Twenty-four/seven: a mixed-method systematic review of the off-shift literature


  • Pamela B. de Cordova,

    1. Pamela B. de Cordova PhD RN-BC
      Post-doctoral Fellow
      Center for Health Outcomes and Policy Research, School of Nursing,
      University of Pennsylvania,
      Philadelphia, Pennsylvania, USA
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  • Ciaran S. Phibbs,

    1. Ciaran S. Phibbs PhD
      Health Economist
      Health Economics Resource Center,
      VA Palo Alto Healthcare System,
      Menlo Park, California, USA
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  • Ann P. Bartel,

    1. Ann P. Bartel PhD
      Merrill Lynch Professor of Workforce Transformation
      Columbia Business School,
      New York, New York, USA
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  • Patricia W. Stone

    1. Patricia W. Stone PhD FAAN
      Centennial Professor in Health Policy
      Columbia University School of Nursing,
      New York, New York, USA
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P.B. de Cordova: e-mail:


de cordova p.b., phibbs c. s., bartel a.p. & stone p.w. (2012) Twenty-four/seven: a mixed-method systematic review of the off-shift literature. Journal of Advanced Nursing68(7), 1454–1468.


Aim.  This article is a report of a review that aimed to synthesize qualitative and quantitative evidence of ‘off-shifts’ (nights, weekends and/or holidays) on quality and employee outcomes in hospitals.

Background.  Healthcare workers provide 24-hour-a-day, 7-day-a-week service. Quality and employee outcomes may differ on off-shifts as compared to regular hours.

Data sources.  Searches for studies occurred between the years 1985–2011 using computerized databases including Business Source Complete, EconLit, ProQuest, PubMed and MEDLINE.

Review design and methods.  Design was a mixed-method systematic review with quantitative and qualitative studies. To be included, studies met the following criteria: (1) the independent variable was an off-shift; (2) the article was a research study and peer-reviewed; (3) the article could be obtained in English; and (4) the article pertained to health care. Studies were not excluded on design.

Results.  Sixty studies were included. There were 37 quality outcome, 19 employee outcome and four qualitative studies. In the quality outcome studies, researchers often used quantitative, longitudinal study designs with large sample sizes. Researchers found important differences between patients admitted on weekends and mortality. Important differences were also found between nighttime birth and mortality and rotating night work and fatigue, stress and low mental well-being. Most studies (9 of 12) did not find an important association between patients admitted at night and mortality.

Conclusion.  Patient outcomes on weekends and employee outcomes at night are worse than during the day. It is important to further investigate why care on off-shifts differs from weekly day shifts.