Patient Safety Tip of the Week
December 2, 2014
ANA Position Statement on Nurse Fatigue
Fatigue in health
care workers as a contributing factor to many patient safety issues has been a
central theme of many of our columns (see the list at the end of today’s
column). Fatigue impacts everyone involved in the health care team and that
even includes patients and their families. However, most of the literature on
fatigue has focused on nurses and housestaff. And it
shows adverse effects of fatigue not only on patient care but also on personal
health.
Now the American
Nurses Association has issued a position
statement on nurse fatigue (ANA
2014) that calls upon nurses and employers to work together and take steps
to minimize the impact of fatigue on patients and staff. It relies heavily on
evidence-based strategies and outlines responsibilities for nurses individually
and collectively and responsibilities for employers.
The position statement stresses that nurses must practice
healthy behaviors to reduce the risk of working while fatigued and to recognize
when they or a colleague are fatigued and potentially putting patient care at
risk. It notes nurses should come to work well-rested and alert, take
appropriate rest and meal breaks, and implement fatigue countermeasures as
needed. The latter may include naps, caffeine, or both as appropriate. Note
that we’ve stressed the value of naps
and “power naps” as important but underutilized strategies to minimize the effects of
healthcare worker fatigue in those working long shifts or night shifts (see
our columns for November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”, April 26, 2011 “Sleeping
Air Traffic Controllers: What About Healthcare?”, January 2012 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety”
and November 2012 “The
Mid-Day Nap”). Employers must provide appropriate environments for such
naps. It also often takes a change in culture to make naps acceptable (many
nurses still fear the potential stigma a sleeping nurse might have in the
perspective of a patient or family). One VA medical center implemented many
good features to mitigate fatigue but did not attempt to introduce the at-work
nap because of space and culture concerns (Fuller
2014).
The ANA position
statement does focus on work hours, with recommendations for both nurses
and employers. It recommends limiting work weeks to 40 or fewer hours per week
and limiting shifts to 12 hours or less. It recommends one or two full days off
to rest after 5 consecutive 8-hour shifts or 2 days off for rest after 3
consecutive 12-hour shifts. Note also that it stresses those hour limits should
include not only paid hours but any time spent on unpaid activities (conferences,
meetings, mandatory training, etc.) and on-call hours should be factored in as
well.
The statement calls
on employers to eliminate the use of mandatory overtime. It stresses
that any nurse can and should refuse overtime or additional hours when
fatigued and such refusal should be free of the risk of retaliation or
other penalty.
Columns we’ve done that have attracted the most attention
have been those looking at the 12-hour
nursing shift (see the full list below). The new ANA position statement
does not specifically comment on the 12-hour nursing shift. However, it does
recommend for employers “Examine work demands with respect to shift length.
Shifts longer than 8 hours may be unsafe when work is physically and
cognitively demanding.” We’ve pointed
out that because the 12-hour shift has become so popular in the US, both with
nurses and hospitals, it will likely take compelling evidence to cause
reversion to shorter shifts. While several pieces of information have pointed
to the downsides of 12-hour shifts, conclusive evidence that adverse patient
outcomes result from such shifts has been elusive, largely due to confounding
variables in all studies.
The statement urges
employers to involve nurses in development of staffing plans and design
work schedules that limit overtime and take into account unanticipated events,
like weather- or disaster-related situations. In addition, the organization
should have in place policies and procedures for what to do if a worker is
too fatigued to work.
Importantly, the ANA
position statement urges nurses to consider the length of any commute before
applying for positions. This is important because the literature demonstrates
the impact of health care worker fatigue on motor vehicle accidents
following work shifts. The ANA position statement also recommends that
employers provide transportation home when a nurse is too tired to drive safely
or provide sleep facilities at or near the facility as an alternative.
General health issues
are important in avoiding fatigue. These include adequate diet and nutrition,
adequate fluid intake, exercise, and stress management. In addition it is
important to understand the potential effects of prescription and
over-the-counter drugs and the signs and symptoms of sleep disorders. The statement
also has recommendations about appropriate sleep hygiene.
Fatigue management
training and education should also be provided not only for nurses and other employees but also managers.
This should include education about sleep disorders as well.
Auditing
adherence to work hour guidelines is an important responsibility of employers.
But your typical hospital just looks at time card data. That does not include
the additional hours noted above. And most hospitals don’t audit to see if
nurses actually take their recommended rest and meal breaks.
Lastly, it is important that organizations have an anonymous reporting system so that
information about fatigue can be conveyed in reports about accidents, errors
and near-misses.
In our July 29, 2014
Patient Safety Tip of the Week “The
12-Hour Nursing Shift: Debate Continues” we predicted that someday
we will have the equivalent of the brief “sobriety” or “breathalyzer” test that
can rapidly identify healthcare workers who are impaired by fatigue. We
envision that at regular intervals beyond 8 hours (maybe even sooner) the
healthcare worker will get buzzed on his/her smartphone and have to complete
some simple test of reaction times or attention span. If the worker scores
outside the established threshold the hospital will need to have resources in
place to take over duties of that worker (completely or at least temporarily
until fatigue is alleviated by, for example, a nap). We are actually not that
far away from such a test. Studies have demonstrated alteration of saccadic eye
movement metrics correlate with fatigue in several settings and recently
studies in surgical residents confirmed such a correlation (Di
Stasi 2014). Such a test could probably be easily adapted to most of
today’s smartphones.
