Working life

Reports highlight the dangers of nurse fatigue and burnout

Sanjay GuptaFebruary 1, 2015 – In recent months several health news outlets have run helpful pieces about dangerously high levels of fatigue and burnout among today’s hospital nurses. On September 19, 2014, an article on the Everyday Health website, credited to physician and CNN correspondent Sanjay Gupta, attributed the high current levels of burnout among U.S. nurses to demanding work schedules and insufficient staffing. On January 14, 2015, the Guardian (U.K.) ran a powerful first person account by an anonymous Accident & Emergency (A&E) nurse who was concerned that excessive workload was leading to “burnout and destruction” in that part of the National Health Service (NHS), including an exodus of senior nurses. And today, USA Today published a piece by Laura Ungar about promising new recommendations by the American Nurses Association (ANA) to reduce nurse fatigue, with a focus on ways to avoid the potentially deadly errors that studies link to the problem. These reports bring out different aspects of the fatigue issue, including causes, effects, and remedies. The USA Today and Everyday Health pieces do understate the importance of understaffing, the effects of which are laid out in distressing detail in the Guardian. But all of the items address the ongoing threats that fatigue and burnout pose to nurses and patients. We thank those responsible for these pieces.

Recovery time

I don’t know how I’m going to survive

If you make one little mistake, you have lives in your hands

Recovery time

Gupta’s piece on the Everyday Health site, “Why America’s Nurses Are Burning Out,” states that a “nursing shortage and long hours has led to high levels of burnout in nurses.” The report is framed by the story of Annette Tersigni, who left the bedside after just a few years because of long night shifts and her fear of making an error. The piece notes that a 2011 ANA survey found that three out of four nurses “cited the effects of stress and overwork as a top health concern,” which the ANA attributed to “a chronic nursing shortage.” The article says that work schedules and insufficient staffing are among the factors driving nurses from the profession, noting the common U.S. practice of working three 12-hour shifts per week–and research finding that nurses who worked shifts longer than nine hours were two-and-a-half times more likely to experience burnout. The piece quotes “study author Linda Aiken, PhD,” director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, as saying the study shows nurses are underestimating their own recovery time and that that three-day schedule may not be sustainable. But “Deborah Burger, RN” of the union National Nurses United suggests that most nurses could handle it with the right levels of support and staffing. “Eva Francis, MSN, RN, CCRN, a former nursing administrator,” also emphasizes the importance of staffing. The piece notes that a recent University of Akron study found that nurses who are driven mainly by a desire to help others, rather than enjoyment of the work, are more prone to burnout. Jill O’Hara, a “former nurse” from Hamburg, NY, who “left nursing” years ago and now operates a “holistic health consulting practice,” says that a “career nurse” can let work go at the end of the day, but a “calling” nurse takes it home. The piece also cites the study of Pennsylvania hospitals finding that worse nurse staffing and nursing burnout were linked to increased patient infections. O’Hara recommends that nursing students be taught the primary importance of self-care. Burger stresses the importance of regular breaks at work. And Tersigni, who “now works part-time at a local hospital, specializing in the health and well-being of other nurses,” has “founded Yoga Nursing, a stress-management program combining deep breathing, quick stretches, affirmations, and relaxation and meditation techniques”—which nurses can simultaneously teach to their patients.

This piece has a lot of helpful material, particularly in getting at the roots and effects of nursing fatigue and burnout. The piece’s focus on nursing experts and research is especially notable. And those experts are generally identified in ways that convey expertise, including in many cases their advanced credentials. It might have been helpful to make clearer that Aiken is a nurse and also that O’Hara and Tersigni are really still in nursing even though they are not giving direct care—nursing is a holistic health science, not just custodial tasks at the bedside. Unfortunately, the treatment of understaffing is fairly weak. To its credit, the piece cites staffing as a significant issue and mentions one piece of research showing that it harms patients. But it says nothing about better staffing in its section on what can be done to ease burnout. And it does not convey the prominence of the issue in nursing, including the battles over mandatory staffing ratios, forced overtime, and the increased use of non-nurse staff. Indeed, readers could come away thinking that the U.S. staffing situation is mainly a function of a shortage of available nurses, when in recent years the key has been the failure of decision-makers to fund enough nursing positions. Still, the piece includes a good deal of useful information.

I don’t know how I’m going to survive

The anonymous Guardian piece, one of a group of pieces about the U.K.’s “A&E crisis,” is “A&E nurse: am I on the road to burnout and destruction?” And the text echoes that sense of desperation. The nurse writer—whose gender is not stated—admits at the outset that because of the lack of mental health support for NHS staff, “I don’t know how I’m going to survive.” The nurse notes that the Royal College of Nursing says one way to resist “emotional and physical exhaustion” is to discuss feelings about work with friends and family. But the nurse says an honest recounting of the nurse’s day, in response to the nurse’s boyfriend’s query, might be:

Well, my first task of the day before I had time to eat breakfast was to respond to a cardiac arrest, performing chest compressions on an overweight patient; I broke out in a sweat that rendered my shower half an hour earlier useless. While this was going on, another patient was thrashing about on their trolley, confused, ripping off their monitoring, lashing out because they were recovering from a seizure. The 89-year-old lady next door needed the commode every five minutes because her dementia was causing her to forget that she’d just been on it. As I didn’t want to upset her further, I assisted her repeatedly. In between running from my post seizure patient to stop them falling off the trolley and harming themselves, and the 89-year-old lady, I had to treat a young girl who had taken a life threatening dose of heroin and drunk a considerable amount of alcohol. She was shouting profanities at me and threatening to kill someone, which in turn was upsetting the 89-year-old. I then found five minutes to eat my breakfast before returning to tell the family of my cardiac arrest that their husband, father and son had died at the age of 57. How was your day?” Unfortunately, this is never how I respond when I come home from work. I don’t expect someone else to have to live through the day I have just had. My response is usually: “I’ve had a busy day, where’s the wine?”

