Nurse fatigue gets a wake-up call

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“We're coming out of this panel with a new position statement that's going to Capitol Hill in a number of ways.”

— Marie-Elena Barry, RN
Senior Nursing Policy and Practice Analyst
American Nurses Association
 

One morning perhaps a decade ago, John Repique, RN, MS, then a young nurse, was pulled over by the police on his way home after working three consecutive 12 hour shifts. “It was one of those mornings I was trying to make it home after three shifts, and I got pulled over because I was swerving and almost hit another car,” said Repique, now a senior vice president and chief administrative officer at Jackson Behavioral Health Hospital in Miami, Florida. “To make a long story short, the cop actually saved my life because I think I was asleep at the wheel. I could have killed someone, like myself.”

If the lives of working nurses can be endangered by fatigue, how does their exposure to that risk trickle down to the quality of patient care they provide? This concern is the motivation behind the Nurse Fatigue Professional Issues Panel (NFPIP), which will complete its work in February 2014.

The brainchild of the American Nurses Association (ANA), the NFPIP could produce the first ANA Position Statement on Nurse Fatigue since 2006, so the panel is serious about triggering real change in the way the nursing profession observes and manages fatigue, said Marie-Elena Barry, RN, senior nursing policy and practice analyst for the ANA, in Silver Springs, Maryland. The ANA wants fatigue recognized as a workplace hazard that is just as deadly as intoxication in an employee operating heavy machinery. This comparison is not an exaggeration; studies have shown that prolonged wakefulness, even in moderate amounts, can impair performance “equivalent to or greater than levels of intoxication deemed unacceptable for driving, working, and/or operating dangerous machinery.”1

With the exception of compassion fatigue, which the ANA feels is a team discussion and not a policy issue in terms of the NFPIP's objectives, the panel is addressing as many of the contributing factors to nurse fatigue as possible, including

  • Overtime
  • Personal and financial anxiety
  • Learning new medical technology
  • Travel nursing and peer training
  • Night shift versus day shift
  • Working multiple jobs
  • Physical fatigue (stress ulcers, etc.)
  • Nurse-to-patient ratios.
The panel, which began conducting deliberations in August 2013, is comprised of more than a dozen health care professionals selected by the ANA from across the country.2 “It's time for a clear understanding of what nurses go through. An understanding that creates changes in management and policy,” said Barry. “We're coming out of this panel with a new position statement that's going to Capitol Hill in a number of ways.”

The NFPIP is a landmark in the campaign to reduce and manage nurse fatigue in that it considers the impact of conditions outside the hospital workplace setting versus only conditions present on the job. Today, an increasing measure of what contributes to nurse fatigue is outside the control or even knowledge of employers. Understanding, for example, that working at more than one hospital unbeknownst to their employers is not uncommon among nurses is helpful when hospitals craft nurse staffing policy, Barry explained.

The ANA's intent is to make the panel's results a catalyst for institutionalizing major changes in the way employers treat nurses, and how nurses can better communicate with employers. The toll that a swelling patient population is taking on nurses has become nothing short of a national infrastructure concern, said Barry. The ANA is choosing a proactive stance to ensure patient safety and nurse quality-of-life rather than a reactive response to a surprise surge in fatigue-related accidents or deaths.

A RISING SURGE

A March 2013 survey of health care professionals revealed that 69% of those surveyed reported that fatigue negatively impacted their ability to perform on the job. In this survey, 65% said they nearly made a fatigue-related error at work while more than 27% admitted flat-out making a mistake on the job due to fatigue.3 One study on nurse fatigue determined that the chance of making an error was 3.4% when nurses got less than 6 hours of sleep in a 24 hour period. In an average teaching hospital with 1,000 nursing shifts per day, this error rate translates into 34 potential nursing errors a day.1 Then, there are tragedies such as a nurse in Ohio who was killed in a car crash on her way home from work; her family believes stress and working extended hours due short-staffing were contributing factors and filed a wrongful death lawsuit in November 2013.4

Mandated staffing ratios such as the targeted 1:5 nurse-patient ratio in California have helped temper nurse fatigue; but while the ANA wants policies in favor of healthy ratios of nurses to patients, it will not try to create a national formula for a nurse-patient ratio. One reason the NFPIP is shying away from a national ratio is the vast differences in care facilities across the country and the way they are defined, said Tricia Hunter, RN, MN, executive director of the American Nurses Association of California, in Sacramento.

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