The night shift should belong to the nurses best able to carry it

In most hospitals I know, the newest nurses work the most nights. My position is that this is backwards, and that acute wards should weight night shifts towards experienced nurses, paying a premium large enough to make that a decision they accept rather than a duty imposed on them. The arrangement most hospitals have now was not designed by anyone. It is the cumulative result of roster preferences granted by seniority, and its effect is to place the least experienced clinicians on duty at the hours when doctors are fewest, senior managers are at home and the patient who deteriorates has the fewest people watching.

I hold this view partly from experience. In March 1997, eight months after registering, I worked eleven night shifts in a month in a surgical intensive care unit, because I was the newest nurse and the experienced nurses had declined them. On the ninth night I made an error that a senior colleague caught before it reached the patient. She asked me how many nights I had worked that fortnight. I did not then think the question was about the roster. I do now.

How seniority sends beginners into the night

In 2021 first-year nurse turnover in our Singapore hospitals reached 29%. Exit interviews mentioned workload, the pandemic and the cost of living, all of which were real. I asked our workforce analysts to look at something more specific: eighteen months of rosters on our medical and surgical wards, broken down by experience. Nurses in their first year had worked 38% of night shifts. Nurses with more than ten years' experience had worked 9%.

Nobody had chosen that distribution. Each ward granted roster preferences broadly by seniority, as most hospitals do, and experienced nurses, many with children or ageing parents, had earned the right to avoid nights. Each decision was reasonable. Together they meant that nights on some wards were staffed mostly by people in their first two years, with a single experienced nurse in charge across several bays, or sometimes no experienced nurse at all.

The consequences were predictable once we looked. First-year nurses who worked many nights left at higher rates than those who worked few. They had less contact with the senior colleagues from whom they learn judgement, because the senior colleagues worked days. And the night was the shift on which escalation decisions depended most on the nurse at the bedside.

Pay for judgement at three in the morning

From April 2022 we changed three things. Nurses in their first six months work no more than three night shifts a month. No first-year nurse is rostered as nurse in charge at night. And the night allowance for senior staff nurses and above rose from S$45 to S$110 a shift, so that a night became work worth choosing for an experienced nurse rather than a burden passed down. Self-rostering software applies the rules, so ward managers no longer bargain individually over every month.

The allowance is the heart of it. I did not want to order senior nurses back onto nights. Many had arranged their lives around days, sometimes over a decade, and a rule forcing them back would have driven out exactly the people we needed. A large premium allows a nurse whose children have grown up, or who wants to save for something, to take nights willingly. It costs real money: about S$4.6 million a year across our Singapore hospitals. Our finance team asked, fairly, whether we could achieve the same effect more cheaply. I could not find a way.

By 2024 first-year turnover in our Singapore hospitals had fallen to 15%. The share of night shifts worked by nurses with more than ten years' experience rose from 9% to 24%. Overtime hours fell by 19%. Medication errors at night fell as well, though other changes in the same period, including new dispensing cabinets on several wards, mean I would not credit the roster alone. We extended the rules to our Malaysian hospitals in 2024.

What the senior nurses were right about

A letter signed by 140 senior nurses opposed the change. They argued that the right to decline nights had been earned through years of carrying them, that we were changing the terms of their working lives without enough notice, and that some colleagues had caring responsibilities which no allowance could offset. They were right on the last two points, and partly right on the first.

We had planned a year-long phase-in at our chief nursing officer's suggestion and shortened it to six months under pressure from managers short of staff. That was a mistake. Worse, I sent every request for exemption through a central committee, which took six weeks to hear 212 appeals. Nurses with sick parents or their own health conditions waited for a hearing while the roster went ahead. Thirty-one senior nurses left in 2022 and cited the change; some would have stayed had their exemptions been agreed individually with their ward managers before the rules began.

The argument that seniority is earned deserves a proper answer. I think it is earned, and should be rewarded. The question is whether the reward should be freedom from nights or payment for them. The first protects the individual nurse at the cost of the junior and the patient. The second lets the senior nurse decide, and makes the hospital pay for the judgement it needs.

There are hospitals where this would not work: those whose senior nurses are too few to carry more nights, or whose budgets cannot sustain a premium of this size. For them a smaller step, such as never rostering a first-year nurse in charge, would still be worth taking.

The question I would put to any hospital board is short. Ask for last quarter's night rosters on two acute wards, broken down by years of experience. If the answer surprises the directors, they should ask who decided it. In our case, nobody had.