Assuring patient safety: registered nurses' responsibility in all roles and settings to guard against working when fatigued.

Originated By: ANA Congress on Nursing Practice and Economics Adopted By: ANA Board of Directors

Purpose:

This position statement articulates the American Nurses Association's position with regard to patient (1) safety and the registered nurse's responsibility (2) in the evaluation of his/ her degree of fatigue when deciding to accept or reject any assignment extending beyond their regularly scheduled work day or week, including a mandatory or voluntary overtime assignment.

ANA Position:

The American Nurses Association (ANA) takes the position that, regardless of the number of hours worked, each registered nurse has an ethical responsibility to carefully consider her/ his level of fatigue when deciding whether to accept any assignment extending beyond the regularly scheduled work day or week, including a mandatory or voluntary overtime assignment.

It is intended that this position statement be used in conjunction with ANA's position statement, Assuring Patient Safety: The Employers' Role in Promoting Healthy Work Hours for Registered Nurses in All Roles and Settings, charging employers with the responsibility of establishing staffing systems and policies that maintain appropriate staffing levels and recognize the registered nurse's right and obligation to refuse an assignment if impaired by fatigue.

History/previous position statements: Foundational to this position statement is the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001a), hereinafter referred to as The Code. The Code serves as a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.

In addition, the ANA 2005 House of Delegates considered a report, Implications of Fatigue on Patient and Nurse Safety. This report provides the policy basis for this position statement. There are two other relevant ANA position statements that have informed this position statement. The first is The Right to Accept or Reject an Assignment (ANA, 1995). The ANA believes that nurses should reject any assignment that puts patients or themselves in serious, immediate jeopardy. The second ANA position statement, Opposition to Mandatory Overtime (ANA, 2001b), expresses opposition to the use of mandatory overtime as a staffing tool.

Supportive material:

The Code serves as a foundational resource for registered nurses and the profession when examining the dilemma that nurses face when having to make a decision about whether to accept a mandatory or voluntary overtime assignment. The Code makes explicit the primary goals, values, and obligations of the profession. The ANA believes that The Code is nonnegotiable and that each nurse has an obligation to uphold and adhere to its ethical precepts (ANA, 1994, ANA, 2001a and ANA, 2006).

Four provisions within The Code (ANA, 2001a) speak to the obligation of registered nurses to act in a manner that is consistent with maintaining patient and personal safety. First, the second provision of The Code states that "the nurse's primary commitment is to the patient, whether an individual, family, group, or community" (ANA, 2001a, p. 9). Noting that nurses can be placed in a position where a conflict of interest arises--such as one that arises when a registered nurse must decide whether to accept an overtime assignment--nurses "must examine the conflicts arising between their own personal and professional values, the values and interests of others who are also responsible for patient care and health care decisions as well as those of patients" (ANA, 2001a, p. 10). In the end, the nurse must strive to resolve such conflicts in ways that ensure patient safety, guard the patient's best interests and preserve the professional integrity of the nurse.

The third provision, "the nurse promotes, advocates for, and strives to protect the health, safety and rights of the patient" (ANA, 2001a, p. 12) is also relevant to consider. The Interpretive Statements for this provision states that:

   The nurse's primary commitment is to the
   health, well-being, and safety of the patient
   across the life span and in all settings in
   which health care needs are addressed. As
   an advocate for the patient, the nurse must be
   alert to and take appropriate action regarding
   any instances of incompetent, unethical,
   illegal or impaired practice by any member
   of the health care team or the health care
   system or any action on the part of others
   that places the rights or best interests of the
   patient in jeopardy. (p. 14)

Given this, the nurse's obligation extends not only to his/her own decision making around the potential impairment that may result from fatigue, but also to that of other members of the health care team. The ultimate evaluation must be whether the decision to continue to work when fatigued places at risk the interests of the patient.

Provision #4: "The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care" (ANA, 2001a, p. 16) recognizes that individual nurses bear the primary responsibility for the nursing care that their patients receive and are individually and collectively accountable for their own practices. In addition, nurses are accountable for judgments made and actions taken in the course of nursing practice irrespective of health care organizations' policies or providers' directives.

