# Presentation: 525036

## Ann E. Rogers PhD, RN, FAAN
Associate Professor
University of Pennsylvania School of Nursing

- Associate Professor
- University of Pennsylvania School of Nursing

***Staff Nurse Fatigue ******and Patient Safety***

**Notes:**
Indicate my pleasure in being back in WA, very sharp and sophiticated group of nurses.  

Plug for Ronda’s upcoming book on patient safety.  Will be free and available on CD-ROM hopefully in Jan

## Case Study

***Case Study***

## On July 4, 2006, a nurse worked a double shift that ended at midnight. The nurse had volunteered for the shifts some time prior to coming to work on July 4 and had arranged to sleep at the hospital following the shifts because she began another scheduled 8-hour shift on the Birthing Unit, at 7:00 a.m. on July 5th.

**Notes:**
READ BEFORE NEXT  SLIDE If work a double shift, very likely to be awake for 19  or more hours.
If awake 19 or 24 hours doesn’t mean that you will make a mistake, but suggests that very high risk of errors, just like someone with a high BAL is likely to have a crash.
Next slide, shows what can happen when nurses are awake for sustained periods.  From CAN website. 

## That morning the nurse made a series of errors that resulted in the death of a patient 

-   1) she failed to place the armband on the patient’s      wrist
-   2) at 11:30 pm she removed the patient’s medications      from the pxyis along with the epidural medications (a      combination of bupivacaine and fentanyl) that she      thought might be needed later and placed them on a      counter in the birthing room
-   3) after starting an IV on her patient at 12:06, grabbed      the bag of what she thought was penicillin and added      it to the IV without checking the bag, scanning the      patients wristband or using the bar-code      administration system

**Notes:**
READ BEFORE NEXT  SLIDE If work a double shift, very likely to be awake for 19  or more hours.
If awake 19 or 24 hours doesn’t mean that you will make a mistake, but suggests that very high risk of errors, just like someone with a high BAL is likely to have a crash.
Next slide, shows what can happen when nurses are awake for sustained periods.  From CAN website. 

## The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. 

**Notes:**
READ BEFORE NEXT  SLIDE If work a double shift, very likely to be awake for 19  or more hours.
If awake 19 or 24 hours doesn’t mean that you will make a mistake, but suggests that very high risk of errors, just like someone with a high BAL is likely to have a crash.
Next slide, shows what can happen when nurses are awake for sustained periods.  From CAN website. 

## The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. 

- The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non-pharmacist dispensing and possessing/illegally obtaining a prescription)

**Notes:**
READ BEFORE NEXT  SLIDE If work a double shift, very likely to be awake for 19  or more hours.
If awake 19 or 24 hours doesn’t mean that you will make a mistake, but suggests that very high risk of errors, just like someone with a high BAL is likely to have a crash.
Next slide, shows what can happen when nurses are awake for sustained periods.  From CAN website. 

## The patient had an almost immediate adverse reaction and the nurse thinking she was reacting to the Penicillin stopped the drug and called a code. 

- The nurse was initially charged with a felony (negligent abuse of a patient, causing great bodily harm), charges reduced to 2 misdemeanors (non-pharmacist dispensing and possessing/illegally obtaining a prescription)
- License suspended for 9 months and no longer allowed to work any OB/birthing area, ICU, or critical care areas, or any shift >12 hours

**Notes:**
READ BEFORE NEXT  SLIDE If work a double shift, very likely to be awake for 19  or more hours.
If awake 19 or 24 hours doesn’t mean that you will make a mistake, but suggests that very high risk of errors, just like someone with a high BAL is likely to have a crash.
Next slide, shows what can happen when nurses are awake for sustained periods.  From CAN website. 

## Could it Happen Again?

***Could it Happen Again?***

## To determine if the extended shifts and overtime worked by full-time hospital staff nurses had an adverse effect on patient safety 

## 895 participants were predominately female (93%), middle-aged (mean age 44.5 ± 8.3,range 22-66), and Caucasian (82%) 
Worked at least 36 hours/week
Were unit based and employed by a hospital
Were members of the American Association of Critical Care Nurses or the American Nurses Association

- Worked at least 36 hours/week
- Were unit based and employed by a hospital
- Were members of the American Association of Critical Care Nurses or the American Nurses Association

***Participants***

**Notes:**
May also want to add a sentence to oral presentation that sample is representative of larger population of nurses in the US. 
I added the last phrase to provide a lead in to state that subjects were randomly selected from national sample of nurses. And to set the stage for a couple of later slides where you mention the two groups of subjects.

