WNA and Wisconsin Nursing Coalition issue working draft on nurse fatigue and patient safety research and recommendations.

The Wisconsin Nurses Association, along with the members of the Wisconsin Nursing Coalition (WNC), have issued a paper regarding nurse fatigue and patient safety. This document is a follow-up to the WNC's Annual Retreat where the legal topic of a nurse being criminalized for making a medication error and how fatigue was a primary factor in making the error was discussed. The purpose of the WNC paper, Nurse Fatigue and Patient Safety Research and Recommendations (working paper May 2007), is to increase awareness for the nurses in Wisconsin about the impact of nurse fatigue and patient safety. The paper includes a brief review of the literature from expert researchers regarding the topic of fatigue and recommendations. The content includes information on the physiological and cognitive dynamics of performing nursing work when sleep deprived. The paper also provides a relationship between our work and our Nursing Code of Ethics. The Wisconsin Nursing Coalition is a semi-formal group comprised of nursing organizations in Wisconsin that include educators, specialty practice, state agency representatives and unions. WNC meets every two months to review and discuss the broader topics and issues that impact nursing practice. Read on to review the document or to print the two page pages go to: www.wisconsinnurses.orghttp://www.wisconsinnurses.org/content.asp?id=497

Nurse Fatigue and Patient Safety Research and Recommendations

The purpose of this document is to alert you, the practicing nurse, to the dangers of working when fatigued, and to give you strategies to consider.

What the Experts are Saying

According to Ann Rogers, PhD, RN, FAAN, leading researcher and primary author of "The Working Hours of Hospital Staff Nurses and Patient Safety" (Health Affairs 23, no. 4 (2004): 202-212), there are three major causes of fatigue: insufficient sleep, nonstandard work hours, and number of hours awake. In her study, Rogers reports:

* RN's average 6.8 hours of sleep on workdays and 8.2 hours of sleep on days off (the ranges were from 0 to 18 hours). Average hours needed for an adequate amount of sleep should be 8 hours. This means that nurses are not getting enough sleep.

* Nonstandard work hours and extended shifts (12 hours or more) are not recommended in industries where workers spend the majority of their shift on their feet. This reflects the work standards for nurses who provide direct patient care.

* The number of hours awake correlate to an increase in the probability of making an error. A nurse who has been awake over 19 hours performs at the equivalent of a blood alcohol level of 0.05 percent. After 24 hours awake, the nurse performs at the equivalent of a blood alcohol level of 0.10 percent.

State and federal regulations do not address restricting the number of hours a nurse may work.

The 2004 report from the Institute of Medicine of the National Academies entitled "Keeping Patients Safe: Transforming the Work Environment for Nurses" recommends: "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).

In December 2006, the American Nurses Association (ANA) Congress on Nursing Practice and Economics issued a position paper entitled: "Assuring Patient Safety: Registered Nurses Responsibility in All Roles and Settings to Guard Against Working When Fatigued" (http://www.nursingworld.org). The ANA Congress is a formal, 58-member nursing group made up of staff nurses, middle managers, administrators, researchers, and policy-makers along with representatives from other nursing specialty organizations. The Congress's position paper states that nurses should consider limiting hours of work because of the impact nurse fatigue can have on patient safety. Furthermore, the Congress identified eight recommendations reflecting the shared responsibility of all members of the nursing profession, including the individual nurse, the nurse administrator, the institution administrator and the educator, to support policies and practices that address minimizing nurse fatigue. The specific recommendations from the ANA Congress are as follows:

Recommendations for Practicing Nurses

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

2. RNs should continue to document unsafe staffing conditions.

3. RN's should recognize that they may have to confront a nursing colleague who is too fatigued to work

4. Collective action (collaboration)--involving individual nurses, colleagues, professional associations and other stake accepts the RN's right and obligation to refuse an assignment if impaired by fatigue.

Recommendations for Employers/Health Care Agencies

5. Recognize that employers also have a significant role in addressing the issue of fatigue.

Recommendations for Education

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

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

Recommendations for Research

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

Our Nursing Code of Ethics

As RNs, we have our "Code of Ethics for Nurses with Interpretive Statements" (ANA, 2001a). Four of the nine provisions in our "Code of Ethics" address our responsibilities to our patients and ourselves as professionals as they relate to assuring patient safety, reporting concerns and respecting our general health and well-being. These four provisions are:

* Provision 2. The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

* Provision 3. The nurse promotes, advocates for, and strives to protect the health, safety and rights 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. Holders--is necessary to change the current work culture to one that recognizes the impact of fatigue on patient safety and

* Provision 6. 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.

This document was prepared by members of the Wisconsin Nursing Coalition, May 24, 2007. Please send comments or questions to: [e-mail].