Nurses’ work shifts

| 10/05/2014

The use of extended work shifts and overtime has escalated as hospitals cope with a shortage of registered nurses (RNs). Little is known, however, about the prevalence of these extended work periods and their effects on patient safety. Logbooks completed by 393 Cayman Islands hospital staff nurses revealed that participants usually worked longer than scheduled and that approximately 40 percent of the 5,317 work shifts they logged exceeded twelve hours.

The risks of making an error were significantly increased when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week. Both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours at a stretch.

Several trends in hospital use and staffing patterns have converged to create potentially hazardous conditions for patient safety. High patient acuity levels, coupled with rapid admission and discharge cycles and a shortage of nurses, pose serious challenges for the delivery of safe and effective nursing care for hospitalized patients. While systematic national data on trends in the number of hours worked per day by nurses are lacking, anecdotal reports suggest that hospital staff nurses are working longer hours with few breaks and often little time for recovery between shifts.

Scheduled shifts may be eight, twelve, or even sixteen hours long and may not follow the traditional pattern of day, evening, and night shifts. Although twelve-hour shifts usually start at 7pm and end at 7am, some start at 3am and end at 3pm. Nurses working on specialized units such as surgery, dialysis, and intensive care are often required to be available to work extra hours (on call), in addition to working their regularly scheduled shifts. Twenty-four-hour shifts are becoming more common, particularly in emergency rooms and on units where nurses self-schedule.

The Cayman Legistative Assembly should restrict the number of hours a nurse may voluntarily work in twenty-four hours or in a seven-day period. The Health Ministry has considered bans on mandatory overtime for nurses and other health care professionals, the PPM government should pass bills prohibiting mandatory overtime for nurses, doctors, paramedics and EMTs. No measure, either proposed or enacted, addresses how long nurses, doctors and paramedics may work voluntarily. The Health Ministry recommends that voluntary overtime also be limited.

The well-documented hazards associated with sleep-deprived resident emergency physicians have influenced changes in house staff rotation policies. In contrast, although shift-working nurses have been the focus of numerous studies, it is not known if the long hours they work have an adverse effect on patient safety in hospitals. The purpose of this is to examine the work patterns of hospital staff nurses, doctors, paramedics and EMTs and to determine if there is a relationship between hours worked and the frequency of errors.

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  1. Anonymous says:

    I'm an old, former EMT from Mississippi.  I'm now in the travel industry.  I drove ambulances when they were operated by funeral homes, so that will tell you I've been around a while.  All of my immediate family is or was in the medical field.  We have some of the same problems in the states that are described here.  
    I remember working a few 24 hr. shifts.  It wasn't safe for me or the patients,, or those on the road when I was driving!  
    My oldest son is now out of the medical field (surgical assistant) because of the stress. He spoke out about conditions and staff problems.  It finally took a toll and he chose to leave.  
    His wife isstill a nurse in surgery.  I see the stress she is under.  My youngest son is a clinical rep. for a major cardiac company. He travels to hospitals to assist the doctors with his products.  I hear the horrors almost daily of poor staff conditions.  And, it seems that the marginal nurses and other staff are the "heroes" to administration.  They agree to whatever the administration mandates and do little to provide the best care for patients.  It's all about the money, even in the non-profit sector.  It appears to be similar in Cayman as well.  
    As a travel agent, sending clients on vacations, I am always concerned about the healthcare when they are in another area.   I love The Cayman Islands.  I also like to learn about the "real" community when I visit, not the tourist version.  I'm thankful for Cayman News Service andCayman27 online.  You have much to be proud of and thankful for. 
    Continue to speak out and stand up for healthcare and reasonable working conditions.  
    You will be in my prayers daily.  
    One question I do have is about Shetty.  Is the care for patients and staff better than the other facilities?  It seems that Dr. Shetty is a concerned physician and wants the best for his patients and staff.  
    OH, as far as the person that had to wait 3 hrs. in the emergency room…..  obviously he was not an EMERGENCY.  Things don't change, emergency rooms are still 80% clinics for those that don't want to go to the doctor's office. 
    Thanks for allowing me to 

  2. Anonymous says:

    How much overtime/additional shifts do you do monthly, and why? For the money, for the fun, nothing better to do?

