1. Hilary Edmondson Megan Keast
Nurse Fatigue
Hilary Edmondson
Megan Keast

2. Learning Objectives

3. Introduction Nurse fatigue: fatigue that affects nurses due to
Working long shifts
Insufficient amount of sleep between shifts
Disturbance in circadian rhythms, especially for night shift workers
Balancing work, personal and social obligations (Phillips & Moffett, 2013)
Working consecutive shifts
Subjective feeling
Physical and mental tiredness or exhaustion
Interferes with ability – both physical and mental – to function at normal capacity (Rahman, Abdul-Mumin & Naing, 2016)
Symptoms of fatigue
Physiological
Yawning
Drooping eyelids and head
Rubbing eyes
Digestive problems
Slowed or slurred speech
Cognitive
Difficulty concentrating
Lapse in attention
Short term memory loss
Failing to communicate
Emotional
Unusually quiet or withdrawn
Lack of motivation or energy
Mood changes
Long-term disorders
Chronic illness (Phillips & Moffett, 2014)
Nurses today tend to work longer hours with fewer breaks. Patients are more critically ill and many hospitals are short staffed when it comes to nursing staff. Working many shifts in a row with not enough sleep in between them and trying to balance work, family and social life creates fatigue for all staff. Night shift nurses also have the added stress of a disturbance in their circadian rhythm (Phillips & Moffett, 2013). Fatigue is a subjective feeling, meaning that everyone feels fatigued differently. However, typically the feeling of being fatigued is physical or mental tiredness which interferes with a person’s ability to function at their normal level (Rahman, Abdul-Mumin & Naing, 2016). Fatigue can produce a variety of symptoms that can be harmful to the nurse or other that the nurse is trying to help. These can include physiological symptoms such as excessive yawning, drooping eyelids or head drooping, rubbing the eyes, along with other internal symptoms such as digestive problems and changes in speech patterns. Cognitive symptoms include difficulty concentrating, a lapse in attention, memory loss and failing to communicate important issues. When someone becomes unusually quiet or withdrawn, show a lack of energy or motivation or experiences mood changes such as irritability or apathy, they make be experiencing emotional symptoms of fatigue. Some long term disorders of fatigue can become chronic illnesses such as obesity, diabetes, cancer, sleep apnea and anxiety (Phillips & Moffet, 2014).

4. Assessment of the Health Care Environment
Policy
ANA
Employers should ensure
Sufficient resources
Work schedule offering adequate time off for rest and recuperation
Sufficient compensation so that RNs don’t feel the need for working another job
Appropriate staffing
Co-workers watching out for each other (Phillips & Moffett, 2014)
Research
Insufficient sleep has adverse effects on cognition, performance and mood
Shift duration inconclusive
Working long hours and physical health (Rogers, 2008)
According to Phillips and Moffett (2014), the American Nurses Association published a position statement recommending that employers should help in addressing nurse fatigue in the following ways: providing sufficient resources that allows nurses to have enough time off in between shifts for rest and recuperation, sufficient compensation so that nurses do not feel the need for extra income by working another job or picking up overtime, and encouraging coworkers to watch out for each other and identify when someone is showing signs of fatigue that could place themselves or others at risk. Research shows that getting an insufficient amount of sleep does produce adverse effects on mood, cognition and performance. However, studies done on shift duration have been inconclusive on whether or not shorter shifts will result in fewer safety related events for patients. Several studies have shown that working long hours or overtime can decrease a person’s physical health (Rogers, 2008).

5. Assessment of the Health Care Environment (cont.)
Financial
Retention
Medical errors
Overtime
Resources
Healthy sleep
7-8 hours
Avoid nicotine, alcohol and caffeine prior to bedtime
Sleep in a dark, quiet room
Exercise early in the day (American Nurses Association, 2017)
Quality and safety
Increased risk of errors
Patient safety
Personal health and safety
Some financial implications of nurse fatigue can include retention, medical errors and overtime. Retention of staff is crucial in order to not only help decrease nurse fatigue by keeping adequate, knowledgeable staff, but also it can help in decreasing the amount of new nurses that are needed to keep adequate staffing. Nurse fatigue has been shown to result in an increase in medical errors, which can be very costly. Nurses are also mandated to work overtime frequently, resulting in higher costs to the institution. According to the American Nurses Association (2017), healthy sleep can be very beneficial to everyone in improving alertness and mood, increased energy, better concentration, motivation and judgement and improved learning. In order to get healthy sleep, one should get 7-8 hours per night, avoid nicotine, alcohol and caffeine before bedtime, sleep in a dark, quiet room, maintain a bedtime routine and exercise earlier on in the day.

