Lack of time off is an important factor contributing to injuries and fatigue in nurses, according to a study by Trinkoff and colleagues, which suggested that nurses need time off to rest and recuperate in order to protect their own health. Now that same team of researchers has released a new study that suggests that hospital administrators and policymakers have even more reason to consider nurses' working conditions, finding that extended work schedules among nurses may be linked to a greater risk of patient death, at least when certain conditions are present.
The study surveyed a total of 633 nurses at 71 acute care hospitals in Illinois and North Carolina. In addition to questions about shift length and hours worked, the nurses were asked how often they worked 13 hours or more at a stretch, the amount of time off between shifts, the number of breaks lasting 10 minutes or more, the number of days worked in a row, whether on-call duty was mandatory, and whether they ever worked when ill.
Deaths from pneumonia and acute myocardial infarction occurred more often in hospitals where nurses worked long hours. Along with long work shifts, a lack of time off from the job was strongly linked to patient deaths from pneumonia and abdominal aortic aneurisms.
Patient deaths from congestive heart failure and pneumonia were associated with nurses working while sick.
"This suggests that nurses are not at their best if they have to work while sick. Yet they may have to work because of staffing constraints," said the study's lead author Alison M. Trinkoff, a professor at the University of Maryland School of Nursing, in an interview with AJN.
According to Trinkoff, an ideal nursing work environment should allow nurses to get sufficient sleep and arrive at work well rested. Nurses should be encouraged to take their allotted vacation time and sick days—and be respected for doing so. On-call duties should be kept to a minimum to prevent phone calls from interrupting rest and sleep. Even more crucial, she said, nurses shouldn't be called back to work on their days off.
During long shifts, according to Trinkoff, nurses should be allowed to take naps, preferably away from the unit. Several hospitals have policies allowing naps and areas where nurses can take them. Electroencephalographic studies show that 15-to-20-minute naps increase alertness, especially in those with partial sleep deprivation. "Naps are very useful," said Trinkoff, adding, "Nurses need to be able to speak up when they are exhausted—without blame—so napping breaks can be implemented in more hospitals."
Trinkoff recommends scheduling relief nurses to cover for full-time staff during peak hours, such as 10 AM to 2 PM, to ensure that nurses receive their work breaks. Meals and break times should be enforced. Relief nurses could also reduce the workloads of older nurses, keeping these experienced staff members at the bedside. In addition, early and late shift starting times should be staggered to help day-shift nurses get adequate rest and maximize efficiency, especially when rotating shifts.
Despite the popularity of 12-hour shifts, which many nurses like because it allows for a three-day workweek, Trinkoff sees benefits in offering shorter shifts. Many nurses aren't suited to 12-hour shifts, and those who can't adapt often leave hospital work. Offering four- or eight-hour shifts could help to attract and retain nurses with young children, older nurses, or those with medical concerns. Nurses with different circadian preferences or sleep disorders or who take medications with peak periods of effectiveness might also prefer shorter shifts. For instance, Trinkoff said, "If a nurse is a morning person, don't put her on nights." Finding ways to reduce fatigue during work hours not only protects nurses, it also protects patients.—Carol Potera