Research on the work hours of nursing staff in nursing homes also has revealed extended work hours. In site visits to 17 nursing facilities in Ohio, Colorado, and Texas in 2001, researchers found that double shifts (i.e., two consecutive 8-hour shifts totaling 16 hours) and extra shifts were performed in many of these facilities on a regular basis. Double shifts in particular were pervasive. In 13 of the 17 facilities, at least one nursing staff member, but frequently more, had worked between one and three double shifts in the previous 7 days. In five facilities, at least one staff member had worked between four and seven double shifts in the last 7 days. In one of the facilities, more than a third of the interviewed nursing staff had worked between eight and eleven double shifts in the last 14 days (CMS, 2002).

The number of hours worked has been identified as a contributing factor to the commission of errors by nurses (Narumi et al., 1999). The AHRQ-funded study mentioned above found that shift durations of greater than 12 hours were significantly associated with increased errors among nurses.

Rapid Increases in New Knowledge and Technology

The IOM (2001) report Crossing the Quality Chasm cites the growing complexity of science and technology, resulting from the tremendous advances made in clinical knowledge, drugs, medical devices, and technologies for use in patient care, as one of the four main attributes of the U.S. health system affecting health care quality. Since the results of the first randomized controlled clinical trial were published more than 50 years ago, health care practitioners have been increasingly inundated with information about what does and does not work to achieve good clinical outcomes. Over the last 30 years, such trials have increased in number from 100 to nearly 10,000 annually. The first 5 years of this 30-year period accounts for only 1 percent of all the articles in the medical literature, while the last 5 years accounts for almost half. Although part of this growth in the literature can be attributed to factors other than new findings and knowledge, there is no doubt that as the knowledge base has expanded, so, too, has the number of drugs, medical devices, and other technological supports (IOM, 2001).

Such increases in technology are beneficial and likely to continue. In a study of hospital organizational and structural features associated with patient mortality, only the presence of high technology or its proxies has been consistently associated with lower mortality (Mitchell and Shortell, 1997). However, these developments also have implications for patient safety and health care providers, including nursing staff. First, as stated in the Quality Chasm report, “Today, no one clinician can retain all the information necessary for sound, evidence-based practice. No unaided human being can read, recall, and act effectively on the volume of clinically relevant scientific



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