Finally, provision #6 states: "The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action" (ANA, 2001a, p. 20). This provision states that all nurses have a responsibility to create, maintain, and contribute to environments that support nurses in fulfilling their ethical obligations. It also states that acquiescing and accepting unsafe or inappropriate practices, even if the individual does not participate in the specific practice, is equivalent to condoning unsafe practice.

While the issues of the impact of prolonged work hours on the safe performance of individuals has been part of the literature for many years, the health care system has lagged behind in recognizing that fatigued health care providers endanger not only themselves, but also the patients for whom they care. Recent research and reports have begun to focus on the impact of fatigue on patient and worker safety.

Findings from a landmark study, The Working Hours of Hospital Staff Nurses and Patient Safety (Rogers, Hwang, Scott, Aiken & Dinges, 2004), clearly demonstrates that the hours a registered nurse worked were related to the errors and near misses made by that registered nurse in patient care. This research also found that the likelihood of making an error was three times higher when nurses worked shifts lasting 12.5 hours or more. The authors recognized that long, unpredictable hours suggest a link between poor working conditions and threats to patient safety.

Findings from the Nurses Worklife and Health Study (Trinkoff, Geiger-Brown, Brady, Lipscomb, & Muntaner, 2006), a longitudinal study of 2,273 registered nurse respondents, suggest that of the one-third who worked more than 40 hours per week, 19 percent worked 41 to 49 hours, 8 percent worked 50 to 59 hours, and 6 percent worked 60 or more hours. Looking specifically at those registered nurse respondents with more than one job, the researchers found that these nurses were "more likely to work 12 or more hours per day (37% versus 28% of the total) and 50 or more hours per week (24% versus 14% of the total)" (p. 65). In addition, registered nurses who work more than one job were more likely to work stretches of consecutive days without breaks, work with insufficient rest, and to work during scheduled time off.

Following a substantial review of the literature, the Institute of Medicine (IOM) Committee on Work Environment for Nurses and Patient Safety found strong evidence to link prolonged work hours and fatigue and its affect on worker performance (IOM, 2004). This effect includes slowed reaction time, lapses of attention to detail, errors of omission, compromised problem solving, reduced motivation, and decreased energy for successful completion of required tasks. This led to the following recommendation:

   To reduce error-producing fatigue, state
   regulatory bodies should prohibit nursing
   staff from providing patient care in any
   combination of scheduled shifts, mandatory
   overtime, or voluntary overtime in excess of
   12 hours in any given 24-hour period and in
   excess of 60 hours per 7-day period. (IOM,
   2004, p. 236)

Trinkoff et al. found that 17% of staff nurses, 4% of managers and 7% of advanced practice registered nurses regularly exceeded the IOM's recommendation.

Another study, Extended Work Shifts and the Risk of Motor Vehicle Crashes Among Interns (Barger et al., 2005) focused on medical interns and demonstrated the potential of impact of long hours and fatigue on motor vehicle crashes, near-miss incidents, and incidents involving involuntary sleeping. Findings from this report showed that extended-duration work shifts posed a serious and preventable safety hazard for the physicians and other motorists, apart from increasing the risk of failures of attention and serious medical errors.

Additional concerns have been raised by registered nurses about the implications of refusing to accept an overtime assignment for fear of being accused of patient abandonment. ANA (1995) strongly believes that nurses should reject any assignment that puts patients or themselves in serious, immediate jeopardy and, thus, does not constitute patient abandonment. A registered nurse who is fatigued could very well be placing both the patient and herself/himself in serious, immediate jeopardy. Furthermore, the National Council of State Boards of Nursing (NSCBN) passed a resolution at its 2001 annual meeting stating that:

   The NCSBN promotes safe and effective
   nursing practice in the interest of protecting
   public health and welfare. Therefore, the
   National Council recognizes the professional
   responsibility of nurses to accept or decline
   overtime assignments based on their self-assessment
   of ability to provide safe care. (K.
   Hellquist, personal communication, April 6,
   2006.)

