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Patient Safety and Quality

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Long work hours and family caregiving affect nurses' hospital performance

Each of the 5 million patients admitted to hospital critical care units in an average year will suffer at least one problem due to a medical error that could have been prevented. The long work hours of critical care nurses may play a role in some of these errors, suggests a new study. The stress and fatigue of caregiving for family members at home may also hinder the performance of hospital staff nurses at work, concludes a second study. Both studies were supported by the Agency for Healthcare Research and Quality (HS11963) and are summarized here.

Scott, L.D., Rogers, A.E., Hwang, W-T., and Zhang, Y. (2006, January). "Effects of critical care nurses' work hours on vigilance and patients' safety." American Journal of Critical Care 15(1), pp. 30-37.

Critical care nurses must notice and quickly respond to subtle changes in the condition of their seriously ill, often unstable, patients in order to minimize errors and patient harm. Working overtime and/or extended shifts reduces their vigilance and patient safety, concludes this study. More than one-quarter (27 percent) of the nurses reported making at least one error, and more than one-third (38 percent) reported making at least one near-error during the 28-day study period. The risk for making an error almost doubled when the nurses worked 12.5 or more consecutive hours. Working more than 40 hours per week increased both errors and near-errors.

Although 44 percent (2,613) of the 6,017 work shifts studied were scheduled for 12 hours or more, 67 percent (4,053) exceeded 12 hours. Almost two-thirds of the critical care nurses struggled to stay awake at least once during the study period, and 20 percent fell asleep at least once during their work shift. The risk of falling asleep at work almost doubled when shifts exceeded 8 hours and more than doubled when shifts were longer than 12 hours. Surprisingly, there was no association between decreased vigilance (struggling to stay awake or falling asleep) and increased risk of errors.

These findings support the Institute of Medicine's recommendations to minimize the use of 12-hour shifts and to limit nurses' work hours to no more than 12 consecutive hours during a 24-hour period. The findings were obtained from 14-day logbooks filled out by 502 critical care nurses. They detailed the hours worked, the time of day worked, overtime hours, days off, and sleep-wake patterns, as well as difficulties in remaining awake while on duty. They also described any errors or near errors that might have occurred.

Scott, L.D., Hwang, W-T., and Rogers, A.E. (2006, February). "The impact of multiple care giving roles on fatigue, stress, and work performance among hospital staff nurses." Journal of Nursing Administration 36(2), pp. 86-95.

Hospital staff nurses providing elder care at home are more fatigued, sleep-deprived, and likely to make errors at work than other nurses. In this study, a total of 398 staff nurses filled out daily logbooks over a 4-week period. They used a visual analog scale to rate their daily perceptions of physical and mental fatigue and stress, and to note any errors or near-errors they made. Nurses who provided care to family members were more sleepy and stressed than nurses without home caregiving responsibilities. Nurses who were providing care for both dependent children and elderly adults reported the most sleepiness, physical fatigue, and mental fatigue over the 4-week study period.

One-quarter of the nurses caring for elderly relatives obtained 5.75 hours or less of sleep on work days and were over twice as likely to make an error at work (the majority were medication-related). However, elder care was not associated with the risk of making near errors. These findings underscore the importance that all nurses get adequate sleep, especially those who engage in caregiving roles both at home and work.

Those caring for relatives at home worked more hours per shift compared with nurses with no care dependents at home (an average of 11.54 vs. 10.96 hours). This may reflect the financial strain and economic burden that is often embedded in the family caregiving experience. Extended work shifts with short off-duty periods do not allow for commuting time, recovery sleep, or time to take care of domestic responsibilities. The resulting sleep loss may explain the connection between providing elder care at home and the likelihood of nurses making an error at work.

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