## Demographic Questionnaire 
Logbooks (2)
      28-day record of sleep/wake patterns, work        hours, difficulties remaining alert on duty and    	 	 errors

- Logbooks (2)
-       28-day record of sleep/wake patterns, work        hours, difficulties remaining alert on duty and    	 	 errors

**Notes:**
Can note that logbooks also used to collect data about errors, the findings of which have been published. 

## The majority of nurses no longer work traditional    8 hour day, evening, or night shifts

|  | ANA Sample      No. of Nurses (%) 
 | AACN Sample      No. of Nurses (%) | Total Sample      No. of Nurses (%)
 |
| --- | --- | --- | --- |
|   8 hours | 150 (38.3%) | 60 (11.9%) | 210 (23.4%) |
|   12 hours | 230 (58.7%) | 436 (86.2%) | 668 (74.2%) |
|   Other | 12 (3.1%) | 10 (1.9%) | 22 (2.4%) |

## The majority of nurses no longer work traditional 8 hour day, evening, or night shifts

##  Over one third of the shifts were scheduled for 12.5 hours or longer, and 43% of the shifts exceeded 12.5 consecutive hours. 
There were 44 shifts scheduled for ≥ 20 consecutive hours, and 123 shifts where nurses worked ≥ 20 consecutive hours.                                                                                     

-  Over one third of the shifts were scheduled for 12.5 hours or longer, and 43% of the shifts exceeded 12.5 consecutive hours.
- There were 44 shifts scheduled for ≥ 20 consecutive hours, and 123 shifts where nurses worked ≥ 20 consecutive hours.

## Scheduled and Actual Shift Durations (ANA Sample)

## Scheduled and Actual Shift Durations (ANA Sample)

- Shifts

***Scheduled and Actual Shift ******Durations (ANA Sample)***

## Scheduled and Actual Shift Durations (ANA Sample)

- Shifts

***Scheduled and Actual Shift ******Durations (ANA Sample)***

## Scheduled and Actual Shift Durations (AACN Sample)

***Scheduled and Actual Shift ******Durations (AACN Sample)***

## Scheduled and Actual Shift Durations (AACN Sample)

***Scheduled and Actual Shift ******Durations (AACN Sample)***

## Working longer than scheduled was normal 
    Nurses rarely left work at the end of their scheduled shift (19%, 13%)
    They averaged almost an hour (55 minutes, 49 minutes) extra work/day
    Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample

-     Nurses rarely left work at the end of their scheduled shift (19%, 13%)
-     They averaged almost an hour (55 minutes, 49 minutes) extra work/day
-     Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). *ANA Sample*

## Working longer than scheduled was normal    Nurses rarely left work at the end of their scheduled shift (19%, 13%)
    They averaged almost an hour (55 minutes, 49 minutes) extra work/day
    Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). ANA Sample
The frequency of mandatory overtime varied
    ANA Sample 360 shifts (7%) were mandated and 143 voluntary overtime shifts (3%) were coerced
    AACN Sample 263 shifts (16.5%) were mandated and 152 voluntary overtime shifts (12.3%) were coerced

-     They averaged almost an hour (55 minutes, 49 minutes) extra work/day
-     Overtime was less frequent when nurses worked 12-hour shifts (79% versus 85%). *ANA Sample*
- The frequency of mandatory overtime varied
-     *ANA Sample* 360 shifts (7%) were mandated and 143 voluntary overtime shifts (3%) were coerced
-     *AACN Sample* 263 shifts (16.5%) were mandated and 152 voluntary overtime shifts (12.3%) were coerced

## Errors

***Errors***

## Just under one-third of the participants reported making an error during the data-gathering period.                                  

Near errors were reported by one third of the participants.

- Just under one-third of the participants reported making an error during the data-gathering period.
- Near errors were reported by one third of the participants.

## Association of Work 

***Duration and Errors***

- * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

| Work Duration (hours) | ANA Sample* |  |  | AACN Sample |  |  |
| --- | --- | --- | --- | --- | --- | --- |
|  | No. Shifts (%) | No.  shifts with at least one error (%) | OR  (p= value) | No. Shifts (%) | No.  shifts with at least one error (%) | OR  (p= value) |
| ≤ 8.5 | 771 (14.4%) | 12 
(1.6%) | 1.0 | 543
 (9%) | 11 
(2%) | 1.0 |
| > 8.5, < 12.5 | 2484 (46.8%) | 77 
(3.1%) | 1.85 (0.06) | 1720 (29%) | 46 
(3%) | 1.42 (0.304) |
| ≥ 12.5 | 2057 (38.9%) | 103 
(5%) | 3.29 (0.0001) | 3748 (62%) | 146 
(4%) | 1.94 (0.028) |
| Total | 5312 | 192 |  | 6011 | 203 |  |

## Association of Work 

***Duration and Errors***

- * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

## Association of Errors with

- * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

***Association of Errors with***
***Overtime (ANA sample)***

## Association of Errors with

| Work Duration 
(hr) | Overtime | No. of Shits ≥ 1 error  (%) | OR (p-value) |
| --- | --- | --- | --- |
| ≤ 8.5 | No | 8/377 (2.1%) | 1.00 |
|  | Yes | 64/2075 (3.1%) | 1.34 (0.42) |
| > 8.5, <12.5 | No | 6/246 (2.4%) | 1.00 |
|  | Yes | 36/937 (3.8%) | 1.53 (0.36) |
| ≥ 12.5 | No | 6/360 (1.7%) | 1.0 |
|  | Yes | 70/1263 (5.5%) | 3.26 (0.005) |
| Total |  | 191/5258 |  |
|  |  |  |  |

- * Rogers, et al, 2004, Hospital Staff Nurse Work Hours and Patient Safety Health Affairs

***Association of Errors with***
***Overtime (ANA sample)***

**Notes:**
Emphases that it made not difference in whether overtime was mandated or voluntary, overtime of any sort was associated with an increased risk of making an error

## Sleepy Nurses

***Sleepy Nurses***

## Difficulties Remaining Alert 

***on Duty Were Common***

## Difficulties Remaining Alert 

***on Duty Were Common (cont.)***

## Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)

***Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)***

## Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)

***Time of Day When Nurses Reported Difficulties Remaining Alert (Both Samples)***

## Long Work Hours Adversely Affect Vigilance (AACN Sample)

| Work Duration  (hours) | Struggling to Stay  
Awake on Duty |  | Fell Asleep on Duty |  |
| --- | --- | --- | --- | --- |
|  | No. shifts (%) | OR (p-value) | No. Shifts (%) | OR ( p-value) |
| ≤ 8.5 | 77 (14%)  | 1.0 | 4 (0.7%) | 1.0 |
| > 8.5, <12.5 | 279 (16%) | 1.1 ( 0.695) | 30 (1.8%) | 1.9 (0.043) |
| ≥ 12.5 | 847 (23%) | 1.15 (0.007) | 44 (3.9%) | 2.40 (0.014) |
| Total | 1203 |  | 178 |  |

***Long Work Hours Adversely Affect Vigilance (AACN Sample)***

## Long Work Hours Adversely Affect Vigilance (AACN Sample)

| Work Duration  (hours) | Struggling to Stay  
Awake on Duty |  | Fell Asleep on Duty |  |
| --- | --- | --- | --- | --- |
|  | No. shifts (%) | OR (p-value) | No. Shifts (%) | OR ( p-value) |
| ≤ 8.5 | 77 (14%)  | 1.0 | 4 (0.7%) | 1.0 |
| > 8.5, <12.5 | 279 (16%) | 1.1 ( 0.695) | 30 (1.8%) | 1.9 (0.043) |
| ≥ 12.5 | 847 (23%) | 1.15 (0.007) | 44 (3.9%) | 2.40 (0.014) |
| Total | 1203 |  | 178 |  |

***Long Work Hours Adversely Affect Vigilance (AACN Sample)***

## Long Work Hours Adversely Affect Vigilance (AACN Sample)

| Work Duration  (hours) | Struggling to Stay  
Awake on Duty |  | Fell Asleep on Duty |  |
| --- | --- | --- | --- | --- |
|  | No. shifts (%) | OR (p-value) | No. Shifts (%) | OR ( p-value) |
| ≤ 8.5 | 77 (14%)  | 1.0 | 4 (0.7%) | 1.0 |
| > 8.5, <12.5 | 279 (16%) | 1.1 ( 0.695) | 30 (1.8%) | 1.9 (0.043) |
| ≥ 12.5 | 847 (23%) | 1.15 (0.007) | 44 (3.9%) | 2.40 (0.014) |
| Total | 1203 |  | 178 |  |

***Long Work Hours Adversely Affect Vigilance (AACN Sample)***

## Sleepy nursescan endangerthe general public

- Sleepy nursescan endangerthe general public

## Drowsy Driving Was Common

|  | ANA Sample | AACN Sample |
| --- | --- | --- |
| No. nurses reporting ≥ 1 episode of drowsy driving | 263 (66.9%) | 331 (65.9%) |
| No. of shifts with drowsy driving | 1281 (24.6%) | 1639 (27.5%) |

***Drowsy Driving Was Common***

**Notes:**
Note that these numbers are very similar to those reported for struggling to stay awake at work.  Approximately 2/3 of sample have trouble staying awake at work.  Slightly higher number of shifts affected.  Drowsiness 1 in 5, drowsy driving approximately 1 in 4 shifts.

## number of times that drowsy driving was reported ranged from 1-20 times
only 21% of those who reported struggling to stay awake driving home, reported it only once
just under 1/4 of participants reported struggling to stay awake driving home from work at least 75% of the time
30 nurses (5%) reported difficulties staying awake driving home after every shift they worked

- only 21% of those who reported struggling to stay awake driving home, reported it only once
- just under 1/4 of participants reported struggling to stay awake driving home from work at least 75% of the time
- 30 nurses (5%) reported difficulties staying awake driving home after every shift they worked

***Drowsy Driving Wasn’t Just a ******One Time Occurrence***

**Notes:**
At present can’t explain the differences between the two samples.  Not sure why age and high caffiene intake shortens sleep among members of ANA sample and not members of the AACN sample. Or why elder care responsiblities shortened sleep by 20 minutes for members of the AACN sample and not the ANA sample. 

## Working 12-hour shifts doubled the risk of drowsy driving
Longer commutes
Working at night (at least 6 hours between 2200 and 0600) nearly quadrupled the risk of struggling to stay awake driving home

- Longer commutes
- Working at night (at least 6 hours between 2200 and 0600) nearly quadrupled the risk of struggling to stay awake driving home

***Factors Associated with Drowsy Driving***

**Notes:**
At present can’t explain the differences between the two samples.  Not sure why age and high caffiene intake shortens sleep among members of ANA sample and not members of the AACN sample. Or why elder care responsiblities shortened sleep by 20 minutes for members of the AACN sample and not the ANA sample. 

## Nurses Who Struggled To Stay Awake Driving Home Obtained Less Sleep

***Nurses Who Struggled To Stay Awake Driving Home Obtained Less Sleep***

|  | ANA Sample | AACN Sample |
| --- | --- | --- |
| Drowsy Drivers   Mean sleep duration (hrs)   Median sleep duration (hrs) |  6.37 ± 2.016.5  | 6.3 ± 2.106.2 |
| Alert Drivers   Mean sleep duration (hrs)   Median sleep duration (hrs) | 6.89 ± 1.636.98 | 6.77 ± 1.656.75 |

**Notes:**
Note that these numbers are very similar to those reported for struggling to stay awake at work.  Approximately 2/3 of sample have trouble staying awake at work.  Slightly higher number of shifts affected.  Drowsiness 1 in 5, drowsy driving approximately 1 in 4 shifts.

## David Dinges PhD
Wei-Ting Hwang PhD
Linda Scott PhD, RN

- Wei-Ting Hwang PhD
- Linda Scott PhD, RN

- American Association of Critical Care Nurses
- American Nurses Association
- Agency for Healthcare Research and Quality (R01 HS11963)
- American Nurses Foundation Grant (Scott)

## Slide 42