Monday October 21st 2019

More than just tired

Nurses, employers should work together to reduce fatigue, its effects

Years ago while driving home after working a 12-hour night shift in a busy emergency department, R. John Repique was pulled over by a Baltimore police officer; he was told he had been swerving.

“Getting stopped that morning saved my life and possibly someone else’s,” said Repique, who realized that feeling tired had become his norm. “That happened in the early 1990s, while I was rotating on nights as a staff nurse. Ever since then I’ve been very passionate about the issue of fatigue and drowsy driving because it can be fatal.”

Now chief executive officer of Friends Hospital in Philadelphia, Repique, MS, RN, NEA-BC, is one of 15 nurses who served on the steering committee of the American Nurses Association (ANA) Professional Issues Panel on Nurse Fatigue, which developed a new position statement on this urgent issue.

John Repique

He emphasized that his former routine was not unlike that of his peers back then or now. Many nurses work long shifts, sometimes at night, attend school to further their education, and juggle a whole host of family and other responsibilities, according to Repique, an ANA member.

Further, insufficient sleep is so widespread in America that the Centers for Disease Control and Prevention characterized it as a public health epidemic.

“Our society does not value adequate sleep, but rather, working long hours,” said Ann Rogers, PhD, RN, FAAN, a steering committee co-chair, Georgia Nurses Association member and author of the 2004 groundbreaking study on nurses’ work hours and patient safety. “And nurses are a reflection of our society.”

Ann Rogers

But fatigue among nurses is particularly vexing.

“It’s a big responsibility to take on the health and welfare of other people,” said critical care staff nurse and stat (rapid response) team member Stephene Swift, BSN, RN, a Washington State Nurses Association member. “I always want to be at the top of my game with my critical-thinking skills and nursing judgment, because I am dealing with life or death situations. When you’re fatigued, you can’t be 100 percent.”

Although Swift and other nurses successfully advocated for better staffing at her facility, she said nurses as a whole are working more with less – a practice that contributes to fatigue.

Revising policy, ramping up efforts around rest

Over the years, ANA has worked with nurses across the nation to address fatigue by developing evidence-based policies, advocating for practices to ensure a healthier work environment and workforce, and providing educational and other resources for nurses that address this multidimensional issue. ANA also has been committed to the overall health of nurses by promoting the importance of self-care.

One of ANA’s most recent efforts is the updated position statement, “Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibility of Registered Nurses and Employers to Reduce Risks,” which also was developed with input from a 350-plus Advisory Committee and from a range of expert and interested stakeholders. Another new offering is a four-part educational series, which covers the impact of fatigue on a person’s mind and body, evidenced-based strategies to prevent and combat it, and ways to evaluate one’s own role and the employer’s role in addressing nurse fatigue. The educational modules reinforce the critical information detailed in the position statement.

Steering committee members say the ANA statement emphasizes the importance of nurses and employers sharing the responsibility of preventing nurse fatigue.

Barbara Hobbs

“Taking steps and measures to reduce fatigue should not be an ‘us against them’ proposition,” said Barbara Hobbs, PhD, RN, NEA-BC, a steering committee and South Dakota Nurses Association member, as well as assistant dean and associate professor at South Dakota State University.  “We’re here for one thing – the patients. We need to work together to build an environment that keeps patients safe and nurses healthy.” Continuing, Hobbs said, “When people are up for many hours, they lose the ability to determine their level of alertness.”

That holds true for nurses who often push through longer shifts on adrenaline, she said.  In addition to the increased risk of making errors because of decreased alertness or the potential harm caused by drowsy driving, repeatedly working long hours without adequate rest can affect nurses’ long-term health – diabetes, musculoskeletal problems and obesity, for example.

Beyond detailing the risks, the new position statement also recommends strategies that nurses and employers can implement. One key measure involves scheduling practices, which is generally enmeshed in staffing.