    I don’t work overtime, period. Well, sort of. Let me explain.

    I used to work overtime. I used to work a lot of overtime.

    At another service a few years ago, I worked 12 hour day shifts, on a rotating schedule. I think they are called Philly 12s or something like that. So I would work Monday, Tuesday, Friday, Saturday, Sunday, Wednesday, then Thursday, and that would repeat every pay period. It was an interesting shift, to say the least. It wasn’t uncommon for me to simply stay on the ambulance at the time.

    I would go into work at 7 in the morning on a Monday, and would literally stay on the ambulance until 7 in the morning Wednesday. I would routinely work 36 and 48 hour shifts.

    I got burnt out, and quickly.

    When I left to join the Cayman Local Ambulance, I began working 24s, and I would routinely stay after my shift for another 12, and sometimes 24 hours.

    The money was fantastic. But it took a toll on me.

    It all culminated a few years ago when I lost control of my emotions on a scene. I spoke to a patient’s family member in an incredibly condescending manner. Without going into details, suffice it to say that I was incredibly rude, terse, and inappropriate. I received a well-deserved complaint, the first of my career.

    Instead of being fired, which my boss had every right to do, I was given an unpaid suspension for three shifts. That hurt my bottom line, and it took about a month to recover financially. But my boss gave me a gift at the same time: some time off.

    During that time off, I learned that the buckets of money weren’t worth it. The big checks aren’t worth coming home tired, cranky, and burned out. That was almost three years ago, and I haven’t worked an extra shift on an ambulance since.

    I will occasionally work an extra shift on a standby event or something, but that is only about twice a year.

    While being a paramedic is part of my life, it is only a small part. I am not a paramedic when I come home at the end of my shift, I am daddy.

    Now, I get to spend my off time playing with my children. I take my son to Kindergarten in the mornings, and I pick him up in the afternoon. About once a week, I take him to get ice cream on the way home, and I get to spend very important time with him. At night, I rock my little Princess to sleep while singing to her, and in the morning, I pick her up out of her crib. Then I get to make breakfast for my family, and we get to eat together. My son helps me cook dinner on the grill, and we all eat at the table as a family. I play trains and superheroes with my son, and have tea parties with my daughter. We play “get daddy” when we are all home, and someone usually laughs so hard they pee a little bit.

    Now that I work 12 hour shifts again, I get to be home roughly half of every month. I get to spend my time at work with a man I consider to be part of my family, Slimm. Then I come home to my home family.

    That time at home is worth an immeasurable amount more than any overtime shift I could ever, ever work. I would rather stretch money a little further in order to spend my time with my family.

    There is no amount of money anyone could pay me to give up that time with my family.

  3. Anonymous says:

    Guys,

    with all due respect to the profession, the efficiency with which the HSA ER staff operate is terrible.

    Judging from my own experience. I have a hospital phobia now. Nurses are more interested in making sure paperwork is filled out than they are in taking care of the living, breathing human being suffering — and perhaps dying — on the stretcher in front of them. Dehumanization and absence of compassion. 

  4. Anonymous says:

    So let me get this straight? Chances are that when I visited the ER at 1am, and the place was dead quite and it took me 3 hours for them to call me in, they were in the back resting up on their OT shift?? What a joke.

    • Anonymous says:

      Just because you see the main patient area "empty" in the emergency room, does not mean that the individuals who work there are sitting back, relaxing and having a grand old time. First of all, there are two trauma beds and a minor operations room on the other side of the emergency room that fall under the care and perview of the physicians and nurses that work in A&E. You have no idea what they were or possibly do deal with in those rooms on a daily basis from the waiting area. Additionally, there is also a paediatric care room and an isolation room as well as a cast and suture area, so you cannot accurately judge the state of the A&E based on how empty the patient beds were. Not to mention the patient reports, blood work, radiography, and dealing with family members/friends/police/ambulance people that the physicans and nurses have to deal with every 5 minutes.

