursing care with the same patients throughout their shifts [48]. The perceived increase in continuity of care over time, in the control over nursing tasks completion, and in the improved communication with patients as reasons for preferring 12 hour shifts [37, 42].

Fatigue (or tiredness) was a feature reported by nurses across all shift lengths, suggesting nurse endure a physical burden when working shifts irrespective of their length. Nursing staff working short [37, 43] and long shifts [27, 38, 40–42, 44, 47–49] reported experiencing fatigue when working shifts. Nurses reported having to pace themselves to complete their shifts, reflecting the necessity for increased physical, mental and emotional stamina when working long shifts [44, 46]. Exhaustion during and after working long shifts was also a common feature reported by nurses [26, 33, 44]. They described that working long shifts led to burnout, reduction in physical and mental health [49].

Nurses’ sleep patterns were reported to be negatively affected by both short [43] and long shifts alike [27, 33], apart for one study where nurses reported an increase in their sleep hours after moving to 12 hour shifts [45]. Some nurses working 12 hour shifts reported fatigue was more manageable since they benefited from more days off-work to recover [38, 45, 47]. In one study, some nurses recognised that fatigue was an adverse effect of long shifts, but they found this was mitigated by the increased number of days off-work [46]. The extra days off and improved work-life balance were often mentioned as the reason for a preference for long shifts [36, 38, 41, 42, 44–49]. Work-life balance was also positively rated by nurses working 8 hour shifts [49]. Noticeably, one study reported that nurses’ views of shift length on their leisure was mixed. The contrast may stem from the fact that the population of interest were student nurses, whose educational commitments may restrict their leisure time [47].

Long shifts was associated with anticipated anxiety to return to work, where nurses apprehended returning to a challenging and unpredictable workplace [44]. Stress could also stem from the changes in skill mix resulting from the implementation of 12 hour shifts. For instance, nurses’ supervision increased as a result of using extensive agency and bank staff to cover for sickness absence. Indeed, these temporary staff were unfamiliar with the ward and needed more support from substantive staff [44]. In contrast, in one study nurses felt that working long shifts reduced sickness and/or family leave, as nurses could benefit from extra days off work [45]. Nurses also reported being able to take more planned breaks when working long shifts [41, 42], albeit this was dependent on patient acuity and case mix [38].

Whilst two studies revealed nurses were satisfied or had a preference for short shifts [42, 49], more studies showed nurses preferring long shifts [37, 38, 41, 45, 47, 49]. Acceptance of 12 hour shifts was facilitated when staff were consulted prior to moving to long shifts, and, in some cases, when the request to change to 12 hour shifts came from staff themselves [41, 45, 47]. Individual characteristics and personal circumstances (e.g. age, marital status, grade or presence of children) influenced the extent to which nurses could adapt to the new shift patterns. For instance, the strain of long shifts on wellbeing was particularly intense for older nurses [25, 44, 46]. A further predictor of adaptation to 12 hour shifts was public healthcare commitment: when nursing staff were devoted to the National Health Service (NHS) and their Trust, nurses expressed they accepted the move to 12 hour shifts because they wanted to be helpful towards a struggling sector and employer [46]. Furthermore, nurses reported wanting to be seen to be coping with long shifts as a means of improving their team’s morale [46]. Nurses also reported that childcare costs were reduced when working long shifts as they allowed them to spend more days at home caring for their children [42].

Time of shift

Nurses working night shifts described how the lack of resources, for example other healthcare professionals and administrative staff, led to higher collaboration among them, higher sense of cohesion and better teamwork [25, 29], but also led to difficulty to taking their breaks [50]. Nurses working night shifts experienced increased autonomy and fewer interruptions to planned healthcare as a result of fewer family visits [25, 51]. More specifically, working night shifts allowed nurses to carry out indirect (e.g. administrative) as well as direct clinical patient care with more autonomy [25]. Relatedly, night working enabled nurses to feel more independent and more skilled, fostering their desire to continue working at night [32, 52].