6. Root Cause Analysis Problem: Nurse fatigue Data: Root cause
Long work hours
Not enough time between shifts
No breaks
Overtime
Poor sleep quality
Causative factors
Lack of resources
Lack of knowledge
Lack of education
Lack of adequate compensation
Root cause
12 hour shifts
Implementation
The problem is that nurses are fatigued during work hours. This fatigue can be caused from a variety of causes including long work hours, poor sleep, not enough time in between shifts for adequate sleep, lack of breaks during work hours and overtime, either mandatory or not. Leading to the causes are problem such as a lack of resources – there are not enough nurses to adequately take care of the high demand and high acuity of patients; there is also a high turnover rate for nurses. A lack of knowledge and education on getting adequate and proper sleep as well as taking time out of our busy work day for ourselves (Rogers, 2008). Often nurses also feel they have a lack of compensation, leading them to take on a second job or work overtime in order to make more money. It can be said that 12 hour shifts could be the root cause of nurse fatigue. 12 hour shifts allow the opportunity to work only three days per week. However, working long consecutive shifts puts nurses at risk of fatigue (Stimpfel, Sloane & Aiken, 2012).

7. Suboptimal Patient Outcomes
Inferences
Long Shifts
Workload Life Stressors Patient Acuity
Suboptimal Patient Outcomes
Medical Errors
Based on research done by the National Association of Neonatal Nurses (2015), the relationship between working long shifts and safety outcomes is complex and may be influenced by patient acuity, workload, and one’s own personal life stressors. Long shifts are linked to suboptimal patient outcomes and an increase in medical errors (Griffiths, et al., 2014). But the question often times lies in, how can we as nurses, who are supposed to provide compassionate, patient-centered care, leave a patient without any healthcare provider, because of complaints of fatigue? It is hard to leave our co-workers stranded without any help because we do not want to work a longer shift because the studies show that working more than 12 and ½ hours per day is too much? National Organizations such as The National Association of Neonatal Nurses recommend that employers implement measures to prevent nurses from having to be faced with long shifts that will lead to fatigue and then puts the patients at risk (2015). Nurse managers must be the leaders in implementing safe strategies for nurses and our patients. These strategies focus on nurse fatigue and should apply to nurses of all shifts, since fatigue is not exclusive to night shift. Nurses must be allowed adequate breaks and be allowed to leave at the end of their shift. Staff nurses have an ethical responsibility to themselves and to their patients, to not work when fatigued from extended shifts. Staff nurses must speak up when fatigue is a concern before patient safety is compromised.

8. Adverse Effects on Patient Safety Adverse Effects on Health
Implications
Sleep Duration in 24 Hour Period
Adverse Effects on Patient Safety
Adverse Effects on Health
< 7 hours
More likely to report struggling to stay awake during work shift14
Increased risk of developing cardiovascular disease and DM among nurses187 Increased risk of becoming obese over a 10-year period53
≤6 hours
Risk of making an error is 3.4% during a work shift among nurses who slept ≤6 hours in 24 hours prior to shift (Dawson, personal communication)
Increased prevalence of DM and altered glucose metabolism56, 168 Risk of obesity is 23% greater than subjects sleeping 7–9 hours53
< 5 hours
Increased subjective and objective sleepiness, and reduced performance on cognitive tasks22, 161
Increased risk of developing DM demonstrated in nurses187 Risk of obesity is 50% greater than among subjects sleeping 7–9 hours53
≤4 hours
Altered levels of appetite-regulating hormones (leptin, cortisol, and thyrotropin)57 Risk of obesity is 73% greater than among subjects sleeping 7–9 hours53
There is enough evidence from studies to support that insufficient sleep can have adverse effects on patient safety and the health of nurses (Rogers, 2008). The effects shown in this table, show that nurses who have less than 7 hours of sleep over a 24 hour period are more likely to struggle staying awake during their shift and are at increased risk of developing cardiovascular disease, diabetes, and obesity. Nurses who sleep less than 6 hours over a 24 hour period have a 3-4% chance of making a medical error during their work shift and are at a higher risk for diabetes, and obesity. Nurses who sleep less than 5 hours have an increased performance in cognitive tasks. Nurses who sleep less than 4 hours during a 24 hour period have altered levels of appetite-regulating hormones and are at a greater risk for obesity. These evidence-based practice implications recommend that nurses sleep 7-8 hours before the start of their shift to maintain the best health for themselves and to provide the safest care for their patients.
Source: Hughes, R (2008)