       

      Also, 3 hours to get into the emergency room when you obviously DID NOT have a life threatening injury or condition – bobo, thats a winner right there. A&E cases are seen on a basis of priority, in other words, the closer you are to dieing, the faster you will be seen.

      • Anonymous says:

        Ok – sorry to offend you and your other co workers. But I guess when those Doctor and Nurses came out with their grumped up face and sleepy yawns – it was more than likely because of the hard work they were putting in on the "invisible" patients in the unseen rooms, ok gotcha. And also, whether or not i was NOT CONSIDERED near death – it still tells me how my life is only prioritized based on my screams! Feel sorry for those who are sitting there patiently waiting for a diagnosis to that "heart burn" pain they are feeling. The hosptial recruits and can only afford the best of the worst from elsewhere.

  5. Slowpoke says:

    I see that the Troll forces are out in full battle mode.  Long live the tea party Caymankind.

  6. Anonymous says:

    Without a doubt, there are not many people whose lives have not been touched by the care and reassurance that nurses provide every hour of the day, every day of the year.But OVERTIME payments for health workers and contract staff, such as locum doctors and nurses, should be slashed to help achieve an $3 million cut in the budget for hospitals this year.

    I'm concerned some doctors were being paid as much as $200,000 in annual overtime on top of base salaries, which average $84,000 to $114,000.Nurses were being paidas much as $125,000 in  annual overtime on top of base salaries,which average $72,000 to $84,000.Paramedics earned $180,000 last year, including base pay of $76,000.The Hospital need to be more efficient,we need to reduced emergency department costs and patients waiting times by involving seniors doctors in the early stage of triage.This meant decisions were made earlier and unnecessary admissions were avoided. But such improvements can go only so far to make up for what doctors, nurses and paramedics say is a chronic shortage of staff and resources.
    There has been an increase in staffing of the ambulance service for over 10 years but demand has been increasing by about 25 per cent per annum, the overtime generally is a forced condition on the paramedics, particularly in the eastern districts. We must find a better way of rotating our staff to help with the disparity of those who are working long hours, beyond their physical capacity to deliver quality care, in order to earn a larger pay cheque, as opposed to others who are working fewer hours and struggling to make ends meet.
    Certainly, this will reduce the potential risk of fatigue, errors, poor mannerism, poor communication, high stress levels, and subtle power play.

    • Anonymous says:

      I have no idea where you're getting your figures from – but I'm a paramedic, and I don't even make one third of $180,000. Nurses don't get paid that amount either – and if doctors are specialists then they can make that much, but doctors are in a different league. You need to quote your sources or state where those numbers are from because all in all – you're not telling anything that even looks like the truth.

      Also, the EMS has actually *declined* in numbers of staff over the years – so again, false information. The RCIPS and fire services however, they have increased.

      • Anonymous says:

        Change is gonna come,so better to accept than fight it.I do not believe the world was created so a small minority of people can dance on the faces of everyone else.You are free to disagree.

      • Anonymous says:

        It appears to me the first poster has some 'insider' knowledge and is quoting the pay for the people who made the most in overtime, not the average. If EMS staff have declined over the years that would seem to further support the assertion that the lower number of staff are being paid more than their base salary due to overtime required to cover shifts due to inadequate staffing levels. No?

      • noname says:

        I just wanted to take the time to post in response to the above comment by one of my fellow paramedics. 

        I wasn't the one who posted that.  I have the gonads to sign my name to things.  🙂

        Sorry for the vulgar language, but I've had things I've written online come back to bite me right in the rump. 

        I won't comment on salaries.  

        I'm currently off island undergoing cancer treatment again, so I read this site as well as The Compass site to keep abreast of Cayman's happenings.

        I thinkthe author of the aforementioned post should just focus on doing their job to the best of their ability.

