1. Fatigue Management Guidelines Georgia Hospital Association May 22, 2014 Robert L. Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE Vice President, Patient Care Services / Chief Nursing Officer Midland Memorial Hospital 1

2. Objectives  To understand the literature related to fatigue management.  To understand the practice at Midland Memorial Hospital before Fatigue Management Guidelines.  Review Midland Memorial Hospital’s Fatigue Management Guidelines and current practice.  Outline a leadership framework for implementing best practices. 2

4. Leading Indicators for Fatigue Causal factors  Long work hours (overtime)  Low job satisfaction  Low control over overtime  Extended work periods Individual risk factors  Age  Need for drug therapy  Illnesses (i.e., diabetes, coronary disease, etc.)  Stress/anxiety  Workers with young children Source: www.asse.org, Professional Safety, December 2010www.asse.org 4

5. Immediate Effects of Fatigue  Reduction in physical capacity (weakness)  Reduction in work  Mistakes  Slips  Lapses  Weariness  Memory loss  Sleepiness  Discomfort  Weakened motivation  Irritability  Illness Source: www.asse.org, Professional Safety, December 2010www.asse.org 5

6. Human Error, Work Environment & Impacts Human errorDefinitionSusceptible environments Impact of cognitive fatigue Mistakes Intentional planning related error (e.g., skill- based errors) Dynamic work environments and standardized work processes do not ensure sufficient worker-hazard interactions Mistakes become more common as workers’ judgment deteriorates during extended periods of work and mistakes remain undetected Slips Unintended erroneous actions that result from mental distractions in familiar work environments Typical work environments with one or more unusual external distractions. Distractions have a greater effect as workers have increasing difficulty focusing on their work tasks. Lapses Unintended erroneous actions that result from temporary memory failure Typical work environments Memory failures increase dramatically during periods of mental fatigue Source: www.asse.org, Professional Safety, December 2010www.asse.org 6

7. Lagging Indicators of Fatigue Effects of fatigue on performance  Reduction in quality  Reduction in productivity  Increased severity of injuries  Increased frequency of injuries Quality of life impacts  Illnesses (i.e., GI, CAD, HTN, etc.)  Stress  Sleep complaints  Unhealthy diets  Lack of exercise  Smoking  Suicide due to overwork Source: www.asse.org, Professional Safety, December 2010www.asse.org 7

8. Working under fatigue may: Hurt or Kill someone! 8

9. Midland Memorial Hospital Practice environment before Fatigue Management Guidelines 9

10. Practice Environment before MMH Fatigue Management Guidelines  16-hour shifts normal for RNs, house supervisors, pharmacists and others.  No regard or respect to the effects of fatigue on safety.  Poor results on surveys (e.g., NDNQI RN Satisfaction Survey, Culture of Patient Safety).  Other effects unrecognized that may have been contributed to poor management of fatigue. 10

11. Midland Memorial Hospital How did we get started? 11

12. Getting started (2008)  Texas Nurses Association’s Practice Committee – Dr. Debora Simmons  Formed interprofessional team to review literature and create a guideline.  Guideline approved through shared governance structure (buy-in). 12

13. Patient Care Services Shared Accountability Structure Patient Care Services Shared Accountability Structure Empirical Outcomes Shared Governance Model 13

14. 14 Professional Practice Model

15. MMH Fatigue Management Guideline (2009)  PURPOSE: To provide a strategy that recognizes and manages the potential negative consequences of sleep deprivation and sustained work hours on patient outcomes and staff well-being.  GUIDELINE: The direct patient caregiver is responsible and accountable for individual practice and understanding the consequences of fatigue in preserving integrity and safety. Guidelines for length of hours worked, and number of hours worked in patient care assignments during a period of seven days will be followed. 15

16. Definitions  On-call  Call hours worked  Extended work period \ sustained work hours  Extended hours worked per week  Fatigue  Circadian rhythms  Off-duty 16

