Nursing is hard work. It tires the mind, the body and the emotions. Nurses are with patients twenty-four hours a day, seven days a week. Some nurses work with well, acutely ill, chronically ill, rehabilitative and/or dying patients. Some nurses work eight hour shifts; some twelve hour shifts; and then there are those that work a shift plus overtime. Some nurses work permanent shifts, some rotating shifts and some work shifts in no particular pattern. All of these factors make nursing a very physically and emotionally draining profession. Other industries have been aware for many years of the links between fatigue and accidents, mistakes, errors and near errors. For instance, the airline and trucking industries limit the number of hours pilots and truck drivers can fly/drive. They also require a certain number of hours between “flights” or “runs”. Why? They do this because empirical research has demonstrated that one’s decision making skills decline with fatigue; reaction times lengthen with fatigue; and problem solving is impaired. All of these outcomes of fatigue contribute to decreased safety in the air and on the highway. Although medicine limited intern and resident work hours several years ago, nursing did not become concerned about fatigue until nurses being forced to work overtime began to worry about how safe they were during the overtime hours. About the same time, the health care system was deeply involved with determining the causes of adverse patient outcomes. In addition, the United States Pharmacopeia (USP) met with professional organizations to discuss the findings of their adverse incident reporting system. Of no surprise to most nurses, the data show that most reported medication errors were “made by nurses”. However, the USP and people familiar with the health care system know there is much more to the findings than the raw numbers indicate; thus, the exploration into factors affecting adverse nursing-sensitive patient outcomes. Evidence In general, excessive total hours worked puts nurses and patients at risk. In addition, rotating shifts can also threaten patient safety. Research by Circadian Technologies Incorporated has found that the number of accidents for all shift workers is 1.2 times greater than that for traditional workers and the resulting incremental cost to business is $8.5 billion. (Bureau of National Affairs, 2003) Following a substantial review of the literature, the Institute of Medicine’s Committee on Work Environment for Nurses and Patient Safety found strong evidence linking prolonged work hours and fatigue and its affect on worker performance (IOM, 2004). This affect includes slowed reaction time, lapses of attention to detail, errors of omission, compromised problem solving, reduced motivation, and decreased energy for successful completion of required tasks. This led to the following recommendation: “To reduce error-producing fatigue, state regulatory bodies should prohibit nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per 7-day period” (IOM, 2004). Trinkoff, Geiger-Brown, Brady, Lipscomb, & Muntaner (2006) found that 17 percent of staff nurses, 4 percent of managers and 7 percent of advanced practice registered nurses regularly exceeded the IOM’s recommendation. In 2004, the Institute of Medicine (IOM) report, Keeping Patients Safe: Transforming the Work Environment of Nurses described the central role of nurses in protecting patient safety and achieving better patient outcomes; and it discussed the frequent mismanagement of the nurse’s work environment (eg., failure to refuse additional patients when the unit is already stressed to its maximum capacity) that often threatens these integral contributions. Among those issues highlighted in the report, the IOM focused on institutional support and structures for maintaining nurse staffing at levels sufficient to avoid patient safety issues caused by nurse fatigue. recognized that creating a healthy work environment for registered nurses that is most conducive to patient safety will require fundamental change within a health care organization. Strong evidence links prolonged work hours (more than 12 hours in a 24-hour span, or more than 60 hours in 7 days), rotating shifts and insufficient breaks to: Findings from a 2004 landmark study, The Working Hours of Hospital Staff Nurses and Patient Safety (Rogers, Hwang, Scott, Aiken & Dinges), clearly demonstrates that the hours a registered nurse works is related to the errors and near misses made by that registered nurse in patient care. This research also found that the likelihood of making an error was three times higher when nurses worked shifts lasting 12.5 hours or more. The authors recognized that long, unpredictable hours suggest a link between poor working conditions and threats to patient safety. Another study, Extended Work Shifts and the Risk of Motor Vehicle Crashes among Interns (Barger et al., 2005) focused on medical interns and demonstrated the potential of impact of long hours and fatigue on motor vehicle crashes, near-miss incidents, and incidents involving involuntary sleeping. Findings from this report showed that extended-duration work shifts posed a serious and preventable safety hazard for the physicians and other motorists, apart from increasing the risk of failures of attention and serious medical errors. Findings from the Nurses Work life and Health Study (Trinkoff, et al., 2006), a longitudinal study of 2,273 registered nurse respondents, suggest that of the one-third that worked more than 40 hours per week, 19 percent worked 41 to 49 hours, 8 percent worked 50 to 59 hours, and 6 percent worked 60 or more hours. Looking specifically at those registered nurse respondents with more than one job, the researchers found that these nurses were “more likely to work 12 or more hours per day (37% versus 28% of the total) and 50 or more hours per week (24% versus 14% of the total).” In addition, registered nurses who work more than one job were more likely to work stretches of consecutive days without breaks, work with insufficient rest, and to work during scheduled time off. Implications for Nurses Implications for nurses of this research are profound when the nurse must choose to work overtime, work a second job or be pressured into working overtime. The implications are mainly ethical with possible legal ramifications, i.e., loosing one’s license from an error committed while fatigued. Foundational to the decision that faces the nurse is the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001). This Code of Ethics for Nurses serves as a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. A code of ethics makes explicit the primary goals, values, and obligations of the profession. Four provisions within the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) speak to the obligation of registered nurses to act in a manner that is consistent with maintaining patient and personal safety.
These ethical provisions must be taken into consideration by any nurse when deciding whether to work prolonged hours. Interpretive Statement 6.3 further delineates the ethical responsibilities of nurse managers and administrators to take action to curtail extended work hours and insufficient rest time between shifts: Although the Registered Nurse is held accountable for her/his practice, the institution also has a responsibility to the nurse, the patient, the facility and the public to recognize the need for a work environment conducive for safe patient care. Summary Fatigue and its impact on the individual Registered Nurse is a complex and individual occurrence. It is, however, a safety and ethical issue. Nursing must work together so nurses do not feel the need to work additional hours or jobs to meet reasonable financial needs. Nursing must also not punish nurses that refuse to work overtime but accept their decision as one made with the best interests of the patient at heart. The question needs to be asked, “Is having a nurse working fatigued a greater threat to patient and nurse safety than not having anyone present at all? Let’s make sure we put the patient’s well-being first, which in this instance means putting our own well-beings first also. BibliographyAmerican Association of Critical Care Nurses. (2003). Mandatory overtime: a statement from AACN. Retrieved March 24, 2006 from http://www.aacn.org/AACN/pubpolcy.nsf/vwdoc/pmp American Nurses Association. (1994). Ethics and human rights position statement: The nonnegotiable nature of the ANA Code for Nurses with Interpretive Statements. Retrieved March 30, 2006 from http://www.nursingworld.org/readroom/position/ethics/etcode.htm. American Nurses Association. (2001). Opposition to mandatory overtime. Retrieved March 30, 2006 from http://www.nursingworld.org/readroom/position/workplac/wkassign.htm. American Nurses Association. (1995). The right to accept or reject an assignment. Retrieved March 30, 2006 from http://www.nursingworld.org/readroom/position/workplac/wkassign.htm. American Nurses Association, House of Delegates. (2005). Implications of fatigue on patient safety and nurse safety. (Available from the American Nurses Association, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910) American Nurses Association. (2000) Nurse staffing and patient outcomes in the inpatient hospital setting. Washington, DC: Author. American Nurses Association. (1995). The right to accept or reject an assignment. Retrieved March 21, 2006 from http://www.nursingworld.org/readroom/position/workplac/wkassign.htm. American Nurses Association, House of Delegates. (2005). Implications of fatigue on patient safety and nurse safety. (Available from the American Nurses Association, 8515 Georgia Ave., Suite 400, Silver Spring, MD 20910). American Nurses Association, House of Delegates. (2004). Transforming the work environment for nurses. (Available from the American Nurses Association, 8515 Georgia Ave., Suite 400, Silver Spring, MD 20910). American Nurses Association. (2000) Nurse staffing and patient outcomes in the inpatient hospital setting. Washington, DC: Author. American Nurses Association. (1995). The right to accept or reject an assignment. Retrieved March 21, 2006 from http://www.nursingworld.org/readroom/position/workplac/wkassign.htm. American Nurses Association, House of Delegates. (2005). Implications of fatigue on patient safety and nurse safety. (Available from the American Nurses Association, 8515 Georgia Ave., Suite 400, Silver Spring, MD 20910). American Nurses Association, House of Delegates. (2004). Transforming the work environment for nurses. (Available from the American Nurses Association, 8515 Georgia Ave., Suite 400, Silver Spring, MD 20910). Association of perioperative Registered Nurses. (2005). Position statement: safe work/on-call practices. Retrieved March 1, 2006 from http://www.aorn.org/about/positions/default.htm Caruso, C., Hitchcock, E. M., Dick, RB, Russo, JM, & Schmit, JM. (2004). Overtime and extended work shifts: recent findings on illnesses, injuries and health behaviors. (DHHS (NIOSH) Publication No. 2004-143). Washington, DC: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. In the Matter of Lorraine Deland v. Hutchings Psychiatric Center et al., 203 A.D. 2d 776 (N.Y. App. Div. 1994).New York Supreme Court, Appellate Division 1994). Landrigan, C.P., Rothschild, J.M., Cronin, J.W., Kaushal R. Burdick E. Katz JT. Lilly CM. Stone PH. Lockley SW. Bates DW. Czeisler CA. (2004). Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine, 351, 1838-1848. Scott, L.D., Rogers, A.E., Hwang, W & Zhang, Y. (2006). Effects of critical care nurses’ work hours on vigilance and patients’ safety. American Journal of Critical Care, 15(1):1-8. U.S. Bureau of Labor Statistics. (2005). Workplace injuries and illnesses in 2004. (USDL 05-2195). Washington: DC. U.S. Government Accountability Office. (2001). Nursing workforce: emerging nurse shortages due to multiple factors. (GAO-01-944). Washington, DC. Retrieved March 13, 2006 from http://www.gao.gov/archive/2001/d01944.pdf
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