        Save lives comrade!

        Chelsea Doxey

    • Anonymous says:

      These figures you're quoting are completely wrong. As a nurse, I WISH I was making that much! Someone direct me to a country where nurses are valued that highly, cause I'm out of HSA if thats the case!

    • Anonymous says:

      You can't really meant all that ..can you?

      First of all I note below the comments from people working in the jobs you mention who tell us that they don't earn close to what you claim. Someone iswrong. I would need convincing  that it is the consistent commentators and not you.

      That aside, why on earht woudl they not be paid for overtime.

      There was another piece earlier this week about public service personnel choosing to take second jobs to enhance their income. There was some disagreement about whether this was motivated by greed or a need to make a bare minimum living (and indeed if either of those motives made taking a second job 'wrong'). However, I don't think that anybody went so far as to say that people can choose to take a second job but if they do they should dotheir government job for free because we could save a lot of money that way.

      Waht is more, in this case these emergency service staff are more often than not not choosing to do extra work but having to do so. If they are being forced (effectively or actually) to work twice as many hours as their contract says they are paid for then why on earth should they not be paid at least twice as much as they were contracted for.

      The issue here is not how much money they may or may not be being paid for overtime but whether it is fair on them to be more or less forced to work excessive hours and whether it is safe for us as patients to rely on their alertness / concentration when they have.

      • Anonymous says:

        One in three comments ids "troll". Not sure what I did to deserve that but hey ho!

      • Anonymous says:

        A lot of people who work for government aren't being fully paid their overtime because it simply cannot be afforded. If the sector is short staffed, and the government/whoever is in charge refuses to hire anyone to relieve the shortage, then the original employees will have to work overtime. Overtime is far more expensive to pay out than normal time, so when the entire work staff is all claiming overtime, vacation pay, public holidays and normal pay all at the same time, you can see that it would become overwhelming.

         

        This is a pretty common problem in Cayman. Especially since we don't have many of our young people who want to go into health care industries or the sciences. All our high school graduates go into the same sector of the economy: tourism, finance or insurance. Consequently, when we have government agencies stating ideologies such as "all-Caymanian" staff, when we have no actual qualified Caymanian candidates for these positions (who aren't already working) then we end up with a permanent deficit within this specialised work force.

         

        The fire service is a perfect example of this. There are no on island fire fighting courses that young Caymanians can take to become qualified or involved in the fire service. Yet, the fire service on island explicitly says they only hire Caymanians. This means then, that the Caymanian people who would be interested in fire fighting have to go off island for 2+ years (the length of time it takes to become fully qualified as a BASIC fire fighter) on their own dime to get the qualifications. Which means then, that if there was a shortage in the fire service staff, and they advertised openings to the island, there would be NO qualified Caymanians who could take up the position.

         

        This was also happening with nursing and other health care positions, but thankfully this has started to change with more on-island training and accredited programs being offered.

      • Anonymous says:

        If they're having to work essentially double the amount of time in their contract, then perhaps there isn't funding to pay them? Ever thought about that?

        Also, as far as it goes for personnel working in the emergency services, most of them already work 12-16 hours per shift, you honestly think that they're going to go and sign up for another job to work in those few hours they have off because they're greedy? If you are working another job after already working a 12 hour shift, chances are its because you need the money.

         

        If paramedics really did make $180K a year like that poster is claiming, then you really think so many of them would be busting themselves working two jobs?

    • Anonymous says:

      I have recently become super obsessed with the possibility of going to the Cayman Islands to be a paramedic. I love that they have "paramedic apprentice/student" programs! From how it looks, it is a 1 year program working on the job and having part time class/studying until you finally become a registered paramedic with a degree in Paramedic Science. It sounds like they are actively trying to recruit more(EMTs) and Paramedics across the US.

      Which of the 2 ambulance trusts are the most interesting to work for? I'd guessShetty of course but they are not currently looking for student medics. I see the entire Cayman Islands are soon accepting applications for paramedic students. How difficult would it be for an American EMT to get into a student paramedic program there ?

