A recent study shows that fatigue has a cascading effect on workers that can lead to ill health, and in turn, an even greater decrease in productivity. It’s just the latest in a growing body of evidence on the impact of fatigue on workers. And, it reinforces ANA’s position that well-rested nurses and safe, effective patient care go hand in hand.

To help nurses make the case against working when fatigued, the ANA Board of Directors recently approved two companion position statements. One focuses on the employers’ responsibility to have adequate RN staffing systems, and to fairly compensate RNs to reflect their expertise and discourage their working excessive hours. The other focuses on the responsibility of nurses to determine whether they—or their colleagues—are too fatigued to work safely.

“It was important for ANA to look at both the nurse and the employer when addressing the issue of fatigue, because each has an ethical obligation to ensure safe patient care,” says Cheryl Peterson, MSN, RN, senior policy fellow in ANA’s Department of Nursing Practice and Policy.

Moreover, it’s important that both nurses and employers take the statements seriously and put them both into action.

Setting the stage
ANA historically has focused on ensuring the safety of nurses and patients by working to improve RNs’ working conditions. ANA worked nationally and with its state associations to raise awareness about mandatory overtime, which led to restrictions in some states through legislative and workplace measures.

“ANA now is addressing the significance of overtime in general and specifically the impact fatigue has on nurses and patient care,” says Susan Foley Pierce, PhD, RN, who co-chaired the fatigue workgroup of ANA’s Congress on Nursing Practice and Economics (CNPE), which developed the statements.

“We want individual nurses to monitor their own level of fatigue and to not work if they feel unsafe to practice,” says Pierce, a North Carolina Nurses Association member and now secretary of the ANA board. “We also want them to be able to stand up and express that concern to their employers without fearing retribution.”

ANA’s efforts to address fatigue were ramped up following the release of the November 2003 Institute of Medicine (IOM) document, Keeping Patients Safe: Transforming the Work Environment for Nurses.

The IOM pointed to evidence that working more than 12 hours in a 24-hour period or more than 60 hours in 7 days, rotating shifts, and having insufficient breaks led to: slowed reaction time, lapses of attention to detail, errors of omission, and compromised problem solving. The IOM document also served as the basis of a 2004 ANA House of Delegates resolution designed to win the commitment of RNs, employers, and other stakeholders to ensure that nurses’ work hours and patterns don’t extend beyond safe limits.

Over the years, researchers have looked at the connection between fatigue and work in many industries, with Ann E. Rogers, PhD, RN, FAAN, being a leader within the healthcare arena. In a 2004 study, she found that nurses who worked shifts lasting 12.5 hours or more were three times as likely to make a mistake. In that same study, she found that nurses routinely worked more than 40 hours a week and more than they originally planned on a daily basis.
Rogers strongly supports ANA’s dual statements.

The recommendations
Assuring Patient Safety: Registered Nurses’ Responsibility in All Roles and Settings to Guard Against Working When Fatigued offers several recommendations to practicing nurses and others. They include:

• RNs should consider the impact having multiple jobs has on their level of fatigue and ability to practice safely.
• RNs should continue to document unsafe staffing conditions.
• RNs should recognize that they may need to confront a colleague who is too fatigued to work.
• Collective action—involving individual nurses, professionalfessional associations, and others—should be taken, if necessary, to change the current work culture and recognize a nurse’s right and obligation to refuse an assignment if impaired by fatigue.

“We can’t prevent nurses from working more hours or holding down jobs at two different facilities,” says Mary Jean Schumann, MSN, MBA, RN, CPNP, director of ANA’s practice and policy department. “We also can’t assure that nurses are well rested, because people have complicated lives outside of work. But sometimes working extra is a matter of personal decision making. We don’t want nurses working if they’ve crossed that line into fatigue and make a mistake that affects patient care.”

“We also realize that some nurses can’t afford to raise a family on a single nurse salary. So it becomes part of the social obligation for employers to ensure that nurses aren’t in situations—forced or voluntary—to work when fatigued to make ends meet financially.”

The recommendations in its companion document, Assuring Patient Safety: The Employers’ Role in Promoting Healthy Nursing Work Hours for Registered Nurses in All Roles and Settings, clearly are targeted to employers and healthcare agencies.

Among those recommendations are:

• RN salaries must appropriately reflect their education, training, experience, and value to the system, so that nurses don’t have to seek supplemental income through overtime and other voluntary practices that contribute to worker fatigue.
• Employers should institute policies permitting the free exchange of ideas about staffing and quality without staff fearing retribution.
• Schools of nursing and facility-based educators should include curricula on the impact that fatigue and certain work schedules have on the safety of patients and nurses.

Both of these documents are available at ANA’s website, www.nursingworld.org, and are being distributed to other groups widely.

“It is the employer’s responsibility to have enough staff to cover patient care, not the individual nurse’s responsibility,” says Rogers, a Maryland Nurses Association member. “Yet staff nurses often feel obligated to patients to continue working past their scheduled shift, or because they want to support their colleagues who may be stuck working short-staffed.”

“Our work culture needs to be shifted, so that it’s acceptable to say no to extra work.”

CNPE workgroup co-chairperson Jeanne Surdo, BSN, MA, RN, says that the dual statements are saying to both nurses and employers that it’s time to “wake up and smell the coffee” and see the link between fatigue and patient safety.

“Nurses often love their overtime, and there are a lot of opportunities for them to work extra because hospitals are operating with fewer staff,” says Surdo, a Minnesota Nurses Association member. “It’s time for hospital employers to step up to the plate and have adequate staffing plans in place, which is possible through better forecasting of admissions and other patient flow patterns.”

“It also falls on the nurses and to the public, who need to understand that it’s not in their best interest to have the same nurse caring for them for 16 hours or more a day.”

Other efforts
Other nursing groups—including the Association of periOperative Registered Nurses (AORN) and the American Association of Critical-Care Nurses (AACN), both ANA organizational affiliates—also have addressed the issue of long work hours.

“AORN knows there is a nursing shortage and that healthcare organizations have to find a way to take care of patients who are coming to their facilities,” says Cathy Kleiner, PhD, RN, AORN vice-president of research and nursing resources. “We also know that when nurses are fatigued, they make more errors. So it was important to develop a document that will influence practice and make it safer for nurses and patients.”

The AORN Position Statement on Safe Work/On-Call Practices states that perioperative RNs shouldn’t be required to work in direct patient care for more than 12 consecutive hours in a 24-hour period and not more than 60 hours in 7 days. It also notes that off-duty nurses should have an uninterrupted 8-hour sleep cycle, and that the number of on-call shifts assigned in a 7-day period be coordinated with the number of sustained work hours and adequate recuperation periods. (For more information, go to www.aorn.org.)

M. Dave Hanson, MSN, RN, CCRN, CNS, AACN president-elect and also a member of the CNPE fatigue workgroup, says that AACN published its statement against mandatory overtime in 2001 and has been working with its members to address fatigue—which he calls a “huge and sometimes unspoken issue.” (For more information, go to www.aacn.org.)

“Fatigue can be an outcome of an unhealthy work environment, which in some cases has been created by healthcare systems,” says Hanson, an Indiana State Nurses Association member. “We must create a healthcare environment in which nurses aren’t put—or put themselves—in unsafe situations because they’re fatigued.”

“The dual approach from ANA—position statements on employer and individual nurse responsibility—helps demonstrate that nurses want patients to make it through the healthcare system safely.”

Susan Trossman, RN, is the senior reporter in ANA’s Communications Department.