17. Guidelines  Except in emergency situations, direct patient caregivers should not work in direct patient care assignments more than 12.5 consecutive hours in a 24-hour period, not more than 60 hours in a seven-day period, and not scheduled more than three consecutive 12-hour shifts. Working outside of these parameters requires Manager and/or Director approval.  Off-duty periods should be inclusive of an uninterrupted sleep cycle, a break from continuous professional responsibilities, and a period of time of not less than eight (8) hours to perform activities of daily living.  Arrangements will be made in relation to the hours worked, to provide additional time off for direct patient caregivers working a longer shift, an extra shift, or hours worked on call to accommodate an adequate off-duty recuperation period.  The number of shifts, or on-call shifts assigned during a seven day period should reflect the above guidelines as to number of sustained work hours and adequate recuperation periods. 17

18. Guidelines (cont.)  An individual’s ability to meet an increased work demand should be taken into account.  All direct patient caregivers should uphold their ethical responsibility to patients and to themselves to arrive at work adequately rested and prepared for duty.  In extreme conditions, i.e. surge management or a disaster, staff may be asked to work additional hours, following the above guidelines for fatigue management.  Leaders have a responsibility to monitor staff fatigue, provide breaks and release staff as soon as possible. 18

19. Other initiatives  Clinical Manager Model  Agency for Healthcare Research and Quality’s (AHRQ) TeamSTEPPS® Training 19

20. Updated Review (2014)  Defined “direct patient caregiver” as clinical nurse, physical therapists, respiratory therapists, pharmacists, scrub tech as required.  Recommendation for all employees.  Sleep Hygiene: the promotion of regular, healthy sleep.  Added adapted Fatigue Management Model from The American Society of Safety Engineers (www.asse.org, Professional Safety, December 2010).www.asse.org 20

21. Adapted Fatigue Management Model Immediate Effects Decreased productivity Increase in mistakes, slips, and lapses Decrease in teamwork Weariness Physical weakness Lack of motivation and/or engagement Sleepiness Irritability Concentration difficulties Stress Burnout Countermeasures Fatigue Management Guidelines Breaks Hydration Decrease pace Increase teaming Sleep hygiene Long-Term Effects Chronic illnesses Insomnia Family problems Increased Mortality & Morbidity Causal Factors Shift work Extended work shifts Work time control Repetitive tasks Nighttime work Individual Risk Factors Age Living Conditions Circadian rhythms Preexisting illness Prior work experience Fatigue 21

22. A Leadership Framework from Kouzes & Posner  Model the way  Inspire a shared vision  Challenge the process  Enable others to act  Recognize the 22

23. References 1.Birmingham, S.E., Dent, R.L., Ellerbe, S. (2013). Reducing the impact of RN fatigue on patient and nurse safety. Nurse Leader. 31-34. 2.Bosek, M.S. (2001) Mandatory overtime: Professional duty, harms, and justice. JONAS Healthcare Law Ethics Regulations. (4):99-102. 3.Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. American Operating Room Nurse, 87(6), 1191-1204. 4.Hallowell, M.R. (2010). Worker fatigue: Managing concerns in rapid renewal highway construction projects. Professional Safety. 18-26. 5.Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: The National Academic Press. 6.Rogers, A.E., Hwang, W.T., Scott, L.D., Aiken, L.H., and Dinges, D.F. (2004) The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 23(4):202-212 7.Trinkoff, A.M., Le, R., Geiger-Brown, J., and Lipscomb, J. (2007) Work schedule, needle use, and needlestick injuries among registered nurses. Infection Control and Hospital Epidemiology. 28 (2) 156- 164. 8.Wells, M.E. and Vaughn, B.V. (2012). Poor sleep challenging the health of a nation. Neurology J. 52: 233- 249. 23

24. Questions? Contact Information: Dr. Bob Dent (432) 221-4566 – Office (432) 559-2911 – Mobile bob.dent@midland-memorial.com You may: Follow me on Twitter @bobdent Connect with me on LinkedIn Thank you! 24