Policy brief: Nurse fatigue, sleep, and health, and ensuring patient and public safety
2019; Elsevier BV; Volume: 67; Issue: 5 Linguagem: Inglês
10.1016/j.outlook.2019.08.004
ISSN1528-3968
AutoresClaire C. Caruso, Carol M. Baldwin, Ann M. Berger, Eileen R. Chasens, James Cole Edmonson, Bárbara Göbel, Carol A. Landis, Patricia A. Patrician, Nancy S. Redeker, Linda D. Scott, Catherine Todero, Alison M. Trinkoff, Sharon Tucker,
Tópico(s)Ergonomics and Musculoskeletal Disorders
ResumoSociety needs critical nursing services around the clock and, as a result, nurses often work shift work and long work hours (SWLWH). These hours can prevent nurses from getting the seven or more hours of quality sleep each day that experts recommend (Watson et al., 2015Watson N.F. Badr M.S. Belenky G. et al.Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society.J Clin Sleep Med. 2015; 11: 591-592Crossref PubMed Scopus (26) Google Scholar). Nurses on SWLWH are at risk for cardiovascular disease, gastrointestinal and psychological disorders, cancer, type 2 diabetes, injuries, musculoskeletal disorders, all-cause mortality, adverse reproductive outcomes, and difficulty managing chronic diseases (Caruso et al., 2017Caruso C.C. Baldwin C.M. Berger A. Chasens E.R. Landis C. Redeker N.S. et al.Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses.Nurs Outlook. 2017; 65: 766-768Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, Caruso and Waters, 2008Caruso C.C. Waters T.R. A review of work schedule issues and musculoskeletal disorders with an emphasis on the health care sector.Indust Health. 2008; 46: 523-534Crossref PubMed Scopus (83) Google Scholar, Gan et al., 2015Gan Y. Yang C. Tong X. Sun H. Cong Y. Yin X. Li L. Cao S. Dong X. Gong Y. Shi O. Deng J. Bi H. Lu Z. Shift work and diabetes mellitus: a meta-analysis of observational studies.Occup Environ Med. 2015; 72: 72-78https://doi.org/10.1136/oemed-2014-102150Crossref PubMed Scopus (303) Google Scholar, Gu et al., 2015Gu F. Han J. Laden F. Pan A. Caporaso N.E. Stampfer M.J. Kawachi I. Rexrode K.M. Willett W.C. Hankinson S.E. Speizer F.E. Schernhammer E.S. Total and cause-specific mortality of U.S. nursing working rotating night shifts.Am J Prev Med. 2015; 48: 241-252Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion 2010U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010). Healthy People 2020: Sleep Health. Retrieved from http://www.healthypeople.gov/2020/topics-objectives/topic/sleep-health.Google Scholar; IARC Monographs Vol 124 Group 2019IARC Monographs Vol 124 GroupCarcinogenicity of night shift work.Lancet Oncol. 2019; 20 (online July 4)https://doi.org/10.1016/S1470-2045(19)30455-3Abstract Full Text Full Text PDF Scopus (144) Google Scholar, National Institute for Occupational Safety and Health (NIOSH) 2015Caruso C.C. Geiger-Brown J. Takahashi M. Trinkoff A. Nakata A. NIOSHNIOSH training for nurses on shift work and long work hours.in: (DHHS (NIOSH) Publication No. 2015-115). Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health, Cincinnati, OH2015https://www.cdc.gov/niosh/docs/2015-115/Google Scholar; Ramin, et al., 2014; Torquati, et al., 2017). Furthermore, tired nurses are at risk for making patient care errors and drowsy driving crashes (Bae and Fabry, 2014Bae S.H. Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review.Nurs Outlook. 2014; 62: 138-156Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, Ftouni et al., 2013Ftouni S. Sletten T.L. Howard M. Anderson C. Lenne M.G. Lockley S.W. Rajaratnam S.M. Objective and subjective measures of sleepiness, and their associations with on-road driving events in shift workers.J Sleep Res. 2013; 22: 58-69Crossref PubMed Scopus (89) Google Scholar, Geiger-Brown et al., 2012Geiger-Brown J. Rogers V.E. Trinkoff A.M. Kane R.L. Bausell R.B. Scharf S.M. Sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses.Chronobiol Int. 2012; 29: 211-219Crossref PubMed Scopus (237) Google Scholar, Geiger-Brown and Trinkoff, 2010Geiger-Brown J. Trinkoff A.M. Is it time to pull the plug on 12-hour shifts? The evidence.J Nurs Adm. 2010; 40: 100-102Crossref PubMed Scopus (80) Google Scholar, Lee et al., 2016Lee M.L. Howard M.E. Horrey W.J. Liang Y. Anderson C. Shreeve M.S. O'Brien C.S. Czeisler C.A. High risk of near-crash driving events following night-shift work.Proc Natl Acad Sci. 2016; 113: 176-181https://doi.org/10.1073/pnas.1510383112Crossref PubMed Scopus (122) Google Scholar, Trinkoff et al., 2011Trinkoff A.M. Johantgen M. Storr C.L. Gurses A.P. Liang Y. Han K. Nurses' work schedule characteristics, nurse staffing, and patient mortality.Nurs Res. 2011; 60: 1-8Crossref PubMed Scopus (141) Google Scholar). The presence of SWLWH is also related to retention issues, including nurses expressing intention-to-leave or quitting the job (Hayes et al., 2012Hayes L.J. O'Brien-Pallas L. Duffield C. Shamian J. Buchan J. Hughes F. Laschinger H.K. North N. Nurse turnover: A literature review. An update.Int J Nurs Studies. 2012; 49: 887-905https://doi.org/10.1016/.ijnurstu.2011.10.001Crossref PubMed Scopus (0) Google Scholar, Moloney et al., 2018Moloney W. Boxall P. Parsons M. Cheung G. Factors predicting Registered Nurses' intentions to leave their organization and profession: A job demands-resources framework.J Adv Nurs. 2018; 74 (Epub 2017 Dec 5): 864-875https://doi.org/10.1111/jan.13497Crossref Scopus (108) Google Scholar). These conditions also have contributed to nursing shortages in certain specialties and practice locations (Marć et al., 2018Marć M. Bartosiewicz A. Burzyńska J. Chmiel Z. Januszewicz P. A nursing shortage: A prospect of global and local policies.Int Nurs Rev. 2018; (Jul 24, Epub ahead of print)https://doi.org/10.1111/inr.12473Crossref Scopus (146) Google Scholar). Shortages are a grave concern, as the population is aging and the need for nurses is projected to strongly increase (Auerbach et al., 2017Auerbach D.I. Buerhaus P.I. Staiger D.O. How fast will the registered nurse workforce grow through 2030? Projections in nine regions of the country.Nurs Outlook. 2017; 65 (Epub 2016 Jul 13): 116-122https://doi.org/10.1016/j.outlook.2016.07.004Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar). Thus, interventions to reduce nursing fatigue are sorely needed. The American Academy of Nursing (the Academy) supports efforts to reduce fatigue in nurses through education, workplace policies and management systems, and fatigue countermeasures. The Academy recommends that healthcare services and standard-setting organizations establish policies to address this pervasive workplace hazard, thereby promoting nurses' health and safety along with patient and public safety. Many nursing jobs require SWLWH due to the need for critical nursing services around the clock. Shift work is work hours that fall outside of Monday to Friday 7 a.m. to 6 p.m. (Caruso and Rosa, 2007Caruso C.C. Rosa R.R. Shift work and long work hours.in: Rom W.N. Environmental and Occupational Medicine, Chapter 90. 4th ed. Lippincott Williams & Wilkins, Philadelphia2007: 1359-1363Google Scholar). Long work hours are shifts with more than eight hours of work or more than 40 hours of work a week. Nurses on SWLWH are at risk for several chronic illnesses, injuries, and adverse reproductive outcomes (Caruso et al., 2017Caruso C.C. Baldwin C.M. Berger A. Chasens E.R. Landis C. Redeker N.S. et al.Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses.Nurs Outlook. 2017; 65: 766-768Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, Caruso and Waters, 2008Caruso C.C. Waters T.R. A review of work schedule issues and musculoskeletal disorders with an emphasis on the health care sector.Indust Health. 2008; 46: 523-534Crossref PubMed Scopus (83) Google Scholar, Gan et al., 2015Gan Y. Yang C. Tong X. Sun H. Cong Y. Yin X. Li L. Cao S. Dong X. Gong Y. Shi O. Deng J. Bi H. Lu Z. Shift work and diabetes mellitus: a meta-analysis of observational studies.Occup Environ Med. 2015; 72: 72-78https://doi.org/10.1136/oemed-2014-102150Crossref PubMed Scopus (303) Google Scholar, Gu et al., 2015Gu F. Han J. Laden F. Pan A. Caporaso N.E. Stampfer M.J. Kawachi I. Rexrode K.M. Willett W.C. Hankinson S.E. Speizer F.E. Schernhammer E.S. Total and cause-specific mortality of U.S. nursing working rotating night shifts.Am J Prev Med. 2015; 48: 241-252Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion 2010U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010). Healthy People 2020: Sleep Health. Retrieved from http://www.healthypeople.gov/2020/topics-objectives/topic/sleep-health.Google Scholar; IARC Monographs Vol 124 Group 2019IARC Monographs Vol 124 GroupCarcinogenicity of night shift work.Lancet Oncol. 