Fatigue and Hours of Work

Overview

Fatigue is an issue that crosses many disciplines, including health care, utilities, transportation, and education. It has attracted national attention as over-the-road truckers and medical residents were both recently in the news because of changes to the number of hours they can work. In both of these cases, recommendations have been made to reduce the number of sequential hours worked.

In the health care industry, an increasing amount of study and research has occurred that has helped to expand understanding of the impact of fatigue on outcomes due to shift length and/or number of days worked. Long hours and fatigue can impair judgment, put employees at risk for injury and patients at risk for errors. Hospitals are working to educate employees and to address the issue through appropriate, evidence-based methods.

Background

Researchers at the University of Pennsylvania, other academic settings and clinicians have begun to create a picture of the current situation. This allows hospitals to build practice on evidence. Research evidence to date:

• Errors and near errors are more likely to occur when nurses work 12 or more hours. (Rogers, et al, 2004
• While nurses work longer than their shift length 81% of the time, only 6% of the time is that a mandate. (Rogers, 2004) Nineteen percent of nurses work two or more jobs for multiple employers. (Trinkoff, et al, 2006 and Scott et al 2/2006)
• NIOSH reviewed 52 recently published studies across all industries relating to long work hours and found that deteriorating performance over 12-hour shifts was found only with work weeks longer than 40 hours. (April 2004)
• In other industries, studies have found no correlation between health effects and whether extended hours of work were required or voluntary. This suggests that the health impact is comparable, regardless of this distinction. (Trinkoff, et al, 2006)
• Nurses average 6.7 hours of sleep on the days that they work. (Scott, et al 2/2006)
• When nurses work overtime, the average amount of time worked over scheduled hours is 49 minutes. (Scott, et al 1/2006)

Organizations have made recommendations about shift length and fatigue. Some of the recommendations were developed based on the above data based in health care settings while other research was from occupations outside of health care.

The Institute of Medicine (IOM) in their 2004 report "Keeping Patients Safe” has recommended that nurses should not provide care in any combination of scheduled shifts, voluntary or mandatory overtime in excess of 12 hours in 24, and no more that 60 hours in a seven-day period. The report also discusses recovery time, but makes no recommendations.

The Joint Commission of Accreditation of HealthCare Organizations (JCAHO), a national organization that accredits hospitals, has recommended four simple strategies to minimize fatigue and its effects:

• Schedule work and on-call hours to reduce fatigue;
• Limit work hours;
• Identify tasks that should not be done by individuals on extended work hours; and
• Use safeguards to ensure that procedures are done correctly.

The American Nurses Association (ANA) has position statements for both employers and nurses relating to work hours and fatigue. These statements speak to rest and recuperation between shifts. The Wisconsin Nursing Consortium released a statement on hours of work and fatigue that is similar to the ANA position statements. Some states have rules regarding "rest time" between worked shifts. These rules expect 8, 10 or 12-hour breaks between shifts. Other industries (over-the-road-trucking and airline pilots) have limitations on time worked.

The Wisconsin Organization of Nurse Executives (W-ONE) has reviewed the research evidence and produced a white paper titled Nurse Scheduling and Fatigue in the Acute Care 24 Hour Setting.

WHA Position

The position of the Wisconsin Hospital Association on nurse work hours, shift length and fatigue is:

• Employers and nurses share responsibility to assure safe care is provided. This includes assuring that adequatenumber and mix of staff are present to provide care and that staff can be alert and vigilant in providing care
• Nurses and employers must monitor and manage hours worked, hours of recovery, number of sequential days at work, days off for recovery, shift length and total rest.
• Both patients and employees are at risk when employees work without adequate rest and while fatigued.
• An employer-only solution ignores the independence of nurses to hold multiple positions, to work in schedules that fit within lives and lifestyles, and also a nurse’s own responsibility to be rested when presenting for work.

Summary

Hours of work for nurses and all hospital workers are complicated by the 24 hour-a-day/seven day a week needs of patients, the physical nature of much of the work, on-call systems that allow emergent patients to be treated whenever necessary, preferences of nurses to work fewer days per week, the unpredictable census patterns in most facilities, and worker shortages, illness and absences from work. Nurses value control over schedules, the ability to flex hours up and down as needed, the ability to flex income up and down as needed, and caring safely for patients. Hospitals and employees bear joint responsibility to assure that despite all the complications of providing care 24/7, staff are rested, refreshed and safely providing that care.

Talking Points

• Hospitals recognize that this is a challenging time to begin a dialogue on fatigue as difficult economic times may lead employees to seek more hours (and pay) to meet changing personal and family financial needs.
• Hospitals are concerned that fatigued employees put themselves at risk. As an example, there is evidence that incidents, such as needle-stick injuries, increase when employees are fatigued.
• Hospitals are concerned that fatigued employees put patients at risk as evidence emerges that fatigue alters an employee’s ability to make sound decisions.
• This issue has perhaps always existed, but as research evidence grows, hospitals want to move to practices that are evidence-based. There is a growing body of research on fatigue, hours of work, and shift work that can help hospitals and employees work together to develop policies based on scientific-evidence in regards to number of hours worked.
• Working conditions are not the only factor blamed for fatigue. Inadequate rest due to family obligations (sick child or spouse), personal lifestyle or sleeping routines, working more than one job, or even signing up for excessive hours on the hospital work schedule all contribute to fatigue.
• As employers, we take our responsibility to address fatigue very seriously by stressing that employees take breaks, developing employee work schedules that do not require exceptionally long shifts, and allowing for adequate recovery between scheduled shifts.
• Education is a critical first step to address the issue. Hospitals are making every effort to make their employees aware of issue and are working with employees to develop appropriate responses to it
• Fatigue is an emerging issue. Solutions are being developed by collecting data at the worksite, reviewing the data with experts, and by working directly with employees. There are no hard and fast solutions or “quick fixes."