Recently I've received several letters from staff nurses responding to my December editorial on “missed nursing care.” All admitted failing, at times, to give needed care to patients because they were too busy. And all expressed regret and guilt at their inability to do so. One letter was especially heart wrenching, reading in part:
“I am highly committed to providing care for my patients that I would want my own family members to receive. However, staffing levels at our hospital mean that I usually have eight patients, and the CNAs… generally have 15 patients each. Many of our patients have dementia or psychiatric issues in addition to the complicated comorbidities…. Often we discharge two to four patients in a couple of hours and are immediately hit with as many new admissions… not to mention the quantities of documentation we are required to complete every day…. Even though I try to care for everyone as though they are my own parents, I know that I am failing, through no fault of my own. I work hard to keep my heart and eyes open, but I am not surprised that so many nurses shut down, doing just the bare minimum to get through the day…. And after working three 12-hour shifts, who has the energy to advocate for changes such as safe staffing that would improve these conditions?”
Many hospitals instituted 12-hour nursing shifts during the 1980s to ease scheduling and increase recruitment, and their use continues. The idea of working three 12-hour days instead of five eight-hour days weekly has appealed to nurses trying to balance work with school or family obligations. But there are significant downsides. Some nurses have taken second jobs at other hospitals, working a total of 50-plus hours per week. And although nurses working 12-hour shifts are no longer likely to be asked to “work a double,” they might be asked to take an extra shift or to stay “just a few more hours” if a unit is short staffed.
The consequences of prolonged hours and worker fatigue can be profound, as this month's AJN Reports details. Last March, Ohio nurse Elizabeth Jasper was killed while driving home after a busy 12-hour night shift. According to family members, she'd complained that she was unable to take breaks, had no time to eat, and was frequently asked to work extra shifts or stay late. They have filed a wrongful death lawsuit claiming that the accident was the hospital's fault—by not providing sufficient staffing, the hospital put Jasper's life at risk. Her husband has said she was “worked to death.” Should Jasper have known her own limits? Or are hospitals obligated to make sure that what's asked of employees doesn't put their lives at risk?
When I discussed this case with other nurses, no one expressed surprise. One nurse, who has worked the night shift in a NICU for over 20 years, said her colleagues all had “horror stories” of falling asleep while driving home from work. She said that when she drives home after a 12-to-13-hour night shift, she always puts the car in park at red lights, because once she dozed off and rolled through an intersection.
Regardless of shift length, without appropriate staffing, hospital nurses often find themselves unable to complete their work. So they skip meals and miss breaks and leave late, perhaps thinking that if they just worked a little faster or more efficiently, they could get it all done. But nurses aren't superhuman. When hospitals don't staff appropriately, missed nursing care is inevitable—and both patients and nurses suffer the consequences. In 2004, the Institute of Medicine recommended that nurses not work more than 12 hours in any 24-hour period. And in 2011, the Joint Commission issued a sentinel event alert based on the evidence linking extended work hours and worker fatigue with increased risk of error and decreased patient and worker safety, and urged hospitals to address the issue.
Many hospitals have touted their efforts aimed at reducing medication errors or improving patients’ experiences. But how many have embarked on adopting evidence-based staffing practices? It's time for certifying bodies to consider the latter when examining accreditation criteria. “Best practices” should also cover the health and safety of those who practice.