We’d be remiss if we failed to point out that in the Di
Stasi study surgical residents who were fatigued (by both the saccadic eye movement
metrics and subjective measures of fatigue) did not have their performance on
simulated laparoscopic procedures affected. That, of course, demonstrates that
fatigue and prolonged work hours do not always result in errors. The
interaction among multiple factors is much more complicated. The literature on
management of fatigue in healthcare has overwhelmingly focused on hours of
work. We know that the work hour reductions for housestaff
have not produced convincing evidence that patient outcomes are improved (see
our many columns on work hours and housestaff listed
below).
A very interesting contribution from the
psychology/sociology literature looked at strategies healthcare workers use to
combat fatigue (Ferguson
2013). Though the research was based upon focus groups and semi-structured
interviews and not correlated with actual patient or staff outcomes (hence not
considered “evidence-based”), it offers a unique look at the additional layers
of defense to prevent fatigue-related errors. And, not surprisingly, it turns
out that most of these strategies involve informal
processes rather than formalized processes and are strongly related to non-technical skills. Yes, use of
caffeine and taking breaks were strategies used by individuals. But they also
found keeping busy to be a useful
strategy. They also used informal error-proofing
practices such as focusing on one
task at a time, switching
temporarily to another task, double
checking oneself or asking a colleague to double check, and deferring decisions to later or to
another colleague. Teams also had work practice strategies such as prioritizing
finishing times for colleagues who had the shortest break between shifts,
facilitating napping by “batching” tasks on the night shift, and rotating
night-shift naps.
Barriers to fatigue management in the Ferguson study were
individual (eg. personal responsibility for work and
non-work time), organizational (eg. staffing,
workload, financial, cultural), and community-based (eg.
expectations for service delivery and availability).
One theme that echoes a point included in the ANA position
statement is the importance of incident
reporting (for fatigue-related incidents and near-misses). Though the
Ferguson study was qualitative rather than quantitative, the general feeling
was that such incidents are currently underreported.
We also found some interesting comments in both the ANA and
Ferguson papers about individual safety
in driving home after long shifts. In the Ferguson study taxi vouchers offered
by some hospitals were seldom used. The ANA paper notes that things we all do
when struggling with drowsy driving (such as putting windows down, turning up
the radio, pinching ourselves) don’t work! Maybe that smartphone app we talked
about above will also mount on our rear view mirror!
We again recommend you read our November 9, 2010 Patient Safety Tip of the Week “12-Hour
Nursing Shifts and Patient Safety” to see some of the excellent
prior work that has been done by Geiger-Brown and colleagues (Geiger-Brown
2010) and Fallis and colleagues (Fallis
2011) regarding some of the strategies to mitigate nurse fatigue and
also our columns listed below on the impact of fatigue in healthcare and other
industries and use of strategies such as power naps.
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping
Air Traffic Controllers: What About Healthcare?”
February 2011 “Update
on 12-hour Nursing Shifts”
September 2011 “Shiftwork
and Patient Safety
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “June
2012 Surgeon Fatigue”
November 2012 “The
Mid-Day Nap”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
Our previous columns
on the 12-hour nursing shift:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
February 2011 “Update
on 12-hour Nursing Shifts”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
Some of our other columns on housestaff
workhour restrictions:
December 2008 “IOM
Report on Resident Work Hours”
February 26, 2008 “Nightmares:
The Hospital at Night”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 2011 “No
Improvement in Patient Safety: Why Not?”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “Surgeon
Fatigue”
November 2012 “The
Mid-Day Nap”
December 10, 2013 “Better
Handoffs, Better Results”
April 22, 2014 “Impact
of Resident Workhour Restrictions”
References:
American Nurses Association. Position Statement. Addressing
Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of
Registered Nurses and Employers to Reduce Risks. September 10, 2014
Fuller HJA, Haubert M-K. Managing
Fatigue. VA National Center for Patient Safety. Topics in Patient Safety TIPS
2014; 14(5): 2
http://www.patientsafety.va.gov/docs/TIPS/tips_sept_oct_14.pdf#page=2
Di Stasi LL, McCamy MB, Macknik, SL, et al. Saccadic Eye Movement Metrics Reflect
Surgical Residents' Fatigue. Annals of Surgery 2014; 259(4): 824-829
Ferguson SA, Neall A, Dorrian J. Strategies used by healthcare practitioners to
manage fatigue-related risk: beyond work hours. Medical Sociology Online 2013;
7(2): 24-33
http://www.medicalsociologyonline.org/Vol7Iss2/MSoVol7Iss2Art1/7.2_Art1.html
Geiger-Brown J. Trinkoff AM. Is It
Time to Pull the Plug on 12-Hour Shifts? Part 3. harm reduction strategies if keeping 12-Hour Shifts. Journal of Nursing Administration 2010; 40(9): 357-9, 2010 Sep
Fallis, WM, McMillan DE, Edwards
MP. Napping During Night Shift: Practices, Preferences, and Perceptions of
Critical Care and Emergency Department Nurses
Crit Care Nurse March 31, 2011 vol. 31
no. 2 e1-e11
http://ccn.aacnjournals.org/content/31/2/e1.full
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