CRNA Work Hours and Patient Safety

Healthcare professionals, including nurse anesthetists, often work variable and extended hours outside of regular daytime working hours.1,2 Nurse anesthetists and other healthcare professionals have the ethical and professional responsibility to be prepared to provide safe patient care. Facilities schedule staff to provide services 24 hours a day and healthcare professionals may prefer extended shifts in order to work fewer days, further highlighting the issue of safety consequences related to fatigue.3

Long and strenuous shifts, unpredictable caseloads, recurrent emergency calls, and/or night work limits opportunities for adequate rest and contributes to the onset of fatigue and poor sleep habits, which may impact a provider’s physical and mental health.4,5 A survey that sampled 325 nurse anesthetists across the United States revealed that eighty two percent of the respondents reported that they experienced fatigue during calls at least occasionally and more than two thirds experiencing physical and psychological symptoms when fatigued.6 Alarmingly, about 28 percent of the sample reported committing an error in patient care due to fatigue.6 It is apparent that fatigue is a concern for nurse anesthetists and other healthcare professionals and a critical patient safety issue.7 Team vigilance, periods of rest, and relief of providers unprepared for duty are important safety measures to mitigate the risks related to fatigue.

Impairment from Fatigue
Fatigue, even periodic sleep deprivation, may impair performance that results in patient safety lapses.6 Healthcare professionals who exhibit signs of fatigue have impaired language, retention of information, short-term memory, and motor skills, which can lead to more accidents and errors.7 Research has shown that accidents and errors are more likely to occur when an individual is fatigued, especially after working long hours. After nine consecutive hours of work, the risk for unintentional and preventable accidents increases exponentially with each subsequent hour worked, putting patients at risk for being harmed by medical errors.5 Such accidents can result in adverse events such as medication errors and improper sterile techniques that can harm patients.

Fatigue also contributes to elevated rates of workplace injuries. Needle-stick injuries are the most frequently reported injury in the healthcare setting and are usually due to carelessness from fatigue, particularly during night shifts.4 Another common error that results from fatigue is the improper donning and doffing of personal protective equipment.8 These events increase the risk of adverse health effects, such as the potential transmission of bloodborne pathogens.

SEE ALSO: Earn CE: The Importance of Sleep

Strategies for Patient Safety

The American Association of Nurse Anesthetists (AANA) is committed to promoting and promulgating patient safety strategies to prevent and reduce errors in healthcare. These considerations are detailed in the AANA document titled, Patient Safety: Fatigue, Sleep, and Work Schedule Effects. Nurse anesthetists and other healthcare professionals should be cognizant of the number of hours worked and the implications of those work patterns. Personal obligations, scheduling needs, and the commute to a job should be considered prior to accepting a position.

Consider single or multi-modal approaches to fatigue management on an individual basis. The following fatigue countermeasures may be helpful preventing or mitigating fatigue:

  • Naps: Naps are beneficial for many individuals and may minimize fatigue. Taking a prophylactic nap prior to beginning a shift is preferable; however, rest should be encouraged when symptoms of fatigue arise while on the job.5,9 During extended shifts, short naps of less than a half hour (i.e., power napping) may help maintain alertness and vigilance and are effective in preventing sleep inertia, a state of grogginess after an abrupt awakening.
  • Caffeine: Caffeine (e.g., coffee, tea, energy drinks, supplements) has been shown to improve alertness, but consumption should be managed as it may impact vigilance and deter the opportunities for adequate sleep.10 Caffeine consumption should be monitored, especially four to seven hours prior to sleep.5
  • Exercise: Regular exercise may play a role in managing fatigue. Rigorous exercise within three hours before sleep may adversely influence quality of sleep.5,10
  • Consistent sleep-wake patterns: Establishing a regular sleep-wake routine may help prevent issues with falling asleep and waking up. If possible, prevent altering bed and wake up times by more than an hour.5 Drastic changes in shifts may deter healthy sleep patterns and should be managed.
  • Recovery between shifts: Fatigue and sleepiness progresses when working consecutive extended shifts. The ability to recover from fatigue and rest between consecutive extended shifts is important for preventing fatigue on the job.11,12
  • Electronic devices: Electronic device use during periods of rest should be minimized to avoid possible distractions.
  • Bright lights: Artificial bright lights alter circadian rhythm timing of traditional sleep-wake periods enabling individuals to stay awake during typical periods of rest, especially for workers who frequently work night shifts. While exposure to bright light may improve vigilance and the ability to stay awake, it may inhibit the ability to initiate intended sleep.13,14
  • Medications: Medications have been approved by the U.S. Food and Drug Administration (FDA) for certain disorders related to sleep and fatigue (e.g., narcolepsy, shift work disorder).14-16 Individuals should be aware of the side effects (e.g., cardiovascular, neurological, psychomotor) of such medications, as they may impair individual health and performance.5,16,17 Seeking medical consultation for fatigue and sleep disorders can help prevent or manage these conditions.