However, lack of resources and of support from other professionals during the night shift led to significant concerns for nursing staff, who reported feeling not considered and appreciated by staff on day shifts [51]. Communication problems between day and night shift nurses could occur, where night nurses felt disconnected from and neglected by day nurses, and struggled to access relevant (patient) information [25]. They perceived their role as under-appreciated by other nurses [29], referring to a universal consensus that night shift nurses are perceived to be practising less or not all [51]. Some nurses experienced fear and insecurity in the last hours of their night shifts resulting from lack of resources [52], exacerbating worries around patient and professional safety [25]. Other nurses denounced inferior working conditions in comparison to their daytime counterparts, including a perception of minimal leadership [51], as well as a lack of welfare facilities [52]. Staffing levels and skill mix were also discussed in relation to night work; night shifts were often covered by temporary staff, and substantive staff felt this was a positive thing because staffing levels could be maintained [29].

Nurses working night shifts valued patient care, as evidenced by the importance they placed in knowing their patients’ conditions and care needs [51]. Nurses’ sense of duties and responsibilities firstly towards their patients also meant they could neglect taking their breaks [50]. The more ‘relaxed’ pace during weekend day shifts allowed nurses to focus more on their patients [29]. However, nurses reported that staffing levels were often inadequate at night [25] or workload was too high [51]; leading staff to report that the quality of care they delivered was negatively affected. Inexperienced nurses (less than one year nursing experience) perceived increased work pressure when working night shifts [52]. Relatedly, nurses experienced tremendous workload when working early shifts, which rendered the work unappealing altogether [30]. Nurses working off-shifts (night and weekend) also revealed they completed more tasks as a result of inadequate staffing level during these shifts [29].

Nights shifts gave rise to educational and clinical learning opportunities from which nurses benefited [25, 32, 52]. Nurses stated that night shifts were more relaxed and some e-learning not available during the day were available at night [25]. In contrast, nurses also reflected on the conundrum of night shifts where their learning opportunities were perceived as suboptimal. This was evidenced by a reduced or lack of education access in comparison to their daytime counterparts, despite added responsibility [51].

Depression, tiredness [31] and fatigue were experienced by nurses working night [25, 51, 52] and day (including evening) [27] shifts. Nurses working night shifts also experienced drowsy driving after completing their shifts [53]. Nurses adopted unhealthy strategies to combat fatigue and adapt to late or night shifts. This included caffeinated drinks and snacking on sugary foods, as well as drinking alcohol to rest and recover after night shifts [27, 28, 39]. Most common strategies to combat drowsy driving after night shifts included listening to music, talking on the phone with relatives, as well as unhealthy snacking [53]. Nurses working early shift also reported being exhausted, as evidenced by their physiological system not being used to start working so early [30].

Nurses asserted their sleep patterns were negatively affected by both early [30] and night shifts [25, 27, 31, 32, 52]. Sleep deprivation stemmed from nurses’ inability to rest between late to early shifts [30], insomnia [52], feeling sleep-deprived while working or the difficulty to achieve a normal sleep pattern after the completion of night work [25]. Nurses reported suffering from anxiety, nutritional imbalance, changed physical appearance and skin pigmentation as a result of working night shifts [32]. Early shifts also caused anticipated anxiety to return to work, with nurses finding difficult to disconnect from work and over-processing their nursing tasks while at home [30]. Stress could also results from dysfunctional organisational structures or poor workplace conditions when nurses worked night shifts [52].

Nurses worked a variety of shift work schedules (i.e. permanent or rotating) and preferences for shift patterns could vary depending on the shift work schedules they were assigned to. For instance, there is evidence nurses preferred working permanent night shifts in comparison to rotating shifts [24, 25, 31]. And there is also evidence that nurses working night shifts on a permanent basis were satisfied with this shift pattern [29]. Whilst working night shifts was exhausting, it also gave nurses a sense of fulfilment [32]. Nurses stated that the environment was more relaxed at night, as evidenced by reduced noise, fewer nursing task interruptions and increased focus-thinking time.

Nurses were able to care for their family when working late or night shifts, despite financial and non-financial constraints for single-parent families [25], or pervasive fatigue [51]. For instance, nurses working night shifts declared benefiting from shared parental responsibility and their presence at home during the day meant they avoided using after-school care [25]. However, nurses also described their sense of guilt when leaving their children to work night shifts, as well as the difficulty in co-ordinating their family and social life [24]. Working early [30] or night shifts could also result in nurses being or feeling isolated from family and friends due to unsociable working hours [25, 28, 31, 51, 52].