9. Consequences Nurses are at a high risk for fatigue
Nurse Fatigue Alcohol Intoxication
Nurse Fatigue Impairment Medical Errors
Nurses are at higher risk for fatigue than residents and physician, because nurses are the ones who have constant direct contact with their patients (Freeman, 2015). This fatigue can lead to a decrease in cognition, limitation on reaction time, loss of memory, and an increase in medical errors. Research has shown that sleep deprivation is similar to alcohol intoxication. A study done in California, reports that a nurse who has been awake for more than 19 hours has a similar impairment to having a blood alcohol content of 0.05% (Freeman, 2015). The consequences of this impairment will result in medical errors. A study done in Pennsylvania by a healthcare consulting firm called The Graham Company, reports a 3-4% chance of a nurse making a medical error if she or he has less than 6 hours of sleep within a 24 hour period. While this may not see like a very big chance, if you think about an average teaching hospital has 1,000 nursing shifts per day, this error percentage equals 34 daily medical errors (Freeman, 2015).

10. Recommendations Evidence based recommendations Employee education
Short breaks
Improve performance & reduce fatigue
May help decrease safety risks
Exercise
Increased alertness
Improved cognitive performance
Often short lasting
Others
Napping
Stimulants (Rogers, 2008)
Research has shown that often, employees need to be educated on fatigue management – teaching them about circadian rhythms, sleep hygiene, shift work and sleep strategies. Providing frequent short breaks has been shown to improve performance and reduce fatigue. Some studies have shown that frequent breaks decrease safety risks while others show that breaks decrease fatigue but not necessarily safety risks. Exercise has also been shown to increase alertness and improve cognitive function, however, it is short lived with 10 minutes of exercise showing only a minute increased alertness. Other recommendations include minute naps and caffeine (Rogers, 2008)

11. Conclusion/Summary
Nurses who are fatigued are putting their own health and their patients’ health at risk.
Nurses must take an ethical responsibility in regards to patient care.
Nurse managers and administrators need to change the culture in regards to nurses long shifts to help limit a nurses’ fatigue.
There is overwhelming evidence that nurses who work longer than 12-hour shifts, who do not get enough rest in between shifts, or who work too many consecutive shifts are putting their patients’ health at risk as well as their own health. Nurses must take an ethical responsibility and know when they are fatigued and are putting their patient’s life in jeopardy. Nurse managers and administrators need to follow recommendations that have been put in place by state and national organizations to change the culture that it is accepted for nurses to work long hours without any breaks and without sufficient sleep.

12. References
American Nurses Association. (2017). Healthy sleep. Retrieved from
Freeman, G. (2015). Nurse fatigue, a “huge” threat to patient safety. Healthcare Risk Management. Retrieved from: addressed
Griffiths, P., Ball, J., Drennan, J., Jones, J., Reccio-Saucedo, A., & Simon, M. (2014). The association between patient outcomes and nurse/healthcare assistant skill mix and staffing levels and factors that may influence staffing requirements. South Hampton, GB: University of South Hampton.
Hughes, R. (2008). Patient safety and quality: An evidence based handbook for nurses. Rockville, MD.
The Joint Commission -- Sentinel Event Alert: Health care worker fatigue and patient safety.
(2011). Alaska Nurse, 61(4), 12.
Martin, D. J. (2014). Literature Review: Nurse Fatigue Related to Shift Length. Missouri State
Board Of Nursing Newsletter, 16(1), 7.
National Association of Neonatal Nurses. (2015). The effect of staff nurses’ shift length and fatigue on patient safety and nurses health [PDF]. Retrieved from: %20and%20Fatigue%20on%20Patient%20Safety%20and%20Nurses%20Health.pdf

13. References (cont.).
Phillips, S. A., & Moffett, C. (2014). The Implications of Nurse Fatigue. Missouri State Board Of
Nursing Newsletter, 16(1), 8-10.
Rahman, H. A., Abdul-Mumin, K., & Lin, N. (2016). A study into psychosocial factors as predictors of work-related
fatigue. British Journal Of Nursing, 25(13),
Randolph, S. A. (2015). Fatigue Risk Management. Workplace Health & Safety, 63(5), 236.
doi: /
Rogers, A. E. (2008). The effects of fatigue and sleepiness on nurse performance and patient safety. In Hughes, R. G. (ed), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from
Stimpfel, A., Sloane, D. M., Aiken, L. H. (2012). The Longer The Shifts For Hospital Nurses, The Higher The Levels Of
Burnout And Patient Dissatisfaction. Retrieved from doi:  /hlthaff