566884
research-article2015
JAPXXX10.1177/1078390314566884Journal of the American Psychiatric Nurses AssociationRepique and Matthew
Letter to the Editor
Nurse Fatigue: A Contemporary and Pressing Workforce Issue for Psychiatric Nurses
To the Editor: Fatigue is a complex phenomenon characterized by a subjective feeling of tiredness, both physical and mental, that can be experienced by nurses in the workplace (Registered Nurses’ Association of Ontario, 2011). In today’s physically demanding and safety-sensitive industries, including health care, fatigue requires attention because it affects job productivity and workforce health and can ultimately negatively affect patient safety (Institute of Medicine, 2004). Given the seemingly gloomy outlook and the often volatile economic climate in health care, the business case for addressing occupational fatigue is compelling: fatigue-related losses in productivity cost employers in the United States an estimated $54 million annually, or about $1,967 per employee (Rosekind et al., 2010). Occupational fatigue due to extended hours of shift (12 consecutive hours or more) is a potent risk factor for health care workers and hospital staff nurses (Institute of Medicine, 2004; Geiger-Brown & Lipscomb, 2010; Geiger-Brown & Trinkoff, 2010b; Trinkoff et al., 2011). The U.S. Occupational Safety and Health Administration (n.d.) has warned that any unusual work shifts extending beyond a consecutive 8-hour work period can cause myriad physical, emotional, and mental health problems. However, despite a growing body of research evidence linking occupational fatigue to long work hours, the tradition of extended shift work and 12-hour shifts among hospital nurses continues. The mainstreaming of 12-hour shifts among hospital nurses in the United States is one of the greatest barriers to moving away from the practice (Rogers, Weing-Ting, Scott, Aiken, & Dinges, 2004; Geiger-Brown & Trinkoff, 2010a; Lothschuetz-Montgomery & Geiger-Brown, 2010). The Institute of Medicine (2004) published a landmark report calling for the transformation of the hospital work environments across the United States, solidifying the role of the frontline nurse at the center of patient safety. One of the overarching themes of the report is the common work practices of extended work hours and shift work among nurses and health care workers and their link to work-related fatigue and the impact on patient and staff safety. In December 2011, The Joint Commission (TJC)
Journal of the American Psychiatric Nurses Association 2015, Vol. 21(1) 19–21 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314566884 jap.sagepub.com
issued its sentinel event alert on health care worker fatigue and the dangers of long work hours and their effects on patient safety. Particularly with regard to nursing personnel, TJC cited the overwhelming evidence linking shift work and long work hours to increased risks to personal safety and well-being. The report called on health care organizations to implement evidence-based actions to help mitigate the risks of occupational fatigue. Yet despite the recurring national agenda calling for the creation of healthy and safe work environments for nurses, the prevailing work culture at the majority of hospitals in the United States today remains practice permissive to long work hours and extended shifts. In November 2014, the American Nurses Association (ANA) published a revised position statement titled Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of Registered Nurses and Employers to Reduce Risks. The updated evidence-based position statement acknowledged the scope of the effect of fatigue on patient safety, nurse job performance, and the individual health of nurses, as well as its implications for public safety. Once again, the statement called for action from employers and nurses to address the urgent workforce issue of nurse fatigue. But this time, the ANA clearly emphasized the shared responsibility employers and nurses bear in unequivocally addressing work-related fatigue by partnering together to promote a culture of health and safety in the workplace. Nurses are asked to be responsible for managing the effects of fatigue on their professional and personal lives. Employers are asked to monitor staffing, the design of work schedules, and the degree to which fatigue affects the incidence of errors in the workplace. Individual nurses are responsible for ensuring that they are rested before their shifts, that breaks are taken, and that they refrain from working too many hours or too many days consecutively. Employers are responsible and accountable for ensuring work schedules that support nurses’ ability to rest and return to work rested. Although the ANA statement does not recommend eliminating 12-hour shifts (a controversial topic often discussed by some members of the American Psychiatric Nurses Association via its online Member Bridge), the numerous research studies cited in the statement support
Downloaded from jap.sagepub.com by guest on November 18, 2015
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Journal of the American Psychiatric Nurses Association 21(1)
the move from 12-hour to 8-hour shifts. In addition, the statement recommends to both nurses and employers that the total number of hours worked not exceed 40 in 7 days. It is critically important that the ongoing debate regarding work-hour limits in nursing be focused on the ethical responsibilities shared by both nurses and employers, because central to the issue is the overwhelming evidence that clearly points to the detrimental effects of fatigue on nurses’ health, patient safety, and quality of care. As psychiatric and mental health nurses, we assist and support our mental health patients and consumers in achieving wellness to help them through their recovery by advocating healthy behaviors such as proper self-care, work-life balance, adequate rest and sleep, daily exercise, and optimal nutrition. But how many of us are role modeling or applying these behaviors in our own lives and are actually practicing what we teach? To date, there is still a dearth of research on nurse fatigue specific to psychiatric and mental health nursing practice. Arguably, the demonstrated negative effects of fatigue on nurses’ decision making, communication, insight, and learning can also affect core areas of psychiatric nursing practice, such as restraint and seclusion reduction, interpersonal relationships with patients, therapeutic communications, and managing compassionate reactions under stress. According to Van Sant and Patterson (2013), the interpersonal connection between psychiatric nurses and their patients is known to promote healing. Thus, it is reasonable to expect that fatigue will have a limiting effect on the ability of psychiatric nurses to maintain therapeutic interpersonal relationships with patients and erode their ability to maintain resilience when working with traumatized individuals. Psychiatric nursing clinicians, administrators, educators, and researchers have an important professional responsibility to disseminate the evidence and support the message of the ANA’s 2014 position statement on nurse fatigue. Specifically, to create a healthier and safer work environment for psychiatric nurses in hospitals, we urge psychiatric nurse leaders and hospital administrators to (a) support reasonable schedules for psychiatric staff nurses, (b) implement creative alternatives to immediately eliminate the practice of mandatory overtime, (c) advocate for adequate psychiatric nurse staffing, (d) implement nurse fatigue management and harm reduction programs in their facilities, and (e) support and encourage nurses taking meal and rest breaks. Individual responsibility is one of the core underpinnings of professional nursing’s contract with society, and nurses are expected to provide care while remaining accountable for their own health (American Nurses Association, 2010). For this reason, we encourage psychiatric nurse educators responsible for the education and training of our future psychiatric nurses to use the ANA’s position statement to facilitate dialogue with their nursing students regarding
the ethical quandaries that may confront nurses in the real world, such as when one is practicing while fatigued. More often than not, this is a common dilemma in today’s busy and potentially fatigue-inducing hospital work environments, given the inherent expectation that professional nurses self-regulate on the job. That is, they are responsible for monitoring and determining their own physical limits and fatigue levels at work to ensure and maintain safe practice. Finally, psychiatric nurse researchers can make significant contributions to the body of nursing knowledge on nurse staffing and fatigue research, in particular by examining the impact of long work hours and shift work on the skills of psychiatric nurses in establishing meaningful and therapeutic interpersonal relationship with patients and also by studying the effects of nurse fatigue in the creation of recovery-oriented and trauma-focused treatment environments in our inpatient psychiatric settings. The 2014 ANA position statement on nurse fatigue is a wake-up call for psychiatric nurses, and we strongly recommend that every member of the American Psychiatric Nurses Association, in various settings and levels of practice, will use it as a springboard to launch grassroots efforts for change. Alas, nurse fatigue is real. It is a complex professional workforce issue for frontline psychiatric nurses that we must collectively address with urgency because the evidence is increasingly clear. The present dangers of fatigue to our health and safety—and those of our patients and the public—are serious and far too many to ignore. Renee John R. Repique, MS, RN, NEA-BC, Friends Hospital, Philadelphia, PA, USA Joanne M. Matthew, MS, RN, PMHCNS-BC, Butler Hospital, Providence, RI, USA Authors’ Note The authors served on the steering committee of the 2014 ANA Professional Issues Panel on Nurse Fatigue, which led the effort to update the ANA’s position statement. The views and opinions expressed are those of the authors and do not necessarily reflect the position of ANA, Friends Hospital or of Butler Hospital. To read the ANA position statement, go to http://www.nursing world.org/MainMenuCategories/WorkplaceSafety/HealthyWork-Environment/Work-Environment/NurseFatigue
Author Roles Both authors were involved in the preparation and writing of the manuscript.
References American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: NursesBooks.
Downloaded from jap.sagepub.com by guest on November 18, 2015
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Repique and Matthew American Nurses Association. (2014). Addressing nurse fatigue to promote safety and health: Joint responsibilities of registered nurses and employers to reduce risks. Retrieved from http://www.nursingworld.org/MainMenuCategories/ WorkplaceSafety/Healthy-Work-Environment/WorkEnvironment/NurseFatigue/Addressing-Nurse-FatigueANA-Position-Statement.pdf Geiger-Brown, J., & Lipscomb, J. (2010). The health care work environment and adverse health and safety consequences for nurses. Annual Review of Nursing Research, 28, 191-231. Geiger-Brown, J., & Trinkoff, A. M. (2010a). Is it time to pull the plug on 12-hour shifts? Part 1. The evidence. Journal of Nursing Administration, 40(3), 100-102. Geiger-Brown, J., & Trinkoff, A. M. (2010b). Is it time to pull the plug on 12-hour shifts? Part 3. Harm reduction strategies if keeping 12-hour shifts. Journal of Nursing Administration, 40(9), 357-359. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press. Lothschuetz-Montgomery, K., & Geiger-Brown, J. (2010). Is it time to pull the plug on 12-hour shifts? Part 2. Barriers to change and executive leadership strategies. Journal of Nursing Administration, 40(4), 147-149.
Occupational Safety and Health Administration. (n.d.). Frequently asked questions: Extended unusual work shifts. Retrieved from https://www.osha.gov/OshDoc/data_ Hurricane_Facts/faq_longhours.html Registered Nurses’ Association of Ontario. (2011). Preventing and mitigating nurse fatigue in health care: Healthy work environments best practice guideline. Toronto, Canada: Registered Nurses’ Association of Ontario. Rogers, A. E., Weing-Ting, H., Scott, L., Aiken, L., & Dinges, D. F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212. Rosekind, M. R., Gregory, K. B., Mallis, M. M., Brandt, S. L., Seal, B., & Lerner, D. (2010). The cost of poor sleep: Workplace productivity loss and associated costs. Journal of Occupational and Environmental Medicine, 52(1), 91-98. The Joint Commission. (2011). Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety. Retrieved from http://www.jointcommission.org/sea_issue_48/ Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), 1-8. Van Sant, J. E., & Patterson, B. J. (2013). Getting in and getting out whole: Nurse and patient connections in the psychiatric setting. Issues in Mental health Nursing, 31, 36-45.
Downloaded from jap.sagepub.com by guest on November 18, 2015
research-article2015
JAPXXX10.1177/1078390314566884Journal of the American Psychiatric Nurses AssociationRepique and Matthew
Letter to the Editor
Nurse Fatigue: A Contemporary and Pressing Workforce Issue for Psychiatric Nurses
To the Editor: Fatigue is a complex phenomenon characterized by a subjective feeling of tiredness, both physical and mental, that can be experienced by nurses in the workplace (Registered Nurses’ Association of Ontario, 2011). In today’s physically demanding and safety-sensitive industries, including health care, fatigue requires attention because it affects job productivity and workforce health and can ultimately negatively affect patient safety (Institute of Medicine, 2004). Given the seemingly gloomy outlook and the often volatile economic climate in health care, the business case for addressing occupational fatigue is compelling: fatigue-related losses in productivity cost employers in the United States an estimated $54 million annually, or about $1,967 per employee (Rosekind et al., 2010). Occupational fatigue due to extended hours of shift (12 consecutive hours or more) is a potent risk factor for health care workers and hospital staff nurses (Institute of Medicine, 2004; Geiger-Brown & Lipscomb, 2010; Geiger-Brown & Trinkoff, 2010b; Trinkoff et al., 2011). The U.S. Occupational Safety and Health Administration (n.d.) has warned that any unusual work shifts extending beyond a consecutive 8-hour work period can cause myriad physical, emotional, and mental health problems. However, despite a growing body of research evidence linking occupational fatigue to long work hours, the tradition of extended shift work and 12-hour shifts among hospital nurses continues. The mainstreaming of 12-hour shifts among hospital nurses in the United States is one of the greatest barriers to moving away from the practice (Rogers, Weing-Ting, Scott, Aiken, & Dinges, 2004; Geiger-Brown & Trinkoff, 2010a; Lothschuetz-Montgomery & Geiger-Brown, 2010). The Institute of Medicine (2004) published a landmark report calling for the transformation of the hospital work environments across the United States, solidifying the role of the frontline nurse at the center of patient safety. One of the overarching themes of the report is the common work practices of extended work hours and shift work among nurses and health care workers and their link to work-related fatigue and the impact on patient and staff safety. In December 2011, The Joint Commission (TJC)
Journal of the American Psychiatric Nurses Association 2015, Vol. 21(1) 19–21 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314566884 jap.sagepub.com
issued its sentinel event alert on health care worker fatigue and the dangers of long work hours and their effects on patient safety. Particularly with regard to nursing personnel, TJC cited the overwhelming evidence linking shift work and long work hours to increased risks to personal safety and well-being. The report called on health care organizations to implement evidence-based actions to help mitigate the risks of occupational fatigue. Yet despite the recurring national agenda calling for the creation of healthy and safe work environments for nurses, the prevailing work culture at the majority of hospitals in the United States today remains practice permissive to long work hours and extended shifts. In November 2014, the American Nurses Association (ANA) published a revised position statement titled Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of Registered Nurses and Employers to Reduce Risks. The updated evidence-based position statement acknowledged the scope of the effect of fatigue on patient safety, nurse job performance, and the individual health of nurses, as well as its implications for public safety. Once again, the statement called for action from employers and nurses to address the urgent workforce issue of nurse fatigue. But this time, the ANA clearly emphasized the shared responsibility employers and nurses bear in unequivocally addressing work-related fatigue by partnering together to promote a culture of health and safety in the workplace. Nurses are asked to be responsible for managing the effects of fatigue on their professional and personal lives. Employers are asked to monitor staffing, the design of work schedules, and the degree to which fatigue affects the incidence of errors in the workplace. Individual nurses are responsible for ensuring that they are rested before their shifts, that breaks are taken, and that they refrain from working too many hours or too many days consecutively. Employers are responsible and accountable for ensuring work schedules that support nurses’ ability to rest and return to work rested. Although the ANA statement does not recommend eliminating 12-hour shifts (a controversial topic often discussed by some members of the American Psychiatric Nurses Association via its online Member Bridge), the numerous research studies cited in the statement support
Downloaded from jap.sagepub.com by guest on November 18, 2015
20
Journal of the American Psychiatric Nurses Association 21(1)
the move from 12-hour to 8-hour shifts. In addition, the statement recommends to both nurses and employers that the total number of hours worked not exceed 40 in 7 days. It is critically important that the ongoing debate regarding work-hour limits in nursing be focused on the ethical responsibilities shared by both nurses and employers, because central to the issue is the overwhelming evidence that clearly points to the detrimental effects of fatigue on nurses’ health, patient safety, and quality of care. As psychiatric and mental health nurses, we assist and support our mental health patients and consumers in achieving wellness to help them through their recovery by advocating healthy behaviors such as proper self-care, work-life balance, adequate rest and sleep, daily exercise, and optimal nutrition. But how many of us are role modeling or applying these behaviors in our own lives and are actually practicing what we teach? To date, there is still a dearth of research on nurse fatigue specific to psychiatric and mental health nursing practice. Arguably, the demonstrated negative effects of fatigue on nurses’ decision making, communication, insight, and learning can also affect core areas of psychiatric nursing practice, such as restraint and seclusion reduction, interpersonal relationships with patients, therapeutic communications, and managing compassionate reactions under stress. According to Van Sant and Patterson (2013), the interpersonal connection between psychiatric nurses and their patients is known to promote healing. Thus, it is reasonable to expect that fatigue will have a limiting effect on the ability of psychiatric nurses to maintain therapeutic interpersonal relationships with patients and erode their ability to maintain resilience when working with traumatized individuals. Psychiatric nursing clinicians, administrators, educators, and researchers have an important professional responsibility to disseminate the evidence and support the message of the ANA’s 2014 position statement on nurse fatigue. Specifically, to create a healthier and safer work environment for psychiatric nurses in hospitals, we urge psychiatric nurse leaders and hospital administrators to (a) support reasonable schedules for psychiatric staff nurses, (b) implement creative alternatives to immediately eliminate the practice of mandatory overtime, (c) advocate for adequate psychiatric nurse staffing, (d) implement nurse fatigue management and harm reduction programs in their facilities, and (e) support and encourage nurses taking meal and rest breaks. Individual responsibility is one of the core underpinnings of professional nursing’s contract with society, and nurses are expected to provide care while remaining accountable for their own health (American Nurses Association, 2010). For this reason, we encourage psychiatric nurse educators responsible for the education and training of our future psychiatric nurses to use the ANA’s position statement to facilitate dialogue with their nursing students regarding
the ethical quandaries that may confront nurses in the real world, such as when one is practicing while fatigued. More often than not, this is a common dilemma in today’s busy and potentially fatigue-inducing hospital work environments, given the inherent expectation that professional nurses self-regulate on the job. That is, they are responsible for monitoring and determining their own physical limits and fatigue levels at work to ensure and maintain safe practice. Finally, psychiatric nurse researchers can make significant contributions to the body of nursing knowledge on nurse staffing and fatigue research, in particular by examining the impact of long work hours and shift work on the skills of psychiatric nurses in establishing meaningful and therapeutic interpersonal relationship with patients and also by studying the effects of nurse fatigue in the creation of recovery-oriented and trauma-focused treatment environments in our inpatient psychiatric settings. The 2014 ANA position statement on nurse fatigue is a wake-up call for psychiatric nurses, and we strongly recommend that every member of the American Psychiatric Nurses Association, in various settings and levels of practice, will use it as a springboard to launch grassroots efforts for change. Alas, nurse fatigue is real. It is a complex professional workforce issue for frontline psychiatric nurses that we must collectively address with urgency because the evidence is increasingly clear. The present dangers of fatigue to our health and safety—and those of our patients and the public—are serious and far too many to ignore. Renee John R. Repique, MS, RN, NEA-BC, Friends Hospital, Philadelphia, PA, USA Joanne M. Matthew, MS, RN, PMHCNS-BC, Butler Hospital, Providence, RI, USA Authors’ Note The authors served on the steering committee of the 2014 ANA Professional Issues Panel on Nurse Fatigue, which led the effort to update the ANA’s position statement. The views and opinions expressed are those of the authors and do not necessarily reflect the position of ANA, Friends Hospital or of Butler Hospital. To read the ANA position statement, go to http://www.nursing world.org/MainMenuCategories/WorkplaceSafety/HealthyWork-Environment/Work-Environment/NurseFatigue
Author Roles Both authors were involved in the preparation and writing of the manuscript.
References American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: NursesBooks.
Downloaded from jap.sagepub.com by guest on November 18, 2015
21
Repique and Matthew American Nurses Association. (2014). Addressing nurse fatigue to promote safety and health: Joint responsibilities of registered nurses and employers to reduce risks. Retrieved from http://www.nursingworld.org/MainMenuCategories/ WorkplaceSafety/Healthy-Work-Environment/WorkEnvironment/NurseFatigue/Addressing-Nurse-FatigueANA-Position-Statement.pdf Geiger-Brown, J., & Lipscomb, J. (2010). The health care work environment and adverse health and safety consequences for nurses. Annual Review of Nursing Research, 28, 191-231. Geiger-Brown, J., & Trinkoff, A. M. (2010a). Is it time to pull the plug on 12-hour shifts? Part 1. The evidence. Journal of Nursing Administration, 40(3), 100-102. Geiger-Brown, J., & Trinkoff, A. M. (2010b). Is it time to pull the plug on 12-hour shifts? Part 3. Harm reduction strategies if keeping 12-hour shifts. Journal of Nursing Administration, 40(9), 357-359. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press. Lothschuetz-Montgomery, K., & Geiger-Brown, J. (2010). Is it time to pull the plug on 12-hour shifts? Part 2. Barriers to change and executive leadership strategies. Journal of Nursing Administration, 40(4), 147-149.
Occupational Safety and Health Administration. (n.d.). Frequently asked questions: Extended unusual work shifts. Retrieved from https://www.osha.gov/OshDoc/data_ Hurricane_Facts/faq_longhours.html Registered Nurses’ Association of Ontario. (2011). Preventing and mitigating nurse fatigue in health care: Healthy work environments best practice guideline. Toronto, Canada: Registered Nurses’ Association of Ontario. Rogers, A. E., Weing-Ting, H., Scott, L., Aiken, L., & Dinges, D. F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212. Rosekind, M. R., Gregory, K. B., Mallis, M. M., Brandt, S. L., Seal, B., & Lerner, D. (2010). The cost of poor sleep: Workplace productivity loss and associated costs. Journal of Occupational and Environmental Medicine, 52(1), 91-98. The Joint Commission. (2011). Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety. Retrieved from http://www.jointcommission.org/sea_issue_48/ Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), 1-8. Van Sant, J. E., & Patterson, B. J. (2013). Getting in and getting out whole: Nurse and patient connections in the psychiatric setting. Issues in Mental health Nursing, 31, 36-45.
Downloaded from jap.sagepub.com by guest on November 18, 2015
