How consecutive workdays affect healthcare services

Healthcare organisations typically follow staffing guidelines based on metrics like staff-to-patient ratios. But at times of high demand, hospitals need to rely on staff working additional consecutive days. What impact does that have on the quality of care? 

Research co-authored by Professor Stefan Scholtes of Cambridge Judge Business School and colleagues from 2 universities in Germany finds that an increase in the average number of consecutive days worked by a nursing team has a negative impact on patient outcomes.  

This is more pronounced when overall staffing levels are low, and the negative effect is amplified for less complex patients because the reduced nursing staff need to tend more to the most vulnerable patients with urgent care needs. 

Why consecutive working days, not only staffing levels, need monitoring 

“Our study focuses on intensive care, and the implications for hospital management is that limiting consecutive working days could significantly improve patient outcomes,” says Stefan, Dennis Gillings Professor of Health Management and Director of the Centre for Health Leadership and Enterprise at Cambridge Judge. 

“We recommend that managers monitor not only daily staffing levels but also consecutive working days. And we urge policymakers to consider imposing limits on the number of consecutive days worked by intensive care nurses. 

“While an all hands on deck strategy might be appropriate in certain hospital settings, our research highlights that a strategy that keeps the nurse-to-patient ratio high at the cost of a nursing team’s higher average number of consecutive working days does not safeguard care quality.” 

The published study was awarded the Wilfried Lorenz Health Services Research Prize 2024 by the German Network for Health Service Research at a conference in Berlin. A 17-member jury cited the study’s high methodological quality and particular relevance for the use of specialist staff in patient care. 

Study is based on data from neonatal intensive care units in Germany 

The study, based on data from German neonatal intensive care units, examined the effects of hospital staff working prolonged consecutive working days without breaks. Compared to other safety-critical industries, working time of healthcare employees is underregulated. “To our best knowledge there is no legal limit on the number of consecutive days a nurse can work in the United States. In Germany, the context of our empirical study, nurses, including intensive care nurses, are allowed to work up to 19 consecutive days without a break day,” the research says. 

Professor Scholtes and co-authors focused on 3,447 nurses in 62 neonatal intensive care units (NICU) in hospitals across Germany for 6 months. They collected data and matched units’ actual daily staffing records with clinical data of 847 very-low-birth-weight babies these nursing teams cared for. 

The authors say they chose to study how prolonged consecutive working days affect healthcare service quality in NICUs for 2 reasons: 

The role nurses play in low-birth-weight babies’ feeding 

The key point for low-birth-weight babies at NICUs is when a patient’s feeding is switched from parenteral nutrition (intravenous) to fully enteral feeding (usually through the mouth, that uses the gastrointestinal tract). This event is an important outcome measure for these patients and is regularly used in medical literature. 

The decision to switch to enteral feeding is heavily influenced by nurses, and a delay in switching increases the risk of severe complications. 

The study thus collected the data from NICUs to analyse the effect “of nursing teams’ consecutive working days on the time from admission to full enteral feeding for 847 low-birth-weight babies, considering nurse-to-patient ratios and patient complexity.” 

The average number of consecutive days worked by a nursing team in the study ranged between 1 and 7 days, with a median of 2.2 days. The study found that limiting this team-average to 2 days would have reduced the time to full enteral feeding by 6.4%. Additionally, shifting from “half a day less to half a day more than the average number of consecutive working days has an impact equal to 20% of the difference in time taken to reach full enteral feeding between low- and high-birth-weight babies”. 

Consequences of healthcare exhaustion: stress, headaches and poor decisions

Previous studies have found that increased number of consecutive working days is associated with headache and pain, occupational injuries, chronic fatigue and sleepiness. It also affects people’s psychology as it acts as a stressor. It can impair workers’ cognitive abilities such us memory, attention and decision making.  

Additionally, a rise in the number of consecutive working days can affect the whole team. “Studies have shown that a drop in motivation and attentiveness due to stress can be contagious to other team members, a phenomenon that is also referred to as ‘ripple effect’”, the researchers said. 

Bigger negative impact on teams with low staffing levels 

The medical literature provides evidence that “an increase in short-term (daily) workload does impact patient outcomes, including error rates, readmission, and mortality.”  This can worsen on the days when the staffing levels are low because nurses “might leave care activities undone”, or due to exhaustion they “may not be as capable at rationing their increasingly limited time and deciding which tasks to prioritise”. 

Prolonged periods of more workload will slow workers down and is likely to occur “earlier when nurses are more exhausted at the start of the shift due to a longer period of consecutive working days”. 

Other team members might be able to compensate for this, but if the workload is high they might not be able to support the struggling colleague.