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How nurse executives can help tired nurses


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by Rebecca Hendren, for HealthLeaders Media, May 17, 2011

Working long hours can compromise patient safety, yet 12-hour shifts are the norm in nursing. Nurses love the flexibility offered by 12-hour shifts and healthcare facilities find them easier to schedule and manage. But research shows incidents of medical errors increase after nurses work more than eight hours.

Nurse fatigue and cognitive overload are topics of increasing concern to the healthcare industry, but simply doing away with 12-hour shifts is not a realistic option. They are extremely popular with staff and management alike.

Twelve-hour shifts allow nurses to complete a full-time job in only three days, a big benefit for a female-dominated profession as it allows more time at home. Another important consideration is that 35% of all nurses are the sole wage earner for their families. Twelve-hour shifts give nurses the chance to earn extra money through overtime or picking up shifts at other organizations.

"So many nurses are single head of household and are the primary wage earners for their families," says Cole Edmonson, DNP, RN, FACHE, NEA-BC, vice president of patient care services/CNO at Texas Health Presbyterian Hospital Dallas. "It explains a lot about why many nurses have multiple jobs, which could also explain why they feel the need to have overtime or 12-hour shifts or volunteer to take holiday and weekend shifts to be able to maximize income."

Statistics are unavailable for how many nurses work two or more jobs. Edmonson estimates 20% to 35% of nurses at his facility report secondary jobs, either at another facility in the system or through agency work. Extra work on top of regularly scheduled full-time hours increases the risk of nurse fatigue.
Attempting to limit such a popular practice is impossible and any talk of doing away with 12-hour shifts is met with vehement protest. In the ongoing debate over 12-hour staffing, nurse fatigue, and patient safety, chief nursing officers must set the tone for the organization.

What is known as complexity compression—the ever-increasing demands on direct care nurses today—is amplified by physical and mental fatigue. Talking about fatigue, stress, and overload must become acceptable and nurses should receive education about ways to mitigate them.

"It starts with the chief nurse at the organization setting expectations about healthy life/work balance, raising awareness of fatigue-related errors, talking about fitness for duty, and really helping nurses to understand how they may put themselves and patients at risk if they come to work not fit for duty," says Edmonson.

He points out that hospitals and healthcare systems have virtually no way of knowing whether a nurse has slept in the last 12 hours before a shift. Which is why the Texas Board of Nursing, Texas Nurses Association, and Texas Organization of Nurse Executives have come together to promote a "fitness for duty" concept that puts the onus on individual nurses to be the gatekeepers for themselves and their fitness for work that day. Fit for duty means they have had enough sleep and that they are mentally and physically prepared for their shift.

"As nurse leaders, we need to give direct care nurses permission to say no," says Edmonson. "Often in order for hospitals to provide staffing, they must continually call nurses asking, 'Can you pick up an extra shift, or can you come in early?' We're trying to make sure we are staffing safely for patients, but we may sometimes unintentionally put nurses in difficult situations. The CNO needs to make sure nurses who work in the facility know they will be supported if they actually do say no to the supervisor or manager or charge nurse or peer calling them to pick up an extra shift if they are not fit for duty."

Edmonson says it's his belief that staff are better at the healthcare facility if they are better at home, so his organization focuses on "life-work balance" (not work-life balance) and emphasizes the importance of nurses concentrating on mental, physical, and spiritual refreshment on time away from work. In fact, Edmonson's organization sponsors retreats for staff and leadership that focus on maintaining a healthy balance as a professional nurse.

"Organizations need to have a healthy work environment philosophy," says Edmonson, which encompasses "taking a hard look at all the policies and practices in the system that might incentivize nurses to come to work ill or when they are not fit for duty."

Edmonson's organization took a look at policies and procedures that sent the wrong message to staff. For example, in one organization, the wording regarding "sleeping on the job" prohibitions was changed to ensure it didn't unintentionally discourage nurses from taking a brief nap during breaks or lunch periods—something that is encouraged if nurses feel they need it.

Many organizations reward nurses for perfect work attendance, which simply results in nurses coming to work sick, compromising patient care, and transmitting infections to patients and other staff.

"There are programs and pay practices across the nation that give perfect attendance bonuses, merits with an attendance factor, or do not allow nurses to participate in certain career enhancement programs if you don't have perfect attendance," says Edmonson. "Those are the types of criteria that we as an organization and as a healthcare industry need to be able to look at and see whether they are truly meeting the intent of the program or whether we are actually incentivizing people for unhealthy behavior."

Nurse executives should look at their organization's policies and remove these types of incentives to ensure we do not penalize nurses for not coming to work when they are ill or not fit for duty.

"We need to make sure that we are a caring and compassionate organization toward the people that we expect to be caring and compassionate toward the patients," says Edmonson.