It’s a challenging situation, a catch-22 if you like: nursing is a 24/7 profession but sleep loss, spending extended time awake, working and sleeping at suboptimal times in the circadian body clock cycle, and mental and physical workload lead to fatigue, which can degrade patient care and increase the risk of clinical error, workplace injuries, and drowsy driving accidents, as well as nursing turnover and healthcare costs.

So, what’s the solution?

This is a question the Safer Nursing 24/7 Project has spent the last three years attempting to answer. Funded primarily by the Health Research Council, with additional funding from the New Zealand Lottery Grants Board, McCutchan Trust, and Massey University, the aim of the Project was to evaluate work patterns and fatigue-related outcomes among New Zealand nurses, and then propose new solutions to manage fatigue and shift work among hospital-based nurses in New Zealand.

In December, the Project team released a Draft National Code of Practice for managing fatigue and shift work in hospital-based nursing for public consultation. This draft code was informed by international research and a national survey of DHB-based nurses working at least 30 hours per week.

“It’s a new approach which moves the focus from managing the length of shifts to managing the risk of fatigue across different shifts,” says Project Manager Dr Karyn O’Keeffe.  “We know the traditional approach for managing fatigue and shift work – limiting maximum work hours and minimum breaks – does not adequately address the causes of fatigue.”

Instead, the draft code encourages DHBs to develop a fatigue and shift work management system (FSMS) to identify hazards, assess risks, mitigate fatigue and monitor fatigue.

“It’s not just about looking at the roster, or just looking at the shift design,” says Dr O’Keeffe. “It’s a systems-based approach that’s used in other industries, such as aviation.”

The code is based on a number of fatigue risk management principles, including, ‘Fatigue is inevitable in 24/7 work. It cannot be eliminated; it must be managed’ and ‘Fatigue risk management must be a shared responsibility [between DHBs and individual nurses] because fatigue is affected by activities outside of work as well as by work demands’.

The survey which informed the code provides the first comprehensive overview of the work patterns and fatigue levels of DHB nurses working in the six target practice areas of child health, emergency and trauma, in-patient mental health, intensive care/cardiac care, medical and surgical.

With regard to patient safety, 30.3% of nurses surveyed recalled a fatigue-related clinical error in the last six months. Emergency and trauma (33.6%), surgical (32.8%) and medical (32.6%) nurses were more likely to report clinical errors than intensive care/cardiac care nurses (22.1%).

In relation to nurses’ health and safety, more than half (51.84%) of the nurses surveyed reported usual sleep of less than seven hours, i.e., less than is recommended for maintaining health and wellbeing for adults. Nurses surveyed were also 1.5 times more likely than the general population to report currently having a sleep problem that has lasted at least six months.

In otherwise healthy adults, short-term consequences of sleep disruption include increased stress responsivity, somatic pain, reduced quality of life, emotional distress and mood disorders, and cognitive, memory, and performance deficits.

Long-term consequences include increased risk of hypertension, dyslipidemia, cardiovascular disease, weight-related issues, metabolic syndrome, type 2 diabetes mellitus, and colorectal cancer.

A quarter (26%) of the nurses surveyed reported some chance of dozing in a car while stopped for a few minutes in traffic, and more than half (55.72%) reported never or rarely getting enough sleep. Both these factors have been shown to independently increase the risk of being the driver in a motor vehicle accident.

Shift workers are more likely than dayworkers to experience fatigue, says Dr O’Keeffe, because their work patterns are more likely to produce sleep loss, extended time awake, and working and sleeping at suboptimal times in the circadian body clock cycle.

“When it comes to shift work, the problem is we are trying to sleep and work at times that are not aligned with our body clock, which leads to shorter sleep and poorer functioning.”

Shift length, she says, is just one of many factors to consider when assessing whether a roster is safe. “For example, a nurse who is working 12-hour shifts might be in a stable, supportive work environment where fatigue is managed well, or they might be in an unpredictable environment with lots of demands. What we need to manage is the safety risk associated with different work patterns.”

Dr O’Keeffe points out that the researchers are still learning about the causes of the poorer health statistics. Many factors come into play, including the type of shift, the length of time a person has worked shifts, their lifestyle and their sleep patterns. Most of the health risks are also shared by people who aren’t getting enough sleep, so a good start to reducing long-term risks is trying for seven to nine hours’ quality sleep every 24 hours.

Dr O’Keeffe says there are four questions shift workers can ask themselves to help judge the risk of being impaired by fatigue. The first is ‘how much sleep have I had in the last couple of days?’ Less than seven hours’ sleep increases our risk of fatigue.

Secondly, ‘how long have I been awake?’. “Our pressure for sleep increases the longer we have been awake. After enough time our functioning starts to decrease.” Anything over a 16-hour gap between bedtimes puts nurses at risk of making poor decisions and having reduced ability to make big-picture judgement calls and communicate effectively.

The third question to ask is ‘what time of day is it?’ Nurses working during the low circadian point of 3 to 5am are at a greater risk of fatigue.

Lastly, nurses should ask themselves, ‘how well have I been sleeping recently?’ If they haven’t been sleeping well, they are more likely to be impaired.

If the National Code of Practice is adopted by DHBs, nurses can look forward to more processes and strategies being put in place to better manage fatigue.

“We are now at the end of the first project, so our next steps are to seek funding for more work in this area,” says Dr O’Keeffe. The team is in discussions with a few DHBs to see if they can pilot the fatigue and shift work management system outlined in the Code of Practice, to see what works well and what will need modification.

“We’re really excited to see where this leads us.”

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