The nurse argues that the “ever-increasing” workload will lead to burnout for nurses, who are putting themselves, their patients, and their profession at risk. At the same time, there has been a “huge exodus” as senior A&E nurses retire. The new nurses naturally cannot do as much as the experienced nurses yet, and that “doubles” the workload. The nurse says that debriefing sessions and praise for effective handling of difficult situations would be helpful, but management offers little support: “They are unsympathetic and half of them still don’t know my name when I’ve worked in the department for two years.” The nurse closes by noting: “I try to remember that I am only human, accept that I work in a stressful environment and constantly remind myself that it’s probably not going to get any easier, so to just do what I can.”

This is a powerful portrait of an A&E setting that really does seem to be in crisis, and in particular of a nurse who seems to be coping with an unreasonable workload at the moment, but as the nurse acknowledges, may not be able to do so indefinitely. In this respect, the piece is reminiscent of an anonymous nurse’s account of understaffing published more than a decade ago in Reader’s Digest (sample line: “How much longer I can work like this, I just don’t know.”). The new article also conveys helpful information about the physical and psychological challenges of nursing today. And if most of the tasks described here may not sound especially complex, at least the note about chest compressions tells readers that nurses play a key role in saving lives. The nurse also includes some pointed advocacy directed at NHS decision-makers, which may help promote better staffing and management. The nurse might have been more specific about the threats posed to patients—such as the increased risks of missed care and death—but on the whole the piece is very effective.

If you make one little mistake, you have lives in your hands

The USA Today article “Nurses seek to reduce long hours and fatigue” focuses on a new policy and awareness campaign by the American Nurses Association. The piece quotes ANA President Pam Cipriano as saying she is optimistic the new recommendations will bring more attention to the issue.

Among [the recommendations] is that employers limit shifts to 12 hours or fewer and work weeks to 40 hours or fewer; eliminate mandatory overtime; keep consecutive night shifts to a minimum for nurses working both days and nights; and provide sleep rooms or transportation when nurses are too tired to drive. The group also says employers should give nurses the right to reject work assignments to prevent fatigue.

The ANA also reportedly says nurses should be sure they arrive at work well rested and take the breaks they need. Cipriano notes that “if a nurse is fatigued, it is possible that a mistake could be made or someone could forget to pass along an important fact, or the person could be more on edge” when dealing with patients. She also stresses that these “voluntary actions” are critical because (in the piece’s words) “national labor law only goes so far – requiring breaks after a certain number of hours, for example.” The piece refers to some relevant research, noting that a “steady stream of studies link fatigue to errors, increased risk-taking, declines in short-term memory and a reduced ability to learn.” A 2004 study in Health Affairs found that those who worked shifts of 12.5 hours or more were three times more likely to make an error. Traveling OR nurse John Kauchick says he has worked shifts of much longer than 12 hours, noting that truck drivers and airline pilots are not allowed to work when too tired, but managers tell nurses that long hours are “what you sign up for.” Kauchick says he has never made a nursing error because of fatigue, but he admits to “driving to work and missing my turn” because of it. At this point the piece notes that some nurses say the fatigue issue “got worse during the economic downturn, as hospitals across the nation laid off staff and depended more on nurses who remained, or contract nurses such as Kauchick.” Maine night-shift ICU nurse Lisa Oliver says that to prevent errors, nurses at her hospital use a “buddy system” to check each other’s work: “This is critical care. If you make one little mistake, you have lives in your hands.” KentuckyOne Health’s “Chief Nursing Officer” Velinda Block says that it’s important to (in the piece’s words) “let…nurses know not to take on too much work.” KentuckyOne has a pool of “flex nurses” who can work shifts in various settings when necessary to reduce the burdens on other nurses. The piece has photos of University of Louisville flex nurse Laura Breedlove in clinical settings, and in a short accompanying video, she recommends that nurses determine which shifts they are suited for, seek balance in their lives, and practice self-care. We also see her interact with a patient about pain management.

This report provides good information on a promising initiative from the ANA. It also includes some good quotes from the ANA president, direct care nurses, and a “chief nursing officer”—it’s always nice to let the public know they exist. Oliver’s statement about nurses holding lives in their hands is especially helpful. In addition, Breedlove’s video comments are sensible and her brief patient interaction is professional. The piece includes a couple critical notes about relevant management decision-making—refuting the notion that nurses “signed up for” dangerous fatigue and at least flagging the decisions to lay off nurses during the recession. But like the Everyday Health item, this report understates the importance of understaffing, a key factor in fatigue and burnout. That issue is conspicuously absent from the description of the ANA initiative. And nurses like the one who wrote the Guardian piece might not react well to suggestions like the one from Block about nurses not “taking on” too much, as if it was all the individual nurse’s choice. Still, on balance the piece is a useful look at the fatigue problem.

See the article “Why America’s Nurses Are Burning Out,” by Sanjay Gupta, posted on the Everyday Health site on September 19, 2014.

See the anonymous article “A&E nurse: am I on the road to burnout and destruction?” posted on the Guardian website on January 14, 2015.

See Laura Ungar’s article “Nurses seek to reduce long hours and fatigue,” posted on USA Today‘s website on February 1, 2015.

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