2019; 20 (online July 4)https://doi.org/10.1016/S1470-2045(19)30455-3Abstract Full Text Full Text PDF Scopus (144) Google Scholar, National Institute for Occupational Safety and Health (NIOSH) 2015Caruso C.C. Geiger-Brown J. Takahashi M. Trinkoff A. Nakata A. NIOSHNIOSH training for nurses on shift work and long work hours.in: (DHHS (NIOSH) Publication No. 2015-115). Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health, Cincinnati, OH2015https://www.cdc.gov/niosh/docs/2015-115/Google Scholar, Ramin et al., 2015Ramin C. Devore E.E. Wang W. Pierre-Paul J. Wegrzyn L.R. Schemhammer E.S. Night shift work at specific age ranges and chronic disease risk factors.Occup Environ Med. 2015; 72: 1000-1007Google Scholar, Torquati et al., 2018Torquati L. Mielke G.I. Brown W.J. Kolbe-Alexander T. Shift work and the risk of cardiovascular disease. A systematic review and meta-analysis including dose-response relationship.Scand J Work Environ Health. 2018; 44: 229-238https://doi.org/10.5271/sjweh.3700Crossref Scopus (195) Google Scholar). Evidence also indicates that SWLWH lead to greater burnout and poorer job satisfaction among nurses and contribute to the nursing shortage (Bae and Fabry, 2014Bae S.H. Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review.Nurs Outlook. 2014; 62: 138-156Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, Geiger-Brown et al., 2012Geiger-Brown J. Rogers V.E. Trinkoff A.M. Kane R.L. Bausell R.B. Scharf S.M. Sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses.Chronobiol Int. 2012; 29: 211-219Crossref PubMed Scopus (237) Google Scholar, Geiger-Brown and Trinkoff, 2010Geiger-Brown J. Trinkoff A.M. Is it time to pull the plug on 12-hour shifts? The evidence.J Nurs Adm. 2010; 40: 100-102Crossref PubMed Scopus (80) Google Scholar, Trinkoff et al., 2011Trinkoff A.M. Johantgen M. Storr C.L. Gurses A.P. Liang Y. Han K. Nurses' work schedule characteristics, nurse staffing, and patient mortality.Nurs Res. 2011; 60: 1-8Crossref PubMed Scopus (141) Google Scholar). Researchers found that nurses working 10-hour or longer shifts were 2.5 times more likely to report burnout, job dissatisfaction, reduced well-being, as well as their intention to resign compared to nurses working shorter shifts (Stimpfel et al., 2012Stimpfel A.W. Sloane D.M. Aiken L.H. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.Health Affairs (Millwood). 2012; 31: 2501-2509Crossref PubMed Scopus (254) Google Scholar). The SWLWH are likely an important factor that drive 43% of new registered nurses in hospitals to leave their jobs within three years (Goodman, 2016Goodman A. Nurse turnover rate infographic.Streamline Verify. 2016; (Retrieved from)https://www.streamlineverify.com/nurse-turnover-rate/Google Scholar). The Centers for Disease Control and Prevention (CDC) found that over 52% of healthcare night shift workers reported sleeping six hours or less a day (Centers for Disease Control and Prevention (CDC) 2012Centers for Disease Control and Prevention (CDC)Short sleep duration among workers—United States, 2010.MMWR. 2012; 61: 281-285PubMed Google Scholar), which is insufficient according to sleep experts (Watson et al., 2015Watson N.F. Badr M.S. Belenky G. et al.Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society.J Clin Sleep Med. 2015; 11: 591-592Crossref PubMed Scopus (26) Google Scholar). Sleep deficiency adversely affects nurses' performance (Bae and Fabry, 2014Bae S.H. Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review.Nurs Outlook. 2014; 62: 138-156Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, Caruso et al., 2017Caruso C.C. Baldwin C.M. Berger A. Chasens E.R. Landis C. Redeker N.S. et al.Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses.Nurs Outlook. 