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Fatigue is a workplace hazard that affects the health and safety of patients, health care providers and the community. Early in my nursing career, I was on an exhausting, mandated schedule of working three eight-hour night shifts, followed by one night off, then seven eight-hour night shifts, followed by three nights off. Later, I progressed to a day/night rotation which meant flip-flopping between days/nights without a day for sleep. Next, the introduction of the coveted 12-hour shift enabled me to be home more.
After decades in nursing, shift rotation continues and 12-hour shifts are still here. As I think back to the times I fell asleep at the stop light on my way home from work or was unable to remember what I was supposed to be doing, I can recognize these instances as signs of fatigue.
Fatigue undermines patient safety
From ensuring quality of care to preventing infections, burnout and workplace injuries, safety is the priority for everyone in health care. But, where is the issue of fatigue when we think about safety? Although the evidence is there, health care providers don't always recognize work-related fatigue as a safety issue, and this could be because of a lack of understanding.
Fatigue—weariness, lack of energy, tiredness or sleepiness due to prolonged mental and physical work, extended periods of anxiety, harsh environments or loss of sleep—negatively impacts a health care worker's well-being and safety. As fatigue severely impairs a nurse's critical thinking, reaction times, judgement and decision-making, the safety of patients and colleagues are also at risk.
Nurses are essential caregivers who must be attentive, focused and able to react quickly. They must use clear, appropriate judgment to perform effectively among high-acuity patients in a changing health care environment. Nurses provide around-the-clock care to the patients they serve, which involves irregular hours and long shifts. According to the Agency of Healthcare Research and Quality, approximately 75 percent of shift workers experience some degree of fatigue or sleepiness while on duty. Regardless of the time of day, nurses who work shifts longer than 12 consecutive hours are at risk for fatigue. Furthermore, the likelihood of making a medication error increases by two to three times compared with nurses who work fewer hours.
Three-step approach to lessen provider fatigue
Health care professionals and leaders can create a culture of safety and mitigate fatigue through three main strategies:
1. Shift the culture of safety to include recognizing and dealing with fatigue.
The Joint Commission released a Sentinel Event Alert in 2011 (an addendum was added in May 2018) that urged health care organizations to address the link between health care worker fatigue and patient safety. The publication offered practical actions to shift the culture, such as conducting a fatigue-risk assessment, involving associates in work schedule designs, and developing and implementing a fatigue-management plan. Additionally, organizations can use data to monitor associates fatigue risk based on absenteeism and injury rate trends.
2. Operationalize fatigue reduction measures within the organization.
As health care leaders, we can use policies to support workplace culture and change behaviors when it comes to fatigue. Evidence-based strategies can decrease safety risks associated with fatigue. For example, implementing standardized scheduling guidelines for consecutive work hours and days is a key reduction measure. The American Nurses Association recommends that registered nurses should not exceed 40 hours of professional nursing in a seven-day period.
A second key reduction measure is to create shift rotation breaks to allow for rest (i.e., 48 hours between night-to-day rotations to allow for adequate rest).
Another key fatigue reduction effort is to ensure that all members of the nursing staff take allotted breaks, which might include napping in some organizations. Leadership must provide nurses with at least 30 minutes in which they are relieved of all patient care responsibilities, including mobile care communication devices.
Lastly, minimizing the use of overtime and leveraging a float pool and per diem staff for filling vacancies is an organizational measure for reducing fatigue.
3. Promote fatigue self-management through preventative strategies.
Registered nurses are role models who should practice healthy behaviors for fatigue self-management. According to the Agency for Healthcare Research and Quality, most adults require 7.5 to 8.5 hours of sleep per night. Without this amount, people can experience issues in cognitive performance. Nurses should minimize sleep loss and develop habits that support their 24-hour internal clock of sleep/wake cycles.
Additionally, the National Institute for Occupational Safety and Health recommends improving sleep environments through controlling noise, light and temperature; planning for recovery and enough sleep; and avoiding overcommitments at home and work.
Arriving for work rested and alert and taking a meal and rest break during working hours are essential. Driving drowsy puts everyone at risk for serious accidents; thus, promoting a safe commute to and from work may mean using a ride-sharing service or public transportation
The consequences of fatigue impact everyone along the care journey. A collaborative commitment to increasing fatigue awareness, mitigation and management will improve the health and safety of patients and health care providers.
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