The position statement calls on nurses to work no more than 12 hours a day and no more than 40 hours in seven days, and urges employers to support these limits. Further, ANA recommends establishing at least 10 consecutive hours a day of protected time off so nurses can get seven to nine hours of sleep, among other rest break strategies.

Research has shown that working more than 12 hours a day or more than 40 hours a week poses a greater risk to nurses, patients and to society, if for example, a fatigued nurse gets into an accident on the way home, said Rogers, director of the graduate program at Emory University’s Nell Hodgson Woodruff School of Nursing and board certified in sleep medicine.

“Managers should also make sure nurses have time for rest breaks, so they can stay alert through their entire shift,” Rogers said.  Night nurses, in particular, should be allowed and encouraged to nap or rest in the middle of their shift, so they are not fighting their circadian rhythms.

Among its many recommendations for nurses and employers, the ANA statement calls for nurses to make sure they have adequate rest before they start a shift and to consider the length of the commute before applying for a job. Others speak to enacting formal policy that allows nurses to reject an assignment if they are fatigued and to prevent the use of mandatory overtime as a staffing solution.

Meeting the challenge in Illinois

When planners at Rush University Medical Center in Chicago were creating a new state-of-the-art hospital, they wanted to ensure its design supported their desire to provide the highest quality of care.

“Being a nurse is a tough job, so we want to do what we can to prevent fatigue and stress,” said Patty Nedved, MSN, RN, CENP, associate vice president, professional nursing practice at Rush. To that end, Rush offers nurses the ability to self-schedule, training on mindfulness and lectures on work-life balance, among other activities.

And then there is the creation of respite rooms. Rush first transformed a vacant room into a respite room in 2009 at the suggestion of nurses and based on research that showed the benefits of naps, Nedved said.

“Then when we designed the new building (which opened in January 2012), we made sure each unit had access to a respite room so staff could take a nap or just rest during their break or before driving home,” Nedved said. Nurses and other staff do take advantage of the rooms, which have fully-reclining chairs and low-level lighting.

In terms of scheduling, Rush offers varied shifts based on the unit, including four, eight, 10- and 12-hour shifts, she added.

In Washington State

To address staffing shortages and fatigue at her hospital, Swift, another staff nurse and a nursing supervisor made a formal presentation to their hospital board. They presented “assignment despite objection” forms that tracked the number of times nurses were working in conditions they felt were unsafe. They also talked about the reasons behind the rising number of nurse vacancies.

“Globally, many nurses were leaving because they were stressed out, fatigued and felt powerless that anything would change,” Swift said. “As nurses, we are more apt to speak out for our patients, but not for ourselves.”

But that reluctance to be self-advocates may be changing, because fatigue is such a big issue for many nurses, according to Swift. As a result of the WSNA nurses’ advocacy, the hospital filled a number of vacancies and added some traveling nurses.

“We had positive outcomes because we spoke out,” said Swift, “and I hope it continues.”

In South Dakota

Hobbs routinely presents on “strategies for surviving shiftwork” through her university-affiliated hospital nurse residency program; it’s an early intervention in the battle against fatigue.

Hobbs specifically talks with new graduate RNs about smart scheduling practices; recognizing fatigue in oneself and in peers; the undesired effects of fatigue on nurses and patients; and strategies to improve sleep.

For those already ensconced in fatigue-inducing practices, Hobbs said that some of the recommendations included in the ANA statement would require a culture change and a behavioral change.

Added Repique, “How we address fatigue should not be politicized. We have decades of research showing that working fatigued has many negative effects. It should be all about health and safety.”

— Susan Trossman is the senior reporter for The American Nurse.

ANA resources


• Full position statement on fatigue
• New ANA CE Course: Your Mind and Body on Fatigue
• Webinar: Navigating Shiftwork: 5 Tips for Managing Fatigue
• Interview of ANA President Pam Cipriano and renowned nurse researcher Linda Aiken.

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