Final Integrated Review of Literature on the Shift Length of Nurses Essay Paper

8-2 Final Project: Submit Integrated Review
Using the six articles from your annotated bibliography, compose an integrated review that focuses on your chosen research problem. An integrated review is a method which summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a particular healthcare problem. Please refer to the assignment rubric and guidelines to ensure you address the key areas of the integrated review. Include headings in your paper as outlined in the assignment guidelines. Ensure that the topic of this integrated review is viewed from the perspective of a healthcare professional who is looking to validate the need for program evaluation at your hospital. Remember to use APA format.  Final Integrated Review of Literature on the Shift Length of Nurses Essay Paper

I. Abstract
Craft a well-drafted abstract. Be sure to adhere to the guidelines from the latest edition of the American Psychological Association’s style guide. Consider
the appropriate length for your audience.
II. Introduction
a) State the purpose, aims, or objectives of the integrated review. What do you wish to achieve through the drafting of this review? Be explicit in
your answer.
b) Introduce the topic of interest. Why is this topic the focus of the review?
c) What is the research question you are going to focus on? If you were to prepare a research proposal, what would your hypothesis be? Why?
d) What variables are of interest to you? How will these variables help you throughout this integrated review? Be sure to label the types of
variables each of these are.
e) Discuss the background and significance of the problem to healthcare administration. III. Literature Search
a) What keywords and combinations were used in the initial search? Which were the most effective? Explain why these keywords and
combinations provided the most useful results.
b) Which databases were searched? Why were these the chosen databases? Assess the characteristics that make these databases the most
c) Evaluate the inclusion and exclusion criteria for the sample. How did you decide to narrow the search and focus the review? How was the final
sample determined? Be sure to include your process.
IV. Methodology Analysis
a) What methodology was used in this research? Was it effective for the research question and hypothesis? Why or why not? Consider including
improvements for the methodology.
b) What statistical data analyses were employed in these articles? Were they appropriate for the research question and methodology? Why or
why not?
c) Evaluate the literature for any gaps that exist. Why do you think these gaps exist? Consider factors such as the location of the research, time the
research was conducted, and so on.
d) Evaluate the literature for inconsistencies that exist across the studies. Why do you think these inconsistencies exist? Consider factors such as
the location of the research, time the research was conducted, and so on.
V. Synthesis and Interpretation
a) Create an evidence table of your results. Be sure to include the following criteria for each study:
1. Report citation
2. Design
3. Method
4. Sample
5. Data collection
6. Data analysis
7. Validity and reliability
b) Compare and contrast the study findings. Be sure to include pertinent conclusions and statistical findings only.
c) Evaluate the research strategies used in the articles, as applicable to healthcare programs. Was the research design appropriate for the study
conducted? Was the statistical analysis employed the best choice for the research questions posed?
d) What ethical issues are pertinent specifically to healthcare research? How can these issues influence the research strategies chosen to
investigate clinical topics? Evaluate these research articles and consider how ethical concerns may have limited these clinical investigations.
e) What patterns and trends exist in the research? What generalizations can you draw from the research?
f) If secondary data was utilized, was the source biased or objective? Why? If original research was conducted, do you think the researchers were
biased or objective? Why? Be sure to support your answer.g) Synthesize the main findings of the research articles. What were the hypotheses of the research studies? Did the research add any new scholarly
information to the existing body of knowledge?
h) Assess whether utilizing secondary data as an alternative to the researchers’ original research would have been a feasible option. If it had been
an option, what resource(s) would be the most appropriate to use? What would be some of the strengths and limitations of using secondary
i) Assess the literature for any ethical concerns that may be present. Consider things such as conflicts of interest between the researcher and the
study sponsors, or the lack of an IRB approval for the study.
VI. Conclusion
a) What are the studies’ strengths? Are there patterns in the articles that you chose regarding their strengths?
b) What are the studies’ limitations? Are there patterns in the articles that you chose regarding their limitations?
c) Were the findings and conclusions reliable and valid? Why or why not? Logically support your answers.
d) What are the implications of this research? How will it influence your topic in the overall large picture of healthcare research?
Annotated Bibliography
This milestone is due in Module Four. Submit a summary and analysis of six research articles relevant to the research problem that you have chosen. This
milestone is graded with the Annotated Bibliography Rubric.
Integrated Review
The final project is due in Module Eight. Using the six peer-reviewed literature articles from your annotated bibliography, compose an integrated review that
focuses on a clinical issue of interest.



