Nurse Fatigue Is Costly—and Costly to Fix

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Tired nurseIt’s no secret that a lot of nurses are seriously fatigued and that costly mistakes result.

But solutions are costly, too, which seems to be the reason not much is being done to lessen the problems.

Whether the fatigue is simply sleepiness during a given shift or during the work commute, or whether it’s a chronic weariness or outright burnout, lots of nurses are tired. More than a third report feeling burned out, according to a University of Pennsylvania study of 7,000 nurses published in the American Journal of Infection Control.

Nursing shifts in hospitals

Ultimately, staffing levels are one of the chief issues. They’re a major reason that nurses’ schedules fluctuate wildly, which plays havoc with sleep patterns. Staffing levels also are the reason that some nurses have to take on less-familiar roles on occasion to fill holes on the ever-varying duty rosters.

California is the only state that mandates minimum staff levels for nurses by law, although Massachusetts enacted a law governing intensive-care units in 2014.

The increasing predominance of 12-hour shifts also seems to be a factor in fatigue and resulting mistakes, although they greatly reduce the number of shift changes that challenge continuity at a hospital and lead to mistakes.

Safety issues in nursing

Mistakes are the problem. And the problem they cause is often infection.

The two most common are catheter-associated urinary tract infections and surgical site infections. The Pennsylvania study said the incidence of each increases the more a nurse has been diagnosed as burned out.

Those situations were quantified further in a landmark study of 393 nurses for the book “Patient Safety and Quality: An Evidence-Based Handbook for Nurses,” conducted and published in the early 2000s by the Agency for Healthcare Research and Quality.

In a chapter of that exhaustive study titled “The Effects of Nurse Fatigue and Sleepiness,” a survey found that nurses who slept significantly less than colleagues were more mistake-prone, at a rate translating to 0.34 events per day at a teaching hospital with 1,000 nurse shifts.

That study, led by Ann E. Rogers, also cited short-staffing and resultant stress. It said each increase of one patient above the optimum number (5.7) per nurse corresponded to one additional catheter-related infection per 1,000 patients.

Stress and burnout in nursing

Stress is among the causes of sleep deprivation — a significant deficit, one to four hours a week according to the Rogers-led study — among all workers, including nurses, who work overnight.

And nurses are sleepy. In the Rogers study, more than that said they actually fall asleep at work at least once a week, the highest incidence being 35.3 percent of nurses whose shift times and locations varied the most.

Sleeping at work isn’t necessarily bad. Full-blown napping, among the recommendations for combating fatigue formally presented in 2009 by the American Nurses Association, has become a significant trend when staffing allows. Naps of 15 minutes to three hours can make a significant difference, the Rogers report said. But staffing levels usually aren’t adequate to make nurses expendable for the naps.

And considering how often nurses don’t take breaks provided by law, often because they’re  intent on getting necessary work done — or, as a majority reports are often not allowed by supervisors to take them — it’s not surprising that on-site naps aren’t prevalent.

Solutions to nursing fatigue

In addition to breaks, the American Nurses Association’s official recommendations for dealing with nurse fatigue include limiting shifts to 12 hours and the workweek to 40; abolishing mandatory overtime; allowing nurses to decline assignments, based on fatigue; restricting consecutive night shifts for nurses who also work days; and providing sleep sites or transportation for workers too tired to drive.

Well-timed jolts of caffeine are readily available and often helpful.

But it’s helping one another that may matter most. A buddy system is becoming a more frequent tool as nurses team up to double-check one another’s data and other work.

Solutions are being proposed and tried.

With few states enacting staffing laws, the federal government has not come up with its own. The failure of a congressional bill, the Registered Nurse Safe-Staffing Act of 2013, was a serious blow to making reforms more widespread. The bill called for hospitals to have standing committees with a say in establishing optimum staffing and/or minimums. Nurses would make up 55 percent or more of these committees.

There were to be annual evaluations of the facility’s compliance, and daily postings of duty rosters. The Department of Health and Human Services would keep track of it all on a database. There were penalties for noncompliance. The duty rosters would specify how closely, or not, nurses’ qualifications matched their assignments. There would be public access to the rosters.

If the argument against the bill was expense, the bill argued back eloquently with its introduction:

“Registered nurses play a vital role in preventing patient care errors. A 2009 study found that sufficient staffing of critical care nurses can prevent adverse patient events, which can cost anywhere from $2.2 million to $13.2 million. By contrast, the nurse staffing costs in the study time period were only $1.36 million.”

“A 2012 study of Pennsylvania hospitals shows that by reducing nurse burnout, which is attributed in part to poor nurse staffing, those hospitals could prevent an estimated 4,160 infections with an associated savings of $41 million. That study also found that for each additional patient assigned to a registered nurse for care, there is an incidence of roughly one additional catheter-acquired urinary tract infection per 1,000 patients or 1,351 infections per year, costing those hospitals as much as $1.1 million annually.”

But the bill died in the House Health and Human Services Committee without a serious airing, and progress is not accelerating toward alleviating nurse fatigue and burnout.

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