News January 5, 2012

Preventing Healthcare Worker Fatigue and Adverse Events

Recognizing the patient safety dangers associated with fatigue, The Joint Commission recently issued a Sentinel Event Alert urging greater attention to the issue and suggesting specific actions for healthcare organizations to mitigate the risks.

“Nurse fatigue is an important issue to address,” said June Marshall, DNP, RN, NEA-BC, director of advancing professional nursing practice at Texas Health Presbyterian Dallas.

Jeanne Geiger-Brown, Ph.D., RN, associate professor at the University of Maryland School of Nursing in Baltimore, whose study of registered nurses found neurobehavioral functioning, including reaction time, declines as they work additional 12-hour shifts, added, “People often think that if you are real professional, you won’t suffer the effects of fatigue, but that’s not the case. These are biological events. There is no amount of professionalism, skill or being a good nurse that will overcome a biological trait.”

The Joint Commission alert, issued in December 2011, outlines the problem of fatigue among healthcare workers and cites a study that found nurses who work more than 12-hour shifts and residents working recurrent 24-hour shifts were involved in three times more fatigue-related preventable adverse events. In addition, healthcare professionals who work long hours are at greater risk of injuring themselves on the job.

Fatigue can lead to lapses in attention and difficulty staying focused, compromised problem solving, memory lapses, poor communication, slowed or faulty information processing and poor judgment, which could contribute to adverse patient events.

Jacob Teitelbaum, M.D., medical director of the Fibromyalgia and Fatigue Centers and author of the book From Fatigued to Fantastic!, of Kona, Hawaii, explained that for adequate energy production, people need good nutrition, sleep and exercise.

Recommendations for organizations

The Joint Commission recommends that healthcare organizations assess fatigue-related risks, including off-shift hours, consecutive shifts worked and staffing levels, and asking staff about work schedules that minimize possible fatigue.

Geiger-Brown advocates for 8-hour shifts, rather than the 12 hours that has become the norm, and if hospitals are not willing to totally do away with 12-hour shifts, at least eliminate them on the overnight shift.

“Night nurses have a real problem with getting enough sleep, and they have the normal circadian low between 3 a.m. and 5 a.m.,” Geiger-Brown said. She added that people usually cannot shift their circadian rhythm.

Geiger-Brown advised managers not to schedule staff meetings at 7:30 a.m. and expect night nurses to stay. That extra hour makes the nurse less safe driving home, and it takes away from the short sleep period they have before the circadian rhythm wakes them up again around 1 p.m.

Marshall added that nurses and other workers also have to take responsibility and say “no” to requests to work additional shifts.

The Joint Commission suggested examining processes related to hand-offs, which are high-risk and may not be carried out as well by fatigued staff, and creating teamwork strategies to double-check each other on critical tasks or complex patients. The accrediting body also recommended creating a fatigue-management plan, providing uninterrupted coverage of responsibilities and educating staff members about good sleep habits and the effects of fatigue on patient safety.

The sleep environment should be dark and quiet, so the resting nurse can fall and stay asleep, without interruptions, Geiger-Brown said. And nurses who have difficulty sleeping should consult a sleep specialist.

A hospital’s fatigue-management plan, according to The Joint Commission, may include strategies for fighting fatigue, such as engaging in conversation, physical activity, strategic caffeine consumption and short naps.

“Napping during work time on breaks should not only be permitted but facilitated by having napping areas,” Geiger-Brown said. “A 25-minute nap gives you an extra hour of alertness.”

Fellow nurses would need to care for the napping nurse’s patients to ensure the napping nurse has uninterrupted rest. Napping need not be limited to the night shift, she said. Day-shift nurses could take a rest break during the circadian low that occurs between 2 p.m. and 4 p.m.

Tips for clinicians

Geiger-Brown suggested nurses drink small amounts of caffeine during the night, enough to keep a blood level up but low enough that they can sleep once they go home.

However Teitelbaum cautioned that caffeine can be a double-edged sword, and that people should not drink more than one to two cups of coffee per day. He called sugars and caffeine “energy loan sharks,” as they are short-term fixes with long-term consequences. He recommended cutting back on sugars and foods with empty calories and taking a good multivitamin, with B vitamins and magnesium. Teitelbaum’s research has shown that ribose can help turbo-charge people’s energy.

To get a quick pick-me-up, Teitelbaum suggested drinking a cold 8-ounce glass of water.

Moving about and exercising, even going outside for fresh air can help combat fatigue, he said. Additionally, rubbing on both ears for 10 to 15 seconds will give a quick energy boost.

But he warned that quick fixes will not solve the problem. Clinicians must go back to the basics and ensure they get a good night’s sleep. Lavender may help combat insomnia as can some herbs or melatonin.

“People need to make time for sleep by cutting out the things in life they least enjoy,” Teitelbaum said. “Make the time to give the body what it needs.”

10 Tips to Prevent Fatigue-related Adverse Events

1. Develop a fatigue-management plan

2. Assess fatigue-related risks

3. Design work schedules that minimize the risk of fatigue

4. Limit the number of consecutive shifts a nurse can work

5. Provide adequate staffing

6. Avoid mandatory overtime

7. Do not schedule staff meetings at the end of the night shift

8. Educate staff members about good sleep habits

9. Assess and improve hand-off processes

10. Consider fatigue as a possible contributing factor when reviewing adverse events