Katre Zirel knows the field of nursing inside out. She is director of nursing at the North Estonia Medical Center(PERH) and also a member of its management board. In addition, she serves on the board of the Estonian Nursing Managers' Association. According to her, 24-hour shifts have long been common in Estonia's healthcare system. Scientific research, however, does not support the practice.

"If we say that healthcare is evidence-based, then international studies make it very clear that long workdays jeopardize both employee health and patient safety. Nurses and doctors who work more than 12 hours, for example, make about twice as many mistakes," Zirel explained.

The list of potential medical errors, the risk of which rises significantly, is extensive. Zirel pointed to mistakes in administering medication, errors in documentation, failures in identifying patients and much more. This could mean that a patient receives the wrong procedure or the wrong treatment.

The risks extend to nurses themselves as well. "Constant sleep deprivation and shift work are associated with a higher risk of cardiovascular disease, diabetes, depression and burnout," Zirel noted.

The Estonian Nurses' Union also emphasizes the harmful effects on nurses' own health. Its president, Laura Keidong, said it is not possible to speak of patient-centered healthcare if the health of healthcare workers is ignored. "This 24-hour shift is almost paradoxical for nurses, because while they help preserve the health of others, the opposite approach is taken toward their own," she said.

The dangers extend beyond hospital walls. When a nurse gets behind the wheel after finishing a 24-hour shift, studies show the effect is similar to being intoxicated, Zirel stressed. "Their reaction speed is worse not only in the workplace but also in traffic. We don't just work in the summer; we also drive in the dark and on icy winter roads."

So what would be the optimal shift length? Zirel believes 12-hour shifts would be a better solution. While even shorter shifts are being discussed elsewhere in the world, she said Estonia must first adapt to simply shorter ones. Keidong of the Nurses' Union argued that shifts should vary in length, somewhere between eight and 12 hours.

"What we also need to consider is that new nurses are coming out of school and more of them are no longer willing to work overtime. They take better care of their own health and want to work part-time as well. Such shifts could offer more flexible scheduling," Keidong said.

Not all nurses in favor of changes

At the same time, both Zirel and Keidong encounter nurses who actually prefer to work 24-hour shifts. The reasons are more days off and higher pay. "It seems attractive to the employee because it allows for longer rest periods and maybe time to take care of family matters. It also improves their financial situation, since working a 24-hour shift means earning more from night shifts. If the schedule only covered daytime hours, that additional pay would disappear," Zirel said.

According to Keidong, it is also common for nurses to work at several hospitals at once, which increases their income. Consecutive days off created by 24-hour shifts provide the necessary flexibility for this. But, she pointed out, this also highlights the issue of nurses' salaries.

"If we can offer fair pay at a single workplace, with regular hours and normal workloads, then a nurse wouldn't need to work elsewhere, wouldn't need to take on 24-hour shifts and wouldn't need to fit in another job in the same week. The fact remains that fair compensation has not yet been sufficiently implemented, and this is something we need to address," Keidong said.

Zirel added that in cases where nurses work in two different places, there is no way to monitor or ensure that they are properly rested in between, which may further increase risks to both patients and healthcare workers.

Hospital to discuss the matter

At the North Estonia Medical Center, discussions about shorter shifts have recently intensified. According to Zirel, some departments have already experimented with them. For example, one unit agreed not to schedule any 24-hour shifts for three months. "Nothing happened. People got used to it — the work was reorganized, family life was reorganized and, in fact, there was no going back to 24-hour shifts. Habits are very powerful," Zirel said. The hospital is also mapping out how many departments still use 24-hour shifts, focusing on workplace safety.

Keidong stressed that shorter shifts could also help ease the shortage of healthcare workers. "A good working environment keeps employees in healthcare longer. Twenty-four-hour shifts place an extreme burden on staff, which only worsens the labor shortage over time, because people burn out more quickly."

A nationwide regulation of working hours for nurses is not considered strictly necessary. Zirel argued that if there are positions in healthcare where the work is less intensive, long shifts do not endanger staff health and patient safety is guaranteed, then it should be up to each employer to decide.

Keidong, however, sees a solution in coordination and dialogue among healthcare professionals. "We are very pleased that nursing managers, who direct nurses' work in hospitals, have acknowledged this problem. It is essential to continue working together to ensure good working conditions and to hold discussions about shift length," she said.

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