The shift length that nurses work is usually a determination made by the nursing leadership in a healthcare organization. Shift lengths are usually not uniform across healthcare organizations. Some have shorter shift lengths while others have longer ones that go up to 10 or even 12 hours per shift. The leadership style of the nurse leaders has an impact on the kind of nurse shift policy that a healthcare setting adopts. Transformational leaders who would like to motivate their nursing workforce would not opt for longer shifts as they lead to burnout and poor patient outcomes. Shorter shifts leave the nurses energized and ready to come to work again during the next day’s shift. Longer shifts cause burnout, apathy, and dissatisfaction among the nurses. Studies show that the longer the shift length the more the nurses commit errors and the more that patient satisfaction with the healthcare services drops. These findings of studies are overwhelmingly similar and the conclusion that can therefore be drawn is that there is a positive correlation between longer nursing shift lengths and poor patient outcomes that are a function of nurse burnout and fatigue.

Keywords: shift length, nurse, burnout, care quality, well-being

Final Integrated Review of Literature on the Shift Length of Nurses and its Impact on Patient Safety, the Wellbeing of Nurses, and the Quality of Nursing Care  

Nurses work in shifts to facilitate the continuity of patient care. However, different organizations have different shift lengths according to their organizational policy. A normal shift length is usually 8 hours. However, other institutions and settings put the shift length at up to 10 to 12 hours. Evidence sourced from scholarly literature shows that longer shift lengths have a direct correlation with adverse patient outcomes (Stimpfel & Aiken, 2013; Stimpfel et al., 2012). This is because the nurses suffer more burnout and are prone to making errors when they are psychologically exhausted. The purpose and aim of this integrated review is to examine the available evidence on this subject of shift length for nurses. It also aims to determine the consequences of the same on the well-being or psychological safety of nurses, patient safety/ outcomes, and the quality of nursing care that is offered in a setting with longer nurse shifts. The other objective of the integrated review is to stimulate scholarly interest in the subject so that more research can be done in the area to facilitate the provision of nursing care that is safe, effective, timely, efficient, equitable, and patient-centered.  These are the six domains of quality as dictated by the Institute of Medicine (Tzelepis et al., 2015). What the author would wish to achieve through the drafting of this review is the determination of the views of nurses on the appropriate shift length and its relationship to how well they can perform their duties. The author would also wish to find out the physical and psychological effects of longer shift lengths on nurses and their relationship to turnover intention among nurses. The reason why the topic of shift length among nurses is a topic of interest in this case is that it directly affects patient safety. Patient safety is the most important outcome measure that determines the viability of a healthcare organization. All quality improvement (QI) initiatives are usually geared towards achieving patient safety. It is also the task of regulatory bodies such as the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to inspect and supervise healthcare organizations. This makes sure they abide by all patient safety protocols and QI requirements. The purpose of this paper is therefore to present an integrated review of the current available literature on the subject of shift length among nurses and it impact on nurse well-being and patient safety.  Final Integrated Review of Literature on the Shift Length of Nurses Essay Paper

Research Questions, Hypotheses, and Variables

In researching about the above topic of shift length among nurses, there were a number of predetermined research questions that were meant to guide the research. These are the same research questions that are going to be focused on in this integrated review. These research questions were:

  1. Does the shift length have any bearing on the psychological safety of nurses?
  2. Do nurses work best in a setting with shorter or longer shift lengths?
  • Do nurses prefer shorter or longer shift lengths?
  1. What is the effect of having longer shift lengths for nurses on the satisfaction of patients with care delivered?
  2. Is there a correlation between shift length for nurses and the occurrence of errors in medication?
  3. Does burnout increase as the shift length for nurses increases?
  • Is the quality of care offered by nurses inversely proportional to the shift length that nurses work?

Stemming from the above research questions guiding the research and the integrated review, the author would have the following null and alternative hypotheses. The reason is that between the two variables that will be determined shortly, there is either a direct correlation or not. The two opposing hypotheses that would be presented in the case of a research proposal are as follows:

  1. Null hypothesis (H0): There is no relationship between the shift length that nurses work and nurse burnout or poor patient outcomes.
  2. Alternative hypothesis (H1): There is a positive relationship between the shift length for nurses and nurse burnout/ adverse patient outcomes.

In every research undertaking, there are variables that are studied. These variables are usually labelled the independent and the dependent variables. In this instance, the independent variable of interest is the shift length that nurses work in their healthcare setting. The dependent variables that then vary with the alteration in this independent variable are nurse burnout rate, patient outcomes, and care quality. In summary, the variables of interest are:

  • Independent variable: Shift length for nurses
  • Dependent variables: Nurse burnout, quality of care, and patient outcomes

The above variables are helpful throughout this integrated review in that they act as guiding beacons that keep the discussion focussed on the topic of interest that is the relationship between nurse shift length and nurse burnout or adverse patient outcomes. Without variables, any research undertaking would be directionless and confused. This is why this integrated review has to determine what the independent variable is and then measure the dependent variables to get answers to the research questions.

Background and Significance of the Problem to Healthcare Administration

Nurses are human beings and therefore it would logically be expected that the longer that they work the more they get tired both physically and in mind. A tired person who is also psychologically exhausted after working for long hours is prone to making errors. In the context of healthcare, this can mean the difference between life and death. An error committed by a nurse who is tired may lead to the death of a patient in the worst case scenario. Other errors may lead to disability and an increased length of stay in the hospital. The nurse also suffers because they may lose their right to practice through sanctions by the nursing regulatory bodies such as the state board of nursing.

Providing a workplace that that is psychologically safe is one of the key considerations that any successful healthcare organization aspires to. Psychological safety means that nurses feel that the workplace is welcoming and that it is considerate of their well-being. In a healthcare organization, the determination of the shift length that nurses have to work is ultimately made by the nursing leadership. As they make this decision, it is expected that they take note of the possible consequences of their decision. In a proper setting, this decision is influenced and guided by available scholarly literature that is peer-reviewed. When this is done, it is in line with best practice that is evidence-based practice or EBP. The nurse manager has to realize that the shift length that will be arrived at for nurses in the organization to work will have profound ramifications for the organization. This is why the matter is of significant interest to the organization. For instance, a longer shift length will impact the psychological safety at the workplace in that nurses will start getting burnout. With this, the workplace will cease to be welcoming and the motivation of the nurses will fall. They will start loathing going to work and will not deliver quality healthcare as would be expected. This is where the leadership style of the nurse managers comes in.

It has been determined by scholarly research that is peer-reviewed that only transformational leaders have the capacity to create a safe and welcoming workplace that is motivating for employees and inspiring for them to deliver their best (Asiri et al., 2016). A longer shift length for nurses does not seem to fit in the transformational leader’s work environment. A transformational nurse manager will therefore instinctively go for a shift length that does not tire the nurse but that makes them stop working their shift when they are still fresh and sharp. A transformational leader empowers her employees and motivates them. This has a great bearing n the aspect of job satisfaction in the organization (Choi et al., 2016). When the nurses are satisfied in their jobs, there is low turnover intention and the organization does not suffer staff shortages occasioned by the high turnover. The significance of this is that the organization saves financial resources that it would have used to constantly recruit new nursing staff. From a QI perspective also; losing experienced nursing staff and recruiting new ones all the time has a negative impact on the quality of care that is offered in a healthcare organization.


Literature Search

To facilitate the search, several keywords and combinations of keywords were used. In the combinations, the keywords and phrases were combined using the Boolean operator “AND”. The ones that proved to be most effective were:

  • Shift length
  • Nurses
  • Correlation
  • Well-being
  • Care quality
  • Burnout
  • Nurses AND shift length AND correlation AND care quality
  • Nurses AND shift length AND burnout AND well-being

These keywords and combinations produced the best results because they:

  • Addressed the research questions specifically
  • They addressed the hypotheses set at the beginning
  • They were specific to the identified practice problem without being ambiguous

Databases Searched

The literature search for this project involved searching for published peer-reviewed scholarly literature from reputable research databases. In this case, these included CINAHL, PubMed, ProQuest, Embase, and Cochrane Database for Systematic Reviews. These were the chosen databases because they have been in existence for a while and keep only literature that is published by peer-reviewed scholarly journals. The journals that they catalogue are those that are professionally respected and whose peer-review process is above reproach. These are some of the characteristics that make these databases be the most reliable for searching literature.

Inclusion and Exclusion Criteria

The inclusion criteria for published studies during the search helped in filtering the results. This is important in that it enabled the search to focus on the research questions. In this case, the inclusion criteria comprised of (i) publication within the last ten years, (ii) being qualitative or quantitative studies, and (iii) publication in the English language only. The exclusion criteria were (i) publication in a language other than English, and (ii) publication more than ten years ago.

Narrowing of the search involved using the inclusion criteria to filter the results. This is what focused the review to only those studies that specifically answered the research questions. Determination of the final sample was made by leaving out all abstracts and only considering studies that were in full text. The initial search yielded 18,253 studies. After applying the filters, these were narrowed down to 6,021 studies. At this point, all the abstracts were removed and this left only 1,302 studies that were in full text. To be sure that the studies were very specific to the research questions and that they contained only the variables specified, all those studies that included dependent additional variables to the ones specified were excluded. The final number of studies that then remained after this exercise were 44 studies. It is some of these 44 studies that are in this integrated review.  Final Integrated Review of Literature on the Shift Length of Nurses Essay Paper

Methodology Analysis

The methodology used in this research was that of a retrospective study. This is a study that sought to find out what has been found out before on the matter of nursing shift length and its impact on the well-being of nurses, care quality, and patient satisfaction. Considering all factors, this methodology was quite effective in answering the research questions and also addressing the hypothesis set at the start of the study. The reason for thus is that the methodology was chosen only after determining the research questions and coming up with the null and alternative hypotheses. This ensured that the methodology remained in consonance with the study objectives. However, there would still be room for improvements to be made in the methodology. If this were the case, it would involve removing geographical bias by including studies published in at least two other languages. The preference in this case would be French and Spanish.

Statistical Data Analyses

The statistical data analyses that were used in these studies were both descriptive statistics and inferential statistical tests. The descriptive statistics included means, standard deviations, percentages, and ratios. On the part of the inferential statistical tests, strong nonparametric statistical tests were also used in these studies to draw inferences and enable the generalization of findings to the entire population of nurses. These tests included chi-square tests, regression analysis, analysis of variance (ANOVA), and student’s t-tests. These statistical data analyses were all appropriate for the research questions and methodology. The reason for this is that they were able to get out of the raw data statistical inferences that could be applied directly to practice.

Literature Gaps

There are a few gaps in the literature that were determined. They included the lack of clarity on the role that particular leadership styles play in the determination of shift length for nurses. It would be important to know what role if any leadership styles like authoritarianism or laisser-faire have in the determination and effect of longer nursing shifts. The location of the research is also important in that a country’s healthcare policies also have an influence in the determination of nursing shift length. For instance, the policies of the NHS in the United Kingdom cannot be the same as those in the United States.

In evaluating the literature, no serious inconsistencies were found. As a matter of fact, all the studies had results that indicated that longer shift lengths are almost always responsible for adverse patient outcomes resulting from nurse fatigue and burnout. Therefore, the location and time of the research have had no impact really by way of any inconsistencies.

Synthesis and Interpretation

Table 1: Evidence table

Stimpfel & Aiken (2013) Stimpfel et al. (2012)
Report citation Determination of shift length and scheduling practices Extended nursing shifts very common nowadays in healthcare settings
Design Qualitative study Quantitative survey
Method Secondary analysis Cross-sectional study
Sample N=22,000 RNs N=22,275 RNs
Data collection Questionnaire Likert-type questionnaire
Data analysis PRISMA Descriptive statistics
Validity and reliability Guaranteed especially by the large sample size Guaranteed by the large sample size


A comparison of the study findings shows that they are pointing towards the same conclusion. There is no difference in the findings. The researchers all agree that longer shift lengths are detrimental for care quality and nurse well-being. The research designs were appropriate for the studies and the statistical tests were also the best choice for answering the research questions posed at the beginning. On ethics, the research must have respect for human dignity for the subjects. In this case, the respondents were asked for informed consent and were also assured that the results of the research would be beneficial to them (OHRP, 2018). The generalizations drawn from the research are that nurses generally do not prefer longer shift lengths. The research in these articles was overwhelmingly objective. These were primary studies and therefore the findings were robust and trustworthy. The researchers were objective because they were directed by the methodology and research questions. There was no room for them to introduce their biases. The hypothesis of the studied articles was that a direct correlation exists between nurse shift length and burnout/ patient outcomes. Indeed, the research added to the body of knowledge for EBP. Utilizing secondary data would have been a feasible option but not with the same objective results. Secondary data allows for a systematic review that gives level I evidence. That is its strength. Its weakness is that it makes the researchers incorporate the methodological mistakes made in the original research in their work. There were no conflicts of interest from the researchers and the studies also received approval from the Institutional Review Board (IRB).


            The study strengths in this case include that they are primary studies, the sample sizes are large, and the studies are fairly current. There are no particular patterns regarding the study strengths. The most obvious limitation is the geographical exclusion. This may make the results not be very representative. The findings and conclusions were reliable and valid, given the methodology and sample sizes. The implications of this research are that it will influence clinical practice and also policies of healthcare organizations regarding the scheduling of nursing shifts.


Asiri, S.A., Rohrer, W.W., Al-Surimi, K., Da’ar, O.O., & Ahmed, A. (2016). The association of leadership styles and empowerment with nurses’ organizational commitment in an acute health care setting: A cross-sectional study. BMC Nursing, 15(38), 1–10.

Choi, S.L., Goh, C.F., Adam, M.B.H., & Tan, O.K. (2016). Transformational leadership, empowerment, and job satisfaction: The mediating role of employee empowerment. Human Resources for Health, 14(1), 73.

Office for Human Research Protections [OHRP] (January 15, 2018). The Belmont Report: Ethical principles and guidelines for the protection of human subjects of research.

Stimpfel, A.W., & Aiken, L.H. (2013). Hospital staff nurses’ shift length associated with safety and quality of care. Journal of Nursing Care Quality, 28(2), 122-129.

Stimpfel, A.W., Sloane, D.M., & Aiken, L.H. (2012). The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs, 31(11), 2501-2509.

Tzelepis, F., Sanson-Fisher, R., Zucca, A., & Fradgley, E. (2015). Measuring the quality of patient-centered care: Why patient-reported measures are critical to reliable assessment. Patient Preference and Adherence, 9, 831-835.  Final Integrated Review of Literature on the Shift Length of Nurses Essay Paper




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