2017; 65: 766-768Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar). Studies report similar adverse performance effects for people awake over 17 hours to those with a blood alcohol concentration (BAC) of 0.05%, and after 24 hours awake with a BAC of 0.10% (Arnedt et al., 2005Arnedt J.T. Owens J. Crouch M. Stahl J. Carskadon M.A. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion.JAMA. 2005; 294: 1025-1033Crossref PubMed Scopus (319) Google Scholar, Dawson and Reid, 1997Dawson D. Reid K. Fatigue, alcohol and performance impairment.Nature. 1997; 388: 235Crossref PubMed Scopus (764) Google Scholar, Williamson and Feyer, 2000Williamson A.M. Feyer A.M. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication.Occup Environ Med. 2000; 57: 649-655Crossref PubMed Scopus (441) Google Scholar). Although, the legal BAC intoxication level for driving is 0.08% in the United States, some countries have set a BAC of 0.05% due to driving impairments (National Highway Traffic Safety Administration 2000National Highway Traffic Safety Administration (2000). On DWl laws in other countries. Retrieved from http://www.nhtsa.gov/people/injury/research/pub/DWIothercountries/dwiothercountries.html.Google Scholar). In addition, investigations of several well-known industrial disasters report worker fatigue to be one of the causal factors (Baker Panel 2007Baker Panel (2007). The report of the BP U.S. refineries independent safety review panel. Retrieved from https://www.csb.gov/bp-america-refinery-explosion/.Google Scholar, National Transportation Safety Board (NTSB) 2004National Transportation Safety Board (NTSB)Grounding of U.S. Tank ship Exxon Valdez on Bligh Reef, Prince William Sound, Near Valdez, Alaska, March 04 1989. NTSB/ MAR-90/04. NTSB, Washington, DC2004Google Scholar, National Transportation Safety Board 2009National Transportation Safety BoardAircraft Accident Report: loss of control on approach, Colgan Air, Inc., operating as Continental connection flight 3407, Bombardier DHC-8-400, N200WQ, Clarence Center, New York, February 12, 2009. NTSB, Washington, DC2009http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1001.pdfGoogle Scholar, Rogers Commission 1986Rogers CommissionReport of the Presidential Commission on the Space Shuttle Challenger Accident. Volume II. Appendix G. U.S. Government Printing Office, Washington, DC1986Google Scholar). SWLWH are associated with greater patient dissatisfaction, patient care errors, and patient mortality (Geiger-Brown and Trinkoff, 2010Geiger-Brown J. Trinkoff A.M. Is it time to pull the plug on 12-hour shifts? The evidence.J Nurs Adm. 2010; 40: 100-102Crossref PubMed Scopus (80) Google Scholar, Olds and Clarke, 2010Olds D.M. Clarke S.P. The effect of work hours on adverse events and errors in health care.J Safety Res. 2010; 41: 153-162Crossref PubMed Scopus (134) Google Scholar, Stimpfel et al., 2012Stimpfel A.W. Sloane D.M. Aiken L.H. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.Health Affairs (Millwood). 2012; 31: 2501-2509Crossref PubMed Scopus (254) Google Scholar). The safety risks extend to the nurse's family, health care organizations, and the public when tired nurses make errors at work or home, or have vehicular crashes due to drowsy driving (Bae and Fabry, 2014Bae S.H. Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review.Nurs Outlook. 2014; 62: 138-156Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, Ftouni et al., 2013Ftouni S. Sletten T.L. Howard M. Anderson C. Lenne M.G. Lockley S.W. Rajaratnam S.M. Objective and subjective measures of sleepiness, and their associations with on-road driving events in shift workers.J Sleep Res. 2013; 22: 58-69Crossref PubMed Scopus (89) Google Scholar, Geiger-Brown et al., 2012Geiger-Brown J. Rogers V.E. Trinkoff A.M. Kane R.L. Bausell R.B. Scharf S.M. Sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses.Chronobiol Int. 2012; 29: 211-219Crossref PubMed Scopus (237) Google Scholar, Geiger-Brown and Trinkoff, 2010Geiger-Brown J. Trinkoff A.M. Is it time to pull the plug on 12-hour shifts? The evidence.J Nurs Adm. 2010; 40: 100-102Crossref PubMed Scopus (80) Google Scholar, Lee et al., 2016Lee M.L. Howard M.E. Horrey W.J. Liang Y. Anderson C. Shreeve M.S. O'Brien C.S. Czeisler C.A. High risk of near-crash driving events following night-shift work.Proc Natl Acad Sci. 2016; 113: 176-181https://doi.org/10.1073/pnas.1510383112Crossref PubMed Scopus (122) Google Scholar, Olds and Clarke, 2010Olds D.M. Clarke S.P. The effect of work hours on adverse events and errors in health care.J Safety Res. 2010; 41: 153-162Crossref PubMed Scopus (134) Google Scholar, Scott et al., 2007Scott L.D. Hwang W.T. Rogers A.E. Nysse T. Dean G.E. Dinges D.F. The relationship between nurse work schedules, sleep duration, and drowsy driving.Sleep. 