fatigue management guidelines georgia hospital association may 22, 2014 robert l. dent, dnp, mba,...
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Fatigue Management Guidelines
Georgia Hospital AssociationMay 22, 2014
Robert L. Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE
Vice President, Patient Care Services / Chief Nursing Officer
Midland Memorial Hospital
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Objectives
To understand the literature related to fatigue management.
To understand the practice at Midland Memorial Hospital before Fatigue Management Guidelines.
Review Midland Memorial Hospital’s Fatigue Management Guidelines and current practice.
Outline a leadership framework for implementing best practices.
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Leading Indicators for FatigueCausal factors Long work hours
(overtime)
Low job satisfaction
Low control over overtime
Extended work periods
Individual risk factors Age
Need for drug therapy
Illnesses (i.e., diabetes, coronary disease, etc.)
Stress/anxiety
Workers with young children
Source: www.asse.org, Professional Safety, December 2010
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Immediate Effects of Fatigue Reduction in physical capacity (weakness)
Reduction in work
Mistakes
Slips
Lapses
Weariness
Memory loss
Sleepiness
Discomfort
Weakened motