Nurse Fatigue And Patient Safety

Nurse Fatigue And Its Effect On Patient Safety

By: Conor Burke in Podcasts, Top Stories, WorkforceMarch 12, 20190

How many hours do you work a day, and how much sleep do you think you get a night?

According to Dr Ann Rogers, it probably isn’t enough. And if that’s the case, your patients are at risk. Studies have shown that the likelihood of a clinician making an error can increase by 36 per cent after working 12-hour shifts on consecutive days.

Fatigue can manifest itself in a number of ways. Forgetfulness, poor decision making, slowed reaction times, reduced vigilance or bad moods, and the obvious nodding off.

An internationally renowned expert in sleep deprivation, Rogers is in Australia to present a paper titled ‘Staff Nurse Fatigue and Patient Safety’ at a public seminar hosted by the Charles Darwin University College of Nursing and Midwifery.

“Everybody needs to be conscious not having enough sleep affects the nurse’s health, it affects patient safety, but it also affects the health of the community,” Rogers said. “Because a tired worker driving home can be very dangerous if they’re trying to stay awake.”

Rogers told Nursing Review about a study that showed a 3.4 per cent probability of an error when a nurse obtained less than six hours sleep at night. In a hospital with 1000 nursing shifts per day, this would translate to a probability of 34 errors per day.

Nursing Review spoke with Rogers ahead of her talk to discuss nurse fatigue.

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Nurse Fatigue: The Cost Of Care

In recognition of the American Nurses Association noting 2017 as the “Year of the Healthy Nurse,” Stevenson University will be exploring the topics of nurse fatigue as well as balancing the mind, body, and spirit to combat the stresses within the nursing field.

What is nurse fatigue? Nurse fatigue is a feeling of persistent tiredness or exhaustion experienced by nurses, making it difficult to perform tasks.

For 15 consecutive years, the Gallup poll has reported that nurses are rated as the most trusted professionals with the highest honesty and ethical standards. Those standards, however, may come at a cost.

What causes nurse fatigue? Perhaps to their own detriment, nurses are known to go above and beyond to serve, protect, and care for their patients and community. Additionally, nurses are routinely scheduled to work 12-hour shifts, and usually work over those hours due to staffing shortages. Per two studies referenced in Patient Safety and Quality: An Evidence-Based Handbook for Nurses, the majority of hospital staff nurses now work 12-hour shifts, some nurses report being scheduled to work for periods as long as 20 consecutive hours. While enduring these long shifts, nurses often do not take breaks or rest, which can be a key contributor to causing nurse fatigue.

Burnout Jeopardizes Patient Safety

In her NBC interview, Joanna Engman also explained the dangers of emotional and physical exhaustion among healthcare workers. A burned-out nurse is a dangerous nurse. An exhausted nurse is not a safe nurse. Unless there are tangible changes, were going to see this get worse.

Research backs up her claims. In a 2010 study from the Canadian Nurses Association and the Registered Nurses Association of Ontario, psychologists found that nurse fatigue has been linked to serious mistakes in patient care. Its important to note that this research was truly extensive, with a sample size of more than 7,000. Therefore, it is safe to assume that it is representative of the issues faced by healthcare workers.

Errors that threaten patient safety include:

• Mistakes when updating patient charts
• Administering incorrect dosages of medication
• Incorrect assessment of the patient
• Slowed reaction time
• Giving patients the wrong medication
• Irritability and tenseness
• Increased errors in the performance of repetitive tasks
• Falling asleep on duty
• Increased risk of falls and injury

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Healthy Nurse Healthy Nation

The ANA Enterprise Healthy Nurse, Healthy Nation Grand Challenge, launched in 2017, aims to improve the nations health by supporting nurses as they pursue their personal wellness. Adequate rest is key to that effort. The nurses who face the greatest challenge to wellness and quality sleep are those who staff the night shift. Evidence-based tips for night nurses are seemingly as elusive as the sleep they need, but some best practices do exist.