Recommendations:

As a means of implementing this position statement, the ANA recommends the following eight activities:

Practicing Nurses:

1. Registered nurses should consider the impact that multiple jobs have on their level of fatigue and ability to practice safely.

2. Registered nurses should continue to document unsafe staffing conditions.

3. Registered nurses should recognize that they may have to confront a nursing colleague who is too fatigued to work.

4. Collective action--involving individual nurses, colleagues, professional associations and other stakeholders--is necessary to change the current work culture to one that recognizes the impact of fatigue on patient safety and accepts the registered nurse's right and obligation to refuse an assignment if impaired by fatigue.

Employers/Heath Care Agencies:

5. Recognizing that employers also have a significant role in addressing the issue of fatigue, this position statement should always be used in conjunction with ANA's position statement, Assuring Patient Safety: The Employers' Role in Promoting Healthy Nursing Work Hours for Registered Nurses in All Roles and Settings.

Education:

6. Schools of nursing should address decision-making within their curriculum related to the impact that fatigue and the habitual neglecting to take meal and rest breaks has on patient safety and harm to self and peers.

7. A consumer education campaign is necessary to educate the public about its expectations of registered nurses; articulate the need for continuity of care with an understanding of fatigue; and strongly advocate that appropriate care requires rest.

Research:

8. Continue research efforts to gain additional knowledge about the impact of shiftwork and overall hours worked on patient and personal safety.

Summary:

The American Nurses Association (ANA) takes the position that, regardless of the number of hours worked, all registered nurses have an ethical responsibility to carefully consider their level of fatigue when deciding whether to accept any assignment extending beyond their regularly scheduled work day or week, including a mandatory or voluntary overtime assignment

References

(1.) ANA in it's Nursing Social Policy Statement "recognized the importance of clearly identifying the recipients of professional nursing care, be they individuals, groups, families, communities, or populations." The Social Policy Statement notes that "to date, professional nursing has not yet selected ... the term best depicting the healthy or ill recipients of professional nursing care." Therefore, the term "patient" was selected to be used "throughout the text to provide consistency and brevity" ... and asks "readers to keep in mind the breadth of nursing practice always includes the various recipients of care" be they the individual, the group, the family, the community or the population." Nursing's Social Policy Statement (2nd edition) 2003. American Nurses Association, p. v & 22.

(2.) While ANA's membership is limited to registered nurses, it is our belief that all health professionals have a similar obligation related to patient safety and monitoring fatigue.

American Nurses Association. (1994). Ethics and human rights position statement: The nonnegotiable nature of the ANA Code for Nurses with Interpretive Statements.

Retrieved March 30, 2006 from http://www.nursingworld.org/readroom/position/ethics/etcode.htm

American Nurses Association. (1995). The right to accept or reject an assignment. Retrieved March 30, 2006 from http://www.nursingworld.org/readroom/position/workplac/wkassign.htm

American Nurses Association. (2001a). Code of Ethics for Nurses with Interpretive Statements. Washington, DC: Author.

American Nurses Association. (2001b). Opposition to mandatory overtime. Retrieved March 30, 2006 from http://www.nursingworld.org/readroom/position/workplac/wkassign.htm

American Nurses Association. (2003). Nursing's social policy statement. (2nd ed.). Washington, DC: Author.

American Nurses Association, House of Delegates. (2005). Implications of fatigue on patient safety and nurse safety. (Available from the American Nurses Association, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910)

American Nurses Association, House of Delegates. (2006). Workplace abuse and harassment of nurses. (Available from the American Nurses Association, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910)

Barger, L. K., Cade, B. E., Ayas, N. T., Cronin, J. W., Rosner, B., Speizer, F. E., et al. (2005). Extended work shifts and the risk of motor vehicle crashes among interns. New England Journal of Medicine, 352(2), 125-134.

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: Author.

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

Trinkoff, A., Geiger-Brown, J., Brady, B., Lipscomb, J., & Muntaner, C. (2006). How long and how much are nurses now working? American Journal of Nursing, 106(4), 60-71.