homes, high turnover rates have been hypothesized to result in low staff morale, staff shortages, and poor quality of care (CMS, 2002).

A 2001 survey of directors of nursing of all U.S. nonfederal acute care hospitals found (for the 14.7 percent of hospitals responding) that, on average, 21.3 percent of all full-time registered hospital nurses had resigned or been terminated during the preceding year. While most hospitals reported turnover rates of 10–30 percent, some cited much higher rates. For example, 2 percent of responding hospitals reported turnover rates of 50 percent or higher (The HSM Group, 2002). Turnover rates among nursing staff in nursing homes are even greater. A national survey conducted by the American Health Care Association (AHCA) in 2001 found annual turnover rates of 78 percent for NAs, 56 percent for staff RNs, 54 percent for LPNs/ LVNs, and 43–47 percent for directors of nursing and RNs with administrative duties (AHCA, 2002).

Long Work Hours

Nursing staff working in in-patient facilities traditionally have worked in 8-hour shifts, but increasingly work longer hours. Reasons include a desire for increased compensation (“elective overtime”), requirements by facilities to work overtime (“mandatory overtime”) to compensate for insufficient staffing, and a desire for more flexible work hours (e.g., 10- or 12-hour shifts) to accommodate the needs of either facilities or nurses or both. Scheduled shifts may be 8, 10, or 12 hours, and may not follow the traditional pattern of day, evening, or night shifts. Moreover, nurses working on specialized units, such as the OR, dialysis units, and some intensive care units, may be required to be on call in addition to their regularly scheduled shifts (Rogers, 2002).

A 2002 study funded as part of AHRQ’s initiative to examine the effects of working conditions on patient safety documented the work patterns of a national sample of hospital staff nurses who are members of the American Nurses Association. The study measured each nurse’s work hours, length of shifts, and amount of overtime hours worked and the effects of these factors on nurses’ commission of errors. It was found that although the majority (84.3 percent) of scheduled shifts were 8 or 12 hours in duration, 3.5 percent were for periods greater than 12 hours, some lasting as long as 22.5 hours.9


Ann Rogers, Ph.D., University of Pennsylvania, unpublished data (manuscript in prepara tion).

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