2007; 30: 1801-1807Crossref PubMed Scopus (161) Google Scholar, Stimpfel et al., 2012Stimpfel A.W. Sloane D.M. Aiken L.H. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.Health Affairs (Millwood). 2012; 31: 2501-2509Crossref PubMed Scopus (254) Google Scholar; Swanson et al., 2012Swanson L.M. Drake C. Arnedt J.T. Employment and drowsy driving: a survey of American workers.Behav Sleep Med. 2012; 20: 250-257Google Scholar, Trinkoff et al., 2011Trinkoff A.M. Johantgen M. Storr C.L. Gurses A.P. Liang Y. Han K. Nurses' work schedule characteristics, nurse staffing, and patient mortality.Nurs Res. 2011; 60: 1-8Crossref PubMed Scopus (141) Google Scholar). Currently, few state and federal laws exist in the United States that concern nurses' work hours. No federal laws limit the number of hours a nurse can work or specifies the design of their work schedules. Whereas in Europe, the European Union's Working Time Directive limits hours worked per week to 48 (European Union 2003European UnionDirective 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of the organisation of working time. 2003http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32003L0088:EN:HTMLGoogle Scholar). One-third of states prohibit or restrict mandatory overtime in nurses (Ohio Nurses Association 2018Ohio Nurses Association. (2018). House Bill 456/Prohibit Mandatory Overtime Passes House. Retrieved from http://ohnurses.org/house-bill-456-prohibit-mandatory-overtime-passes-house/.Google Scholar). These laws do not address nurses who volunteer to work overtime although nurses' health and safety as well as patient and public safety consequences are similar. Many of the existing overtime laws have emergency provisions that are loosely interpreted, allowing facilities to override the limits. Furthermore, many states have no laws that require employers to provide workers with meal and rest breaks during their workshifts (45U.S. Department of Labor (ND). State labor laws. Retrieved from http://www.dol.gov/whd/state/state.html.Google Scholar). Nurses and managers in health care organizations may not fully understand the health and safety risks that are associated with sleep deficiency, fatigue, and SWLWH. They may also be unaware of the available evidence-based strategies to reduce these risks (Baldwin et al., 2016Baldwin C.M. Schultz A.A. Barrere C.C. Evidence-based practice (pp. 637–659).in: Dossey B.M. Keegan L. Holistic nursing: a handbook for practice. 7th ed. Jones & Bartlett, Burlington, MA2016Google Scholar, National Institute for Occupational Safety and Health (NIOSH) 2015Caruso C.C. Geiger-Brown J. Takahashi M. Trinkoff A. Nakata A. NIOSHNIOSH training for nurses on shift work and long work hours.in: (DHHS (NIOSH) Publication No. 2015-115). Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health, Cincinnati, OH2015https://www.cdc.gov/niosh/docs/2015-115/Google Scholar). Evidence shows, however, that it is possible to limit or modify the adverse impact of SWLWH by improving sleep and reducing fatigue. The American Academy of Nursing recommends that health care service and standard-setting organizations implement policies that promote the sleep health (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion 2010U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010). Healthy People 2020: Sleep Health. Retrieved from http://www.healthypeople.gov/2020/topics-objectives/topic/sleep-health.Google Scholar) of nurses. These policies are vital for promoting an alert, healthy workforce that is better able to provide excellent nursing care around the clock and support nurses' ability to maintain their own health and safety. The Academy supports efforts to reduce fatigue in nurses through education, workplace policies and management systems, and fatigue countermeasures. Health care managers and nurses share in the responsibility for making sleep health a priority in the management systems for organizing the work and the nurse's personal life. Given nursing shortages and the increasing demand for nursing services, research is needed to test interventions that promote nurses' ability to provide care around the clock and to ensure that sufficient nurses are available to provide high-quality care and meet patient care needs. Moreover, the Academy supports funding to investigate nurse fatigue risk mitigation, and related provider wellness and patient safety issues. Work Schedule Design. Innovative designs for work schedules can help reduce fatigue. Managers should set limits on shift length, number of hours and shifts worked per week, and the number of consecutive shifts allowed. Since health and safety risks increase as work hours increase (Bae and Fabry, 2014Bae S.H. Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review.Nurs Outlook. 2014; 62: 138-156Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar), managers can avoid implementing shifts longer than 12 hours and use shorter shifts, especially during night hours when nurses have added challenges with sleep and maintaining alertness (Drake et al., 2004Drake C.L. Roehrs T. Richardson G. Walsh J.K. Roth T. Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers.Sleep. 2004; 27: 1453-1462Crossref PubMed Scopus (304) Google Scholar, Pilcher et al., 2000Pilcher J.J. Lambert B.J. Huffcutt A.I. Differential effects of permanent and rotating shifts on self-report sleep length: a meta-analytic review.Sleep. 2000; 23: 155-163Crossref PubMed Scopus (219) Google Scholar). If shift rotations are used, they should be "forward" (e.g. days to evenings, evenings to nights). Managers should identify and eliminate policies that encourage excessive overtime and set restrictions on how much and when nurses can work overtime. More specifically:•Schedule night shifts of no longer than 8 hours because long night shifts have greater risk for patient care errors and adverse health and safety outcomes for nurses (Bae and Fabry, 2014Bae S.H. Fabry D. Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: systematic literature review.Nurs Outlook. 2014; 62: 138-156Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, Drake et al., 2004Drake C.L. Roehrs T. Richardson G. Walsh J.K. Roth T. Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers.Sleep. 2004; 27: 1453-1462Crossref PubMed Scopus (304) Google Scholar, Geiger-Brown et al., 2012Geiger-Brown J. Rogers V.E. Trinkoff A.M. Kane R.L. Bausell R.B. Scharf S.M. Sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses.Chronobiol Int. 2012; 29: 211-219Crossref PubMed Scopus (237) Google Scholar, Geiger-Brown and Trinkoff, 2010Geiger-Brown J. Trinkoff A.M. Is it time to pull the plug on 12-hour shifts? The evidence.J Nurs Adm. 2010; 40: 100-102Crossref PubMed Scopus (80) Google Scholar, Fischer et al., 2017Fischer D. Lombardi D.A. Folkard S. Willetts J. Christiani D.C. Updating the "Risk Index": A systematic review and meta-analysis of occupational injuries and work schedule characteristics.Chronobiol Int. 2017; 34: 1423-1438https://doi.org/10.1080/07420528.2017.1367305Crossref Scopus (52) Google Scholar, Pilcher et al., 2000Pilcher J.J. Lambert B.J. Huffcutt A.I. Differential effects of permanent and rotating shifts on self-report sleep length: a meta-analytic review.Sleep. 2000; 23: 155-163Crossref PubMed Scopus (219) Google Scholar, Trinkoff et al., 2011Trinkoff A.M. Johantgen M. Storr C.L. Gurses A.P. Liang Y. Han K. Nurses' work schedule characteristics, nurse staffing, and patient mortality.Nurs Res. 2011; 60: 1-8Crossref PubMed Scopus (141) Google Scholar).•Design work schedules with at least 10 or more continuous hours off each day so that nurses can obtain 7 or more hours of sleep per day as recommended for adults by experts (Watson et al., 2015Watson N.F. Badr M.S. Belenky G. et al.Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society.J Clin Sleep Med. 2015; 11: 591-592Crossref PubMed Scopus (26) Google Scholar).•Review nurses' future work schedules and intervene to prevent work schedule patterns with high risk for fatigue. Fatigue Risk Management Systems (FRMS) (Lerman et al., 2012Lerman S.E. Eskin E. Flower D.J. George E.C. Gerson B. Hartenbaum N. Hursh S.R. Moore-Ede M. American College of Occupational and Environmental Medicine Presidential Task Force on Fatigue Risk ManagementFatigue risk management in the workplace.J Occup Environ Med. 2012; 54: 231-258Crossref PubMed Scopus (217) Google Scholar). Employers can establish FRMS to provide a comprehensive approach to reduce risks from fatigue. FRMS contribute to a Just Culture (American Nurses Association 2010American Nurses Association (2010). Position statement: Just culture. Retrieved from https://www.nursingworld.org/∼4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf.Google Scholar) that recognizes flaws in workplace systems are often important causes of errors. FRMS include several elements: 1) instituting workplace polices to reduce risk for fatigue; 2) establishing procedures to protect tasks that are vulnerable to fatigue-related errors; 3) promoting education for managers and nurses; 4) including fatigue-related factors in incident investigation; 5) establishing anonymous near miss and incident reporting systems; 6) addressing sleep disorders; and 7) striving for continuous improvement. Prevent Drowsy Driving. Evidence is growing that SWLWH, disruption to circadian rhythms, and sleep deficiency increase the risks for drowsy driving and vehicle crashes (Ftouni et al., 2013Ftouni S. Sletten T.L. Howard M. Anderson C. Lenne M.G. Lockley S.W. Rajaratnam S.M. Objective and subjective measures of sleepiness, and their associations with on-road driving events in shift workers.J Sleep Res. 2013; 22: 58-69Crossref PubMed Scopus (89) Google Scholar, Lee et al., 2016Lee M.L. Howard M.E. Horrey W.J. Liang Y. Anderson C. Shreeve M.S. O'Brien C.S. Czeisler C.A. High risk of near-crash driving events following night-shift work.Proc Natl Acad Sci. 2016; 113: 176-181https://doi.org/10.1073/pnas.1510383112Crossref PubMed Scopus (122) Google Scholar, Scott et al., 2007Scott L.D. Hwang W.T. Rogers A.E. Nysse T. Dean G.E. Dinges D.F. The relationship between nurse work schedules, sleep duration, and drowsy driving.Sleep. 2007; 30: 1801-1807Crossref PubMed Scopus (161) Google Scholar, Swanson et al., 2012Swanson L.M. Drake C. Arnedt J.T. Employment and drowsy driving: a survey of American workers.Behav Sleep Med. 2012; 20: 250-257Google Scholar). Scott et al. emphasized the need to increase nurses' awareness and establish management systems to prevent drowsy driving for the nurse's and the public's safety (Scott et al., 2007Scott L.D. Hwang W.T. Rogers A.E. Nysse T. Dean G.E. Dinges D.F. The relationship between nurse work schedules, sleep duration, and drowsy driving.Sleep. 2007; 30: 1801-1807Crossref PubMed Scopus (161) Google Scholar). Managers should organize education campaigns and establish procedures for transporting nurses who are too tired to drive home safely (National Institute for Occupational Safety and Health (NIOSH) 2015Caruso C.C. Geiger-Brown J. Takahashi M. Trinkoff A. Nakata A. NIOSHNIOSH training for nurses on shift work and long work hours.in: (DHHS (NIOSH) Publication No. 2015-115). Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health, Cincinnati, OH2015https://www.cdc.gov/niosh/docs/2015-115/Google Scholar). For example, managers can provide taxi service or call a family member to provide transportation. Another option is arranging sleeping rooms close to the worksite for tired nurses. Systems for Emergencies. During environmental emergencies or other disasters, managers should establish management support systems to increase nurses' ability to continue working. These systems could include services that reduce non-work demands on nurses so they can devote their time off to rest and sleep. Some examples include providing onsite sleeping rooms, childcare, and laundering of uniforms. During these situations, managers should avoid pressuring nurses to work overtime since longer shifts are associated with increased errors and injuries as well as burnout. Education. Nurses and their managers need education about the health and safety risks associated with SWLWH and the evidence-based strategies that can reduce these risks. Free, comprehensive, online training is available from the National Institute for Occupational Safety and Health (NIOSH) entitled, NIOSH training for nurses on shift work and long work hours (National Institute for Occupational Safety and Health (NIOSH) 2015Caruso C.C. Geiger-Brown J. Takahashi M. Trinkoff A. Nakata A. NIOSHNIOSH training for nurses on shift work and long work hours.in: (DHHS (NIOSH) Publication No. 2015-115). Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health, Cincinnati, OH2015https://www.cdc.gov/niosh/docs/2015-115/Google Scholar). Another resource is the American Nurses Association Position Statement, Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of Registered Nurses and Employers to Reduce Risk (American Nurses Association 2014American Nurses Association (2014). Addressing nurse fatigue to promote safety and health: joint responsibilities of registered nurses and employers to reduce risk. Retrieved from https://www.nursingworld.org/∼4afdfc/globalassets/practiceandpolicy/health-and-safety/nurse-fatigue-position-statement-final.pdf.Google Scholar). Additionally, content on leading sleep disorders and their treatment, nurse's and patient's safety risks from fatigue related to sleep disorders and SWLWH, and strategies to reduce the risks should be included in associate, undergraduate, and graduate nursing curricula. These are strategies to reduce sleepiness and fatigue. They include short naps and rest breaks during the work shift, and judicious use of caffeine. Health care organizations should establish policies for 10 to 15 minute rest breaks during shifts every 2 hours and additional breaks for meals to reduce risk for fatigue, errors, and injuries (Fischer et al., 2017Fischer D. Lombardi D.A. Folkard S. Willetts J. Christiani D.C. Updating the "Risk Index": A systematic review and meta-analysis of occupational injuries and work schedule characteristics.Chronobiol Int. 2017; 34: 1423-1438https://doi.org/10.1080/07420528.2017.1367305Crossref Scopus (52) Google Scholar). Managers can also create schedules with time for brief planned naps during work shifts: research supports that brief naps (15 to 30 minutes) increase alertness during work shifts (Geiger-Brown et al., 2016Geiger-Brown J. Sagherian K. Zhu S. Wieroniey M.A. Blair L. Warren J. Hinds P.S. Szeles R. Napping on the night shift: a two-hospital implementation project.Am J Nurs. 2016; 116: 26-33Google Scholar, Scott et al., 2010Scott L.D. Hofmeister N. Rogness N. Rogers A.E. An interventional approach for patient and nurse safety: a fatigue countermeasures feasibility study.Nurs Res. 2010; 59: 250-258Crossref PubMed Scopus (56) Google Scholar). Another well-supported countermeasure is the use of small amounts of carefully timed caffeine (National Institute for Occupational Safety and Health (NIOSH) 2015Caruso C.C. Geiger-Brown J. Takahashi M. Trinkoff A. Nakata A. NIOSHNIOSH training for nurses on shift work and long work hours.in: (DHHS (NIOSH) Publication No. 2015-115). Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health, Cincinnati, OH2015https://www.cdc.gov/niosh/docs/2015-115/Google Scholar). Additionally, employers should work to establish non-punitive procedures for nurses who are too fatigued to work such as a backup staffing plan. Finally, State Boards of Nursing incident investigations should include details about the work hours and sleep-related factors that occurred 3 or more days before the error to identify contributors to the incident (Lerman et al., 2012Lerman S.E. Eskin E. Flower D.J. George E.C. Gerson B. Hartenbaum N. Hursh S.R. Moore-Ede M. American College of Occupational and Environmental Medicine Presidential Task Force on Fatigue Risk ManagementFatigue risk management in the workplace.J Occup Environ Med. 2012; 54: 231-258Crossref PubMed Scopus (217) Google Scholar).
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