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Fatigue Management Guidelines

Georgia Hospital AssociationMay 22, 2014

Robert L. Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE

Vice President, Patient Care Services / Chief Nursing Officer

Midland Memorial Hospital

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Objectives

To understand the literature related to fatigue management.

To understand the practice at Midland Memorial Hospital before Fatigue Management Guidelines.

Review Midland Memorial Hospital’s Fatigue Management Guidelines and current practice.

Outline a leadership framework for implementing best practices.

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Leading Indicators for FatigueCausal factors Long work hours

(overtime)

Low job satisfaction

Low control over overtime

Extended work periods

Individual risk factors Age

Need for drug therapy

Illnesses (i.e., diabetes, coronary disease, etc.)

Stress/anxiety

Workers with young children

Source: www.asse.org, Professional Safety, December 2010

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Immediate Effects of Fatigue Reduction in physical capacity (weakness)

Reduction in work

Mistakes

Slips

Lapses

Weariness

Memory loss

Sleepiness

Discomfort

Weakened motivation

Irritability

Illness

Source: www.asse.org, Professional Safety, December 2010

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Human Error, Work Environment & ImpactsHuman error

Definition Susceptible environments

Impact of cognitive fatigue

Mistakes Intentional planning related error (e.g., skill-based errors)

Dynamic work environments and standardized work processes do not ensure sufficient worker-hazard interactions

Mistakes become more common as workers’ judgment deteriorates during extended periods of work and mistakes remain undetected

Slips Unintended erroneous actions that result from mental distractions in familiar work environments

Typical work environments with one or more unusual external distractions.

Distractions have a greater effect as workers have increasing difficulty focusing on their work tasks.

Lapses Unintended erroneous actions that result from temporary memory failure

Typical work environments

Memory failures increase dramatically during periods of mental fatigueSource: www.asse.org, Professional Safety, December

2010

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Lagging Indicators of Fatigue

Effects of fatigue on performance

Reduction in quality

Reduction in productivity

Increased severity of injuries

Increased frequency of injuries

Quality of life impacts

Illnesses (i.e., GI, CAD, HTN, etc.)

Stress

Sleep complaints

Unhealthy diets

Lack of exercise

Smoking

Suicide due to overwork

Source: www.asse.org, Professional Safety, December 2010

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Working under fatigue may:

Hurt or Kill someone!

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Midland Memorial HospitalPractice environment before Fatigue Management Guidelines

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Practice Environment beforeMMH Fatigue Management Guidelines

16-hour shifts normal for RNs, house supervisors, pharmacists and others.

No regard or respect to the effects of fatigue on safety.

Poor results on surveys (e.g., NDNQI RN Satisfaction Survey, Culture of Patient Safety).

Other effects unrecognized that may have been contributed to poor management of fatigue.

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Midland Memorial HospitalHow did we get started?

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Getting started (2008)

Texas Nurses Association’s Practice Committee – Dr. Debora Simmons

Formed interprofessional team to review literature and create a guideline.

Guideline approved through shared governance structure (buy-in).

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Patient Care ServicesShared Accountability Structure

EmpiricalOutcomes

Share

d G

overn

ance

Model

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Pro

fess

ional Pra

ctic

e M

odel

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MMH Fatigue Management Guideline (2009)

PURPOSE: To provide a strategy that recognizes and manages the potential negative consequences of sleep deprivation and sustained work hours on patient outcomes and staff well-being.

GUIDELINE: The direct patient caregiver is responsible and accountable for individual practice and understanding the consequences of fatigue in preserving integrity and safety. Guidelines for length of hours worked, and number of hours worked in patient care assignments during a period of seven days will be followed.

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Definitions On-call

Call hours worked

Extended work period \ sustained work hours

Extended hours worked per week

Fatigue

Circadian rhythms

Off-duty

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Guidelines Except in emergency situations, direct patient caregivers

should not work in direct patient care assignments more than 12.5 consecutive hours in a 24-hour period, not more than 60 hours in a seven-day period, and not scheduled more than three consecutive 12-hour shifts. Working outside of these parameters requires Manager and/or Director approval.

