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President's Message

Keeping Individuals with Kidney Disease Safe: Raising Awareness of the Effects of Nurse Fatigue
by ANNA President Sandra Bodin

The effects of fatigue on worker performance are well documented in the literature. In recent years, increased attention has been given specifically to the effects of fatigue on nurses and the ensuing impact on patient safety that results. The evidence is clear: there is a well-documented relationship between nurse fatigue and an increased risk of nurse error leading to a concern for patient care and safety.

In a landmark study of working hours of nurses and patient safety, researchers found the risks of making an error were significantly increased when work shifts were longer than 12 hours, when nurses worked overtime, or when they worked more than 40 hours per week. The authors noted that nurses working on specialized units, such as dialysis, are often required to be available to work extra hours on call in addition to working their regularly scheduled shifts (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). Any hour worked after 8 hours is when the most errors occur; and a nurse working longer than 12 hours triples his or her chance of committing an error during patient care.

Sometimes nurses find it difficult to balance personal finances with their ethical obligation to provide safe care. Nurses who work two or more jobs to increase their income may be jeopardizing the safety of patients. As nurses, we must be sensitive to these economics; if we put the public at risk for personal gain and more money, we will eventually lose the trust of the public. There is enough guilt to go around; both employers and nurses play a role in this issue.

Factors Contributing to Fatigue
Factors contributing to nurse fatigue can be personal or employment related and include:

Overtime hours, either by choice or as required
Total number of hours worked in a week
Rotating shifts
Chronic short staffing
Working while sick
Working extra jobs
Personal health and wellness
Age
Caregiver responsibilities at home.

Nurse fatigue has been linked to adverse effects that may result in one or more of these negative outcomes:

Memory lapses
Loss of concentration
Loss of focus
Delayed reaction time in decision making in nursing tasks
Inability to process information
Decreased productivity
Decreased problem-solving ability
Increased risk for medication errors, patient injury, and adverse patient outcomes
Loss of communication skills
Loss of empathy
Co-worker relationships suffer
Diminished ability to detect subtle changes in a patient.�

In addition, the adverse effects of fatigue on the nurse are decreased job satisfaction, reduced motivation and increased risk for accident and injury, addictive behavior, obesity, depression, and illness.

Ways to Reduce Fatigue
To reduce nurse fatigue and its effects, nurses and employers need to create a culture that encourages nurses not to work when they are fatigued. We should learn from other industries, like the airlines, nuclear power plants, and the military, which recognize the effect of fatigue in the workplace and consider fatigue factors when scheduling staff. Behaviors that discourage working while fatigued are:

Limiting the number of hours worked in a week based on your personal performance
Taking meal breaks
Arranging for power naps at work when working long hours or night shifts
Promoting healthy work behaviors
Practicing healthy habits in areas of nutrition and exercise
Limiting alcohol and caffeine
Developing good sleep habits
Getting adequate rest
Taking your vacation time.

A Responsibility to Practice Safely
As nurses, we have an ethical responsibility to practice safely. Unfortunately, we are rarely able to accurately evaluate our own self for fatigue. Meanwhile, employers have an ethical responsibility to provide safe and quality nursing care for their patients – therefore, nurses and employers must take action when they know a fatigued nurse is providing nursing care (Kleiner & Brady, 2007).

Several fundamental changes must occur in order to create work environments for nurses that are most conducive to patient safety. The Institute of Medicine (IOM) not only encourages regulation that would limit the number of hours that a nurse can work in a day and in one week, but also recognizes that changes are required in the beliefs and practices of nurses (IOM, 2004). Typically, nurses feel guilty when they cannot work overtime because they know their colleagues may be left working short in a patient care area. Instead, nurses should feel guilty if they do work the overtime when fatigued, particularly if it will be more than 12 hours, because they are endangering patients (Hinshaw, 2006).

Our world is not perfect, and sometimes nurses end up working long hours or in fatigued conditions. Awareness of the results of fatigue on patient care and knowledge of actions we can take to decrease the effects of fatigue are necessary for nephrology nurses to practice safely.

References
Hinshaw, A. (2006). Keeping patients safe: A collaboration among nurse administrators and researchers. Nursing Administration Quarterly, 30(4), 309-320.

Institute of Medicine (IOM). (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: National Academies Press.

Kleiner, C., & Brady, M. (2007, November). Principles of fatigue that impact safe nursing practice: The work of the Nursing Organizations Alliance (NOA) Fatigue Taskforce. Presented at the NOA Fall Summit, Milwaukee, WI.

Rogers, A., Hwang, W., Scott, L., Aiken, L., & Dinges, D. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212.

Sandra Bodin, MA, RN, CNN
ANNA President