Limit nursing shifts to protect patients

Fatigue has impact for patients, workers

Nurses should be restricted from working more than 12 hours at time or more than 60 hours per week to prevent "error-producing fatigue," an Institute of Medicine (IOM) panel recommended in a comprehensive review of the nursing work environment. Health care should learn from other "safety-sensitive" industries such as aviation and nuclear energy to establish limits on nurse scheduling, the panel said. For example, hospitals should staff their intensive care units with one nurse for every two patients and should involve nurses in setting scheduling patterns, the panel said.

"We just have not paid attention to designing systems to make sure that errors don’t reach the patient and instead have assumed that we are superhuman," says Donald M. Steinwachs, PhD, chair of the panel and chair of the department of health policy and management at the Bloomberg School of Public Health of Johns Hopkins University in Baltimore. "This report addresses what a health care organization has to do in order to really tackle the issue of patient safety," he says.

The issues of shift work, mandatory overtime, and fatigue-related errors in health care have recently been receiving more attention. Four states — California, New Jersey, Maine, and Oregon — prohibit mandatory overtime for nurses. California has adopted minimum staffing levels. The National Institute of Occupational Safety and Health (NIOSH) recently announced a study of shift work and its impact on worker safety.

Recommendations from the IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses, will be presented to Congress and shared with the Joint Commission on Accreditation of Health Care Organizations. But Steinwachs says the panel was speaking directly to hospitals with many of its major points. "This report will provide [hospital CEOs] with a blueprint for how to address patient safety on the organizational level," he says, and notes that the panel recommended adding staffing information on federal hospital report cards. "If someone says, We can’t afford to do this,’ You have to ask the question also, Can you afford not to do this?’" he says.

Long shifts similar to intoxication

"Prolonged wakefulness" can be as harmful as intoxication in its effect on work performance, according to studies cited by the panel. Yet overtime and extended shifts are commonplace in nursing. The report cites 2001 surveys by the Washington, DC-based American Nurses Association (ANA) and the Aliso Viejo, CA-based American Association of Critical Care Nurses, in which 60% of nurses reported being required to work mandatory overtime. Many nurses also take advantage of incentives to work voluntary overtime.

After 12 hours, you commit more errors’

"We’ve got enough information to know that after 12 hours, we are putting patients at higher risk, and no nurse wants to do that," says Ada Sue Hinshaw, PhD, RN, vice chair of the IOM panel and dean of the School of Nursing at the University of Michigan in Ann Arbor. "We didn’t address the issue of whether it’s voluntary overtime or mandatory overtime because either way the effects are the same. After 12 hours, you commit more errors." In other industries, studies have shown that errors increase after nine hours, double after 12 hours, and triple after 16 hours, the report said.

The report lends credibility to concerns nurses have raised, says Cheryl Peterson, RN, a senior policy fellow at the ANA. "Nurses have been talking about issues of mandatory overtime, or feeling tired and overworked, for many years," she says. "Our hope is that it creates as much of a momentum for change as we saw from the 1999 [IOM patient safety] report, To Err Is Human." The ANA also will need to educate members about fatigue and voluntary overtime, she says. "We ultimately must put patient safety first," she says.

NIOSH study will examine impact of fatigue

More information will soon be available on the impact of sleep, fatigue, and work schedules on worker safety. Researchers from NIOSH have proposed to survey 1,000 nurses from 10 hospitals. The nurses will keep a sleep and activity diary and an overtime diary. They also will complete questionnaires that ask about cardiovascular, musculoskeletal, and gastrointestinal symptoms, lifestyle issues, their workplace safety climate, and other risk factors. Researchers also will review work schedules from the hospitals.

"We need nurses in the workplace to be alert and healthy and optimally functioning," says Claire Caruso, PhD, RN, a research health scientist at NIOSH in Cincinnati who is heading the study. "We don’t know much about how [nurses’] work schedules affect their alertness and their health. Patterns of work schedules can vary tremendously," she explains.

How can you address work scheduling in the midst of a nursing shortage? The panel concluded that a poor work environment contributes to turnover — and thus to staffing problems and shortages. Hospitals need fundamental changes in their culture, giving nurses a greater voice in hospital leadership, involving front-line nurses in decision making, and promoting a "culture of safety," the IOM panel said. They also advised hospitals to spend more money on education and training and to rely less on contract or agency nurses. Some duties, such as transporting patients or retrieving medications, could be shifted to other workers to allow nurses to spend more time on clinical tasks, the panel said.

"If we could build a stronger, more productive work environment, it would not only [improve] patient safety, it could quite possibly be a substantial savings," Hinshaw says. "Cutting turnover alone would make a big difference. "Most of the work environment and culture of safety recommendations essentially assume that every person in the organization will be responsible for and on the alert for safety issues," she says.

Supporting front-line care providers

"A great deal of the care for patients will be decentralized to the front-line staff who care for patients. While we need strong leadership, particularly nursing leadership, at every level of the organization, we need it to be patient-centered and supportive of the front-line individuals so they can make quick decisions."

That sort of environment can be found today in magnet hospitals, where turnover is low and some hospitals actually have a waiting list for nursing applicants, Hinshaw says. New nurses will be looking for that kind of environment, Hinshaw says, noting that the American Association of Colleges of Nursing has developed a brochure on characteristics of a good working environment.

The panel urged hospitals not to take a "piecemeal" approach to the recommendations on the work environment, stating that "none of these recommendations is less important.’"

(Editor’s note: A copy of the IOM report can be found at