      • Anonymous says:

        As someone who worked for the service for a number of years on island – I'd recommed not wasting your time. If you're not Caymanian, you're not going to get a position working with the EMS. The government in Cayman have been making a push towards having the emergency services staffed by Caymanians. The fire service have already achieved this. Unless you are remarkably qualified (perhaps with additional degrees in emergency medicine management, or paramedic instructor certifications) it won't happen. They have already put in place local training programs with the sole intention of having local people move into the service – educated, trained and then working all on island.
         

         

        You might have more luck finding work with the private ambulance service (if Shetty starts one up, I live on island and work in the health industry and I haven't heard anything concrete about that yet), but you can essentially count out working with the government service if you're non-Caymanian. Also, if you're someone who can't take non-politically correct work places, then this is definitely not the place for you.

         

        • Anonymous says:

          Yeah, well… what emergency service do you know that is totally politically correct

      • Anonymous says:

        There are no student paramedic programs on this island. Maybe 2 years ago they did an EMT-B training program where they trained maybe 5 or 6 people who were already working within the Health Services Authority up to being EMT-B's but they still had to go off island to complete portions of the training and certification.

      • Anonymous says:

        Don't bother looking at the government service, it'll be a waste of your time. It is a very, very, very closed service.

      • Anonymous says:

        You might want to keep in mind, though, that your time in Grand Cayman is likely to change your outlook forever. And the struggles you go through in the foreign environment will seem like a cake-walk compared to what you may go through upon returning. Most of my friends who've worked in Grand Cayman agree that they felt totally suffocated by our traditional EMS protocols when they got back. I can tell you that going from a drug pack of 14 meds to 118 here at home, having a dispatcher tell you to go park on a street corner and wait . . . well, you can imagine that it might mess with your head. And taking orders from those of small mind who view their islands protocols as the gold standard, well you get the picture.

        Your mileage may vary. Best of luck.

      • Anonymous says:

        Forget it.

    • Redneck says:

      Which planet did you say you come from?

      You have got to stop smoking that stuff, you are loosing your grip on reality, this comment is so fictional that it is farcical…..you have absolutely no idea what you are talking about.

      Most HSA Staff have not had a pay rise for 5 years, it is becoming increasingly difficult to attract the caliber of staff that the island deserves and many now find it extremely hard to manage financially, certainly the figures you quote have the decimal point in the wrong place…..I challenge you to find anyone earning anything close to the figures you quoted…..perhaps we should make FOI request, to prove just how deluded you actually are.

      The George Town Hospital is top heavy with "managers" who think that indulging in 'box ticking' will make the situation better. These are also the people who lend the hundreds of patients, who have no insurance, interest free loans to pay their hospital bills!….how stupid is that? An institution facing financial crisis operating as an interest free Bank.

      The hospital has an acute lack of materials and  regularly runs out of the basic medications, required to manage even the most common conditions, yet I suspect that most of this is attributable to their complete lack of  financial management and Cinico not paying their bills.

      Mr Alden, if you read this, please do something to address this chaotic situation, it is your own countrymen who are ultimately suffering as a consequence and it is entirely unnecessary, but the comments posted above are simply  a work of fiction written by a lunatic.

       

    • Anonymous says:

      This poster has absolutely no grip on reality. I'm a doctor, and I'm still paying back my student loans – even before my monthly payments, I don't make anywhere near that amount of money. All this considering the fact that I have 4 degrees, a membership to a royal surgical fellowship, and 2 highly trained specialties, plus 17 years experience. $200,000 sounds fantastic to me! When can I sign up? I would have finished my student loans a decade ago.

      • Anonymous says:

        Can the people who labelled the above doctor's post troll pls explain. He is stating facts as they apply to him/her… Not opinions. As such unless you think they are lying I don't get it how that is trolling. PS I am not the poster!

  7. observer. says:

    Nurses are human beings too. They get sick and they have families. The thing with shift work, you can not have a perfect system. Some people will be on vacation, sick, on leave for various reasons, and you will need others to fill in their place.

  8. Anonymous says:

    This is a lose-lose-lose solution to a none existence problem. The patients will lose, the physicians in training will lose and medical training in this island will lose.
    I trained in the 'bad old 80s' before this degradation and dumbing down of medical education really got rolling, where 36 hour shifts (with whatever naps you could catch) and 100+ hour workweeks were the norm.
    Briefly in the 90s I was an attending on a major training medical university that already instituted a 16 hr rule. Every morning the teaching team rounded on patients admitted the night before, and cared for by the previous day's 16hr team. Each morning we had to reinvent the wheel because the interns and residents who had admitted or made critical decisions the preceding 16hrs had been sent home. The universal answer to critical questions as to the patient's history and treatment decisions were 'I don't know, so and so who went home did not tell me that.'
    Patient care suffered and trainee education suffered because their decisions and actions could not be critiqued and medical costs skyrocketed because needless and redundant tests and extended stays resulted because the doctor on the spot was long gone.
    Another reflection of the entire educational system in this island racing to the lowest common denominator and simply being is the final goal, not excellence.The real problem is that the handover between shifts did not work.But every morning there was a handover meeting where all patients in the ward were attended to. First for all the doctors in the department, a to-the-point presentation, thereafter each team took a brief on their patients. In attendance were the doctors leaving the shift and the responsible nurses. I think the patients benefited from this. We were tired, but after a 16 hours on you informed the next man on what was the latest developments with each and every patient in your care.
    It is a matter of discipline, care and organisation. The sacred long shifts and debilitating hours we can live without, and doctors in our islands on an average do perform worse than those in the US – if patient outcome is taken into consideration.
     

  9. Anonymous says:

    As someone who works in the HSA at the GT hospital, I can tell you that I've worked 48 hour shifts before; and for people in professions such as mine (Emergency Room), working more than 12-16 hour shifts is dangerous. Productivity falls, attention span is decreased, forgetfullness increases – these are not issues we want to deal with while a patient's life may be on the line.

     

    The government should take more care of the people who work in these jobs – nurses, doctors, paramedics, EMTs – but everyone seems to overlook us. We're short staffed, and no relief staff is ever hired… we work hours and hours of overtime to cover shifts for a small service and the government doesn't pay us! And then we don't have the right to say no to a shift if we are called in because it is our duty, and we cannot refuse in emergency situations. But at the end of the day – it is always an emergency, there is always a crisis, there are always short shifts and no one around to work them; and the situation is just getting worse and worse.

     

    The government and the HSA need to be looking for emergency short term staff to relieve the back log of over worked employees who spend 50 hours a week in high stress situations. Don't get me wrong, I love my job and I would not have spent 10 years in school if I didn't want to be a doctor, but working back to back shifts for 2 and 3 days at a time is just not helpful for anyone.

    • Anonymous says:

      Isn't it illegal? To work over certain hours?

      • Anonymous says:

        It is supposed to be, there are labour laws for every profession on island, but who is really enforcing them?

        • Anonymous says:

          This is nothing new.  The same thing is being done with some workers at the Francis Bodden Girls Home and also at the Pines.  No matter who you speak to or write to there are no changes!  The Board doesn't even take or return calls.

        • Anonymous says:

          This is so incredibly true. I have worked multiple back to back shifts before, at the request of my senior staff, and no one has batted an eyelid. Even though it is in clear breach of labour laws.

  10. Anonymous says:

    Love don’t pay the bills. They might as well use that study time and do law or accounting. We need to offer a salary that will attract the best health care and teachers in the world and encourage the good ones to stay and not leave to go to private. Maybe if we cut some of the salary of overpaid government members we could afford to keep up. Y’all remember the times when those jobs where creme de la creme? Priorities people, priorities.

  11. Anonymous says:

    I hear that the nurses at a certain hospital are treated badly by their bosses, maybe a management review would  attract and retain the right talent, going forward.