Off-duty periods should be inclusive of an uninterrupted sleep cycle, a break from continuous professional responsibilities, and a period of time of not less than eight (8) hours to perform activities of daily living.

Arrangements will be made in relation to the hours worked, to provide additional time off for direct patient caregivers working a longer shift, an extra shift, or hours worked on call to accommodate an adequate off-duty recuperation period.

The number of shifts, or on-call shifts assigned during a seven day period should reflect the above guidelines as to number of sustained work hours and adequate recuperation periods.

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Guidelines (cont.)

An individual’s ability to meet an increased work demand should be taken into account.

All direct patient caregivers should uphold their ethical responsibility to patients and to themselves to arrive at work adequately rested and prepared for duty.

In extreme conditions, i.e. surge management or a disaster, staff may be asked to work additional hours, following the above guidelines for fatigue management.

Leaders have a responsibility to monitor staff fatigue, provide breaks and release staff as soon as possible.

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Other initiatives

Clinical Manager Model

Agency for Healthcare Research and Quality’s (AHRQ) TeamSTEPPS® Training

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Updated Review (2014)

Defined “direct patient caregiver” as clinical nurse, physical therapists, respiratory therapists, pharmacists, scrub tech as required.

Recommendation for all employees.

Sleep Hygiene: the promotion of regular, healthy sleep.

Added adapted Fatigue Management Model from The American Society of Safety Engineers (www.asse.org, Professional Safety, December 2010).

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Adapted Fatigue Management Model

Immediate Effects• Decreased productivity• Increase in mistakes, slips,

and lapses• Decrease in teamwork• Weariness• Physical weakness• Lack of motivation and/or

engagement• Sleepiness• Irritability• Concentration difficulties• Stress• Burnout

Countermeasures• Fatigue Management

Guidelines• Breaks• Hydration• Decrease pace• Increase teaming• Sleep hygiene

Long-Term Effects• Chronic illnesses• Insomnia• Family problems• Increased Mortality &

Morbidity

Causal FactorsShift work

Extended work shifts

Work time control

Repetitive tasksNighttime work

Individual Risk Factors

AgeLiving ConditionsCircadian rhythmsPreexisting illness

Prior work experience

Fatigue

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A Leadership Framework from Kouzes & Posner Model the way

Inspire a shared vision

Challenge the process

Enable others to act

Recognize the

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References

1. Birmingham, S.E., Dent, R.L., Ellerbe, S. (2013). Reducing the impact of RN fatigue on patient and nurse safety. Nurse Leader. 31-34.

2. Bosek, M.S. (2001) Mandatory overtime: Professional duty, harms, and justice. JONAS Healthcare Law Ethics Regulations. (4):99-102.

3. Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. American Operating Room Nurse, 87(6), 1191-1204.

4. Hallowell, M.R. (2010). Worker fatigue: Managing concerns in rapid renewal highway construction projects. Professional Safety. 18-26.

5. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: The National Academic Press.

6. Rogers, A.E., Hwang, W.T., Scott, L.D., Aiken, L.H., and Dinges, D.F. (2004) The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 23(4):202-212

7. Trinkoff, A.M., Le, R., Geiger-Brown, J., and Lipscomb, J. (2007) Work schedule, needle use, and needlestick injuries among registered nurses. Infection Control and Hospital Epidemiology. 28 (2) 156-164.

8. Wells, M.E. and Vaughn, B.V. (2012). Poor sleep challenging the health of a nation. Neurology J. 52: 233-249.

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Questions?

Contact Information:

Dr. Bob Dent

(432) 221-4566 – Office

(432) 559-2911 – Mobile

bob.dent@midland-memorial.com

You may:

Follow me on Twitter @bobdent

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Thank you!