Are Over-Tired Nurses Putting Patients at Risk?

Sleep-deprived nurses may not only be putting their own health at risk but the health of their patients as well. As the effects of sleep deprivation become better understood, evidence is surfacing that it’s time to put to rest any practices that prevent nurses from getting the sleep they need between shifts.

To Sleep, Perchance to Dream

Why does sleep matter so much? A chronic failure to get sufficient sleep has a profound effect on health, job performance, and the bottom line. It plays a role in cognitive function and job performance because it results in slower reaction times, impaired memory and psychomotor coordination, and flawed decision making. Missing only 1½ hours of sleep can reduce alertness by as much as 32%, inhibiting the ability to think and process information. Drowsiness also doubles the risk of an occupational injury. Over the long-term, sleep deprivation impairs immune function and can contribute to hypertension, heart attack, stroke, obesity, depression and other mood disorders, and mental impairment.

Sleep deprivation also puts nurses at risk on the road. The National Highway Traffic Safety Administration (NHTSA) estimates that drowsy driving contributes to at least 100,000 automobile crashes, 71,000 injuries, and 1,550 fatalities each year. A survey conducted by the American Nurses Association reported that 10% of its respondents had been involved in auto accidents that were thought to be caused by fatigue.

Eyes Wide Open

Statistics about our current sleep habits are an eye-opener. Sleep experts recommend at least 8 hours of sleep in every 24-hour period, but on average, sleep hours have decreased from 9 hours in 1910 to as little as 6.9 hours on work days in 2002. Like the general population, nurses are getting less sleep, typically averaging only 6.8 hours on work days.

Most frightening about this statistic is the fact that most people cannot accurately judge the extent of impairment that sleep deprivation inflicts. They may believe they are performing well with judgment intact when, in fact, disastrous events are about to unfold. Lack of sleep can be a player in judgment errors that cost the U.S. up to $18 billion a year. High-profile accidents—such as Three Mile Island, Chernobyl, the Exxon Valdez, and the launch of the tragically fated Space Shuttle Challenger—all had roots that were traced back to decisions made either at night or during early morning hours when alertness is at its worst.

Here’s an alarming thought: Studies show that when an individual has been awake for as few as 17 hours straight, cognitive and psychomotor performance deteriorates to working with a blood alcohol level of 0.05%. Clearly, few nurses would consider coming to work drunk, but caring for patients while sleep-deprived can have equally serious consequences.

The Cost of Lost Sleep

Much discussion about the safety risks from working excessively long shifts has focused on resident physicians and interns. Perhaps less attention has been paid to the effect of fatigue on nurses. Some recent studies, however, demonstrate that long shifts and overtime are related to inability to stay awake on the job and nearly triple the risk of error. In one study, more than 60% of nurses admitted they struggled to stay awake on the job while 20% actually fell asleep. Another study found that nurses who had reported an error had significantly less sleep than nurses who did not. The study highlighted the depth of the problem: Only 27.2 % of the participants in the study had at least six hours sleep before working their shift; more than 29% of the shifts studied were worked by nurses who had less than 6 hours sleep—a level of sleep deprivation that is clearly associated with a higher risk of errors. Although more study is needed, a pattern has emerged: Sleep deprivation is a danger to nurses and their patients.

To Sleep or Not to Sleep

In response to growing concern about the risks of healthcare worker fatigue, the Joint Commission issued a sentinel event alert. In it, they recommended that healthcare organizations take action to reduce the risks of fatigue, including implementing a fatigue management plan, providing education to staff about sleep and fatigue, encouraging naps during the work shift when needed, involving staff in scheduling, and improving work schedules, staffing levels, and hand-off processes.

Sleep experts offer this advice to nurses, nurse managers, and nursing administrators to work together to change the culture so that nurses get enough sleep:
• Limit work hours to 12 hours a day and 60 hours a week with no fewer than 10 hours a day off duty. One to two days off should follow five consecutive 8-hour shifts or four consecutive 10-hour shifts. Two days off should follow three consecutive 12-hour shifts.
• Enforce rest breaks every few hours. Anecdotal evidence suggests that nurses often sacrifice breaks to provide patient care. Shorter, more frequent breaks are more effective in fighting fatigue than fewer, longer breaks.
• Educate staff about the dangers of lack of sleep and the resources available to help them resolve any difficulties with work schedules.
• Analyze close calls and incident reports to determine if fatigue was a contributing cause.

Nurses can take steps to help ensure that they remain alert while caring for patients. First and foremost is getting enough sleep. Although this can prove challenging and sometimes require difficult lifestyle choices, the importance of sufficient sleep can’t be stressed enough. When sufficient sleep is not an option, these strategies may help:
• If your nurse manager approves, take a short nap—less than 45 minutes—during breaks. If your facility does not already have a policy in place that allows for napping, work with your nurse manager to create a culture that encourages nurses to get enough sleep.
• Take a nap before starting a shift that begins at 11 p.m. or later. Most nurses who work on late shifts are awake longer before beginning their shift than nurses on other shifts.
• Caffeine can be therapeutic. When short on sleep, have some caffeine at the beginning of the shift or about an hour before you think you will reach your “slump.” One or two cups are enough to provide a significant increase in alertness and performance. Combining caffeine with a short nap is even more effective than either napping or caffeine alone.

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