Fatigue and sleep deprivation are professional and patient safety issues. Healthcare requires services at all hours of the day and the intensity of work varies based on setting, case load, and patient acuity. The consequences of fatigue have serious implications for patient safety and the overall wellness of healthcare professionals. Wellness is the foundation of safe practice and individuals should maintain familiarity with strategies that prevent and mitigate fatigue. In addition, team safety practices help reduce accidents and errors that occur as the result of fatigue. The AANA encourages nurse anesthetists and healthcare professionals to participate in the development of facility policies, team training and education regarding practices that promote safety. Managing fatigue has the potential to improve the quality of patient care and outcomes to spur excellence in clinical and professional practice.

References

1. Asaoka S, Aritake S, Komada Y, et al. Factors associated with shift work disorder in nurses working with rapid-rotation schedules in Japan: the nurses’ sleep health project. Chronobiology international. May 2013;30(4):628-636.

2. Boivin DB, Boudreau P. Impacts of shift work on sleep and circadian rhythms. Pathologie-biologie. Oct 2014;62(5):292-301.

3. Kronos Incorporated. Evidence Supports the Positive Impact of Automated Staff-Scheduling Technology in Healthcare. 2011; http://www.govhealthit.com/sites/govhealthit.com/files/resource-media/pdf/Evidence_Supports_Postive_Impact_of_Automated_Staff_Scheduling_Oct2011.pdf. Accessed March 17, 2015.

4. Keller SM. Effects of extended work shifts and shift work on patient safety, productivity, and employee health. AAOHN journal : official journal of the American Association of Occupational Health Nurses. Dec 2009;57(12):497-502; quiz 503-494.

5. Sinha A, Singh A, Tewari A. The fatigued anesthesiologist: A threat to patient safety? Journal of anaesthesiology, clinical pharmacology. Apr 2013;29(2):151-159.

6. Domen R, Connelly CD, Spence D. Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered nurse anesthetists: a national survey. AANA journal. Apr 2015;83(2):123-131.

7. Biddle C, Aker J. The National Study of Sleep-Related Behaviors of Nurse Anesthetists: Personal and Professional Implications. AANA journal. 2011;79(4):324-331.

8. Centers for Disease Control and Prevention. Preventing Worker Fatigue Among Ebola Healthcare Workers and Responders. http://www.cdc.gov/niosh/topics/ebola/pdfs/preventingworkerfatigueamongebolahcw122914.pdf. Accessed March 4, 2015.

9. Alspach G. Napping on the Night Shift: Slacker or Savior? 2009; http://ccn.aacnjournals.org/content/28/6/12.full. Accessed March 17, 2015.

10. Tewari A, Soliz J, Billota F, Garg S, Singh H. Does our sleep debt affect patients’ safety? Indian journal of anaesthesia. Jan 2011;55(1):12-17.

11. Scott LD, Arslanian-Engoren C, Engoren MC. Association of sleep and fatigue with decision regret among critical care nurses. American journal of critical care : an official publication, American Association of Critical-Care Nurses. Jan 2014;23(1):13-23.

12. Chen J, Davis KG, Daraiseh NM, Pan W, Davis LS. Fatigue and recovery in 12-hour dayshift hospital nurses. Journal of nursing management. Jul 2014;22(5):593-603.

13. Stimulants in models of shift work and shift work disorder. In: Wesensten NJ, ed. Sleep Deprivation, Stimulant Medications, and Cognition. 1 ed: Cambridge Medicine; 2012:108-115.

14. Wright KP, Jr., Bogan RK, Wyatt JK. Shift work and the assessment and management of shift work disorder (SWD). Sleep medicine reviews. Feb 2013;17(1):41-54.

15. Sherman BW, Strohl KP. Management of shift work sleep disorder: Alice in Wonderland redux? Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine. Oct 2004;46(10):1010-1012.

16. Rajaratnam SM, Howard ME, Grunstein RR. Sleep loss and circadian disruption in shift work: health burden and management. The Medical journal of Australia. Oct 21 2013;199(8):S11-15.

17. American Nurses Association. Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of Registered Nurses and Employers to Reduce Risks. 2014; http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/Work-Environment/NurseFatigue/Addressing-Nurse-Fatigue-ANA-Position-Statement.pdf. Accessed January 15, 2015.

 

Marlene R. McDowell is the public relations manager for the American Association of Nurse Anesthetists (AANA).

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