For this year's National Nurses Week (May 6 to 12), the American Nurses Association chose the theme “Culture of Safety: It Starts with you.” It's a departure from many earlier, more celebratory messages, such as “Nurses Are the True Spirit of Caring” (2001). But it's a laudable reminder that we're each duty bound to ensure that our patients can trust us to look out for them. From the new nurse at the bedside to the advanced practice RN, each has a role in creating and maintaining that culture of safety.
I'm reminded of a conversation I once had with the late Cheryl Johnson, shortly after she was elected president of the United American Nurses union in 2000. We were sharing stories of our days in critical care nursing, speaking of how, so often, it falls to the nurse to recognize and prevent a life-threatening error. Johnson believed that nurses were the final checkpoint: “The buck stops with nurses. We're the ones who make or break the patient's experience.” It was why she was so passionate about fighting for adequate staffing.
I couldn't agree more. Nurses have always been the sentinels, the around-the-clock watchers, detecting the changes that might herald a patient's deterioration. Nurses are the ones that the system looks to—and often blames—when there's a failure to rescue. Such constant vigilance requires that nurses be present in adequate numbers and with full attention.
The question of what constitutes adequate nurse staffing, long debated, will likely continue to be so, with direct caregivers decrying staff shortages that hinder patient care and administrators claiming that budget constraints won't support more staffing. Yet an abundance of research implicates inadequate staffing in patients’ experiences of less-than-optimum care, and demonstrates that higher nurse–patient staffing ratios are important to patient safety. True, hospital administrators have to make difficult choices about how to allocate resources. But all too often, they opt for new technologies despite a lack of evidence that these improve outcomes—instead of acting on the evidence at hand and hiring more nurses.
Still, we'd be foolish not to acknowledge that there are other reasons for unsafe care. Even when staffing is adequate, errors can result from inexperience, miscommunication, and fatigue. Indeed, fatigue is such a problem that the Joint Commission issued a Sentinel Event Alert in 2011, noting that “fatigue increases the risk of adverse events, compromises patient safety, and increases risk to personal safety and well-being.” Many hospitals and nurses insist on keeping 12-hour shifts, although extended shifts are associated with poorer quality patient care and lower hospital safety scores. And many nurses regularly work more than the recommended maximum of 60 hours per week. The cumulative effects of sleep loss and minimal recovery time between shifts can have “substantial adverse effects on the physical, cognitive, and emotional well-being of nurses,” as Linda Eanes reported earlier in this journal (see “The Potential Effects of Sleep Loss on a Nurse's Health,” April 2015); even one night of insufficient sleep can reduce cognitive performance by as much as 25%.
The shift issue is thorny and unlikely to be resolved soon. But there are things we can do to reduce nurses’ fatigue. In this issue, Jeanne Geiger-Brown and colleagues examine barriers to workplace napping (see “Napping on the Night Shift: A Two-Hospital Implementation Project”). Their original research article highlights a critical factor in the success or failure of many initiatives—nurse manager support at the unit level. In this project, some nurse managers saw more problems than potential benefits and opposed even a trial period of napping. But on the unit with a nurse manager who was willing to implement napping, participants indicated that napping improved their alertness at work and on the drive home, thus helping to ensure the safety of both patients and nurses.
We must continue to push for better staffing, at levels that allow nurses adequate time to provide truly individualized patient and family care. And it's time that each of us also owns up to our duty to arrive for work as rested, alert, and ready for engagement as possible. As this year's National Nurses Week theme reminds us, we represent our patients’ best hope for a safe hospital stay.