Nurse Fatigue: Short On Sleep Short On Safety

Shift work, organizational barriers, and nurse preferences continue to challenge nurse wellness.

Takeaways:

• Shift workincluding long shifts, rotating shifts, double shifts, evening and night shiftshas the potential to cause health and safety risks for nurses and the patients they care for.
• As nursing leaders and professionals, it is our ethical responsibility to abide by recommendations to promote health and safety of employees and patients.
• We must pursue solutions to significantly reduce workplace fatigue.

Healthcare operates 24 hours a day, 7 days a week. To meet patient demands and ensure optimal outcomes, no rest for the weary is common, and shift work can result in nurse health and safety risks. To further complicate matters, some nurses maintain second jobs, potentially leading to even greater risk. Lack of sleep, caused by extended work hours and circadian rhythm misalignment, increases the risk of car accidents, patient care errors, and health issues such as obesity, heart disease, and hypertension. Solutions supported by research must be promoted by healthcare organizations to address the issue of fatigue and ensure nurse wellness and patient safety.

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Design And Data Sources

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted. PubMed, CINAHL, PsychInfo, Scopus, and Embase were the search engines used. The inclusion criteria were any primary studies examining burnout among nurses working in hospitals as an independent variable, in peer-reviewed journals, and written in English. The search was performed from October 2018 to January 2019 and updated in January and October 2020.

Dangers Of Nurse Burnout

Nurse burnout is a substantial concern for all concerned: nurses, employers, and patients. Nurses themselves are at risk for developing depressive disorders and other mental health conditions and for quitting their job. For institutions, a decrease in the quality of patient care can affect their reputation and bottom line. For patients, nurse burnout can directly impact their health.

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Proper Nursing Education Is The First Step To Reducing The Problem Of Nurse Fatigue

When your welfare is in someone elses hands, you want that someone to be alert. Thats obvious, and yet nursesfrom RNs to nurse practitionersare at constant risk of fatigue due to their stressful jobs and demanding work schedules.

This is especially true in a pandemic, as nurses and other medical personnel work around the clock to fight the deadly virus. The COVID-19 pandemic accentuates the dynamics associated with nursing fatigue, says Dr. Mary A. Bemker, core faculty member with Walden Universitys College of Nursing. Caring for self as well as one does others is paramount to positive nursing practice. One minute of deep breathing can decrease stress. Visualizing a peaceful place, closing one’s eyes and listening to music, and watching comedies can also be stress and fatigue relievers.

Numerous studies have shown stress to be a serious problem, including a study by the University of Pennsylvania School of Nursing that concluded fatigue can result in expensive job turnover, and can negatively affect patient care.1

To prevent nurse fatigue, we need better nursing education centered on the causes and consequences of fatigue and better strategies to reduce fatigue. Here are a few facts about the problem, and tips on how to address it.

Descriptive Statistics And Study Characteristics

Nineteen studies measured burnout, sixteen measured wellbeing, and the remaining eleven included both a measure of burnout and of wellbeing. Of the burnout studies, the vast majority of studies used some variant of the Maslach Burnout Inventory , such as the MBI-Human Services Survey, the EE scale of the MBI, or an international variation of the MBI. Alternative measures were Shirom-Melameds Burnout Scale, Copenhagen Burnout Inventory , Physician Well-Being Index, a single question approach and a symptom-based stress survey. The wellbeing measures were far more varied and included General Health Questionnaire , Harvard National Depression Screening Day Scale , linear stress scales, Quality of Life scales, and emotional distress, among others. For a full list of measures and other study characteristics, see S1 Table. Most of the measures used were pre-existing, validated and reliable measures.

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Sentinel Event Alert 4: Health Care Worker Fatigue And Patient Safety

The link between health care worker fatigue and adverse events is well documented, with a substantial number of studies indicating that the practice of extended work hours contributes to high levels of worker fatigue and reduced productivity. These studies and others show that fatigue increases the risk of adverse events, compromises patient safety, and increases risk to personal safety and well-being. While it is acknowledged that many factors contribute to fatigue, including but not limited to insufficient staffing and excessive workloads, the purpose of this Sentinel Event Alert is to address the effects and risks of an extended work day and of cumulative days of extended work hours.

See Addenda on Pages 2 and 3.

Nurse Staffing And Patient Safety

Nurse staffing ratios

Nurses’ vigilance at the bedside is essential to their ability to ensure patient safety. It is logical, therefore, that assigning increasing numbers of patients eventually compromises a nurses ability to provide safe care. There are many key factors that influence nurse staffing such as patient acuity, admissions numbers, transfers, discharges, staff skill mix and expertise, physical layout of the nursing unit, and availability of technology and other resources.1,2

Several seminal studies linked in this sentence have demonstrated the association between nurse staffing ratios and patient safety, documenting an increased risk of patient safety events,morbidity, and even mortality as the number of patients per nurse increases. The strength of these data has led several states, beginning with California in 2004, to establish legislatively mandated minimum staffing ratios. According to the American Nurses Association, only 14 states have passed nurse staffing legislation as of March 2021 and most states do not specify registered-nurse -to-patient ratios, which vary by state and are also setting-dependent.

Nurse staffing and settings of care

Adequate nurse staffing depends on several factors such as lack of training, administrative demands, distractions, and interruptions that can impact nurses work.5

Nurse staffing and education and training

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Limitations Of The Studies

This review is limited in its ability to determine the nature of the associations between wellbeing, burnout and patient safety, due to the limitations of the studies included. The primary limitation was the measure of safety, which is a general problem within patient safety research. The measures used often relied on self-reported errors with recall as long as a year ago, making the results vulnerable to a variety of memory biases and cognitive failures. However despite these limitations, self-reported measures do provide a number of advantages over subjective measures they are more sensitive, they can provide information across all types of errors, and they can be measured at the individual level more easily than objective measures can. There is a lack of studies measuring both objective and subjective measures of safety, with those that measured both differing in the type of errors measured by the two different methods .

Nurse Fatigue A Huge Threat To Patient Safety

EXECUTIVE SUMMARY

Nurse and staff member fatigue increasingly is recognized as a significant threat to patient safety. Risk managers should adopt strategies to reduce fatigue caused by scheduling, overtime, and excessive workloads.

High turnover rates among nurses can indicate fatigue risks.

Hospital culture must encourage staff to admit fatigue and to report fatigue in others.

Creative scheduling can reduce nurse fatigue.

When fatigue is addressed in the healthcare workplace, attention often goes first to physicians and particularly medical residents who are sleep-deprived and overworked. Increasingly, risk managers are focusing on the patient safety threats posed by nurses and other staff members who are too tired to do their jobs properly.

Fatigue poses a huge threat to patient safety, says Richard C. Boothman, JD, chief risk officer and executive director of clinical safety at the University of Michigan Health System in Ann Arbor. The healthcare industry has not connected the dots between how clinical and business pressures can fatigue nurses to the point of threatening patient safety, he says.

The nurse was charged initially with a felony, criminal neglect of a patient causing great bodily harm, but was allowed to plead no contest to two misdemeanors. The Wisconsin Board of Nursing suspended her license for nine months, and she lost her job.

Comparable to alcohol

Risk managers must lead

Brandi Crow, BSN, RN, Clinical Analyst, MD Buyline, Dallas. Email:

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Fatigue Undermines Patient Safety

From ensuring quality of care to preventing infections, burnout and workplace injuries, safety is the priority for everyone in health care. But, where is the issue of fatigue when we think about safety? Although the evidence is there, health care providers don’t always recognize work-related fatigue as a safety issue, and this could be because of a lack of understanding.

Fatigueweariness, lack of energy, tiredness or sleepiness due to prolonged mental and physical work, extended periods of anxiety, harsh environments or loss of sleepnegatively impacts a health care worker’s well-being and safety. As fatigue severely impairs a nurse’s critical thinking, reaction times, judgement and decision-making, the safety of patients and colleagues are also at risk.

Data Extraction And Quality Assessment

The selection process began by reading the titles and summaries of each article. Second, after excluding abstracts that were not adequate, the articles were read in full.

Data on method, participants, interventions, and outcomes were analyzed and extracted by two independent reviewers. In order to assess the risk of bias and the quality of the study, the Chochrane Manual for Systematic Intervention Reviews was used, where any discrepancies were resolved by a third researcher.

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Study Quality And Risk Of Bias

See Fig 2 for an overview of all the studies combined risks of bias, based on the format suggested by the COCHRANE guidelines. For separate quality rating graphs for the wellbeing and burnout studies, see S5 File.

Risk of bias graph displaying the overall study quality for all 46 studies.

A common concern amongst the studies with regards to quality was the measure of patient safety used, as the majority of studies used solely self-reported measures of error, which has a number of limitations including social desirability and fear of blame and retribution. This shall be discussed further in the following section.

There was not much variability in study quality/risk of bias between those that measured wellbeing and those that measured burnout. The criteria in which the burnout studies generally displayed a lower risk of bias than the wellbeing studies were representativeness , and measures of burnout/wellbeing , respectively. There were a similar number of studies demonstrating a medium to large effect size for the relationship between patient safety and burnout as there were for patient safety and wellbeing .

The Effects Of Burnout On Nurses And Patients

Its clear that the demands and responsibilities of nursing, regardless of the facility type, are already incredibly high. And as nurses try to focus on patient safety, nurse burnout can create an environment that makes this task seem impossible.

When a nurse is experiencing burnout, the effects will often negatively impact the nurse and affect their patients safety. In a recent American Organization for Nursing Leadership survey on the impact of COVID-19 on nursing leadership, administered in February 2021, nurse leaders reported two major challenges they face due to the pandemic. Of all 2,471 respondents:

• 67% said mental health and wellbeing of staff was a major challenge
• 65% said surge staffing, training, and reallocation was a major challenge

The following are common effects of nurse burnout on nurses themselves and on patient safety.

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How Nurse Burnout Impacts Your Rns And Lpns

The pandemic has pushed nurse burnout into overdrive. For many healthcare workers, the trauma and long hours required due to COVID have caused them to become overwhelmed. They then face a difficult choice: Do they persevere or find a new line of employment?

In an interview with NBC News, Colorado nurse Joanna Engman said,

Youre seeing someone who is scared and suffering, and youre not able to be present with them because youre so overworked. The hardest part for me was feeling like I had no support. There was no one could speak to, and our mental well-being was beginning to deteriorate.

After more than a decade in the field, Engman chose to leave in February of this year. When you consider the issues that she and other nurses face, its no surprise that many have made the decision to seek new opportunities. Overnight shifts, staff shortages, responsibility overload, feelings of hopelessness, high-stress environments, and bullying from coworkers or patients all contribute to increasing levels of nurse burnout.

Ultimately, burnout has the following effects on nursing staff:

• Near-constant fatigue or exhaustion
• Poor attitude about work, dreading shifts
• Loss of appetite
• Higher rates of depression and anxiety
• Inability to pay attention or concentrate on tasks
• Compassion fatigue

The list above illustrates exactly why this phenomenon poses an incredible threat to patient safety.

Nurses’ Working Conditions And Patient Safety

The causal relationship between nurse-to-patient ratios and patient outcomes likely is accounted for by both increased workload and stress, and the risk of burnout for nurses. The high-intensity nature of nurses’ work means that nurses themselves are at risk of committing errors while providing routine care. Human factors engineering principles hold that when an individual is attempting a complex task, such as administering medications to a hospitalized patient, the work environment should be as conducive as possible to carrying out that task. However, operational failures such as interruptions or equipment failures may interfere with nurses’ ability to safely and effectively perform such tasks several studies have shown that interruptions are virtually a routine part of nurses’ jobs. These interruptions have been tied to an increased risk of errors, particularly medication administration errors. While some interruptions are an entrenched part of patient care, the link between interruptions and errors is one example of how deficiencies in the day-to-day work environment for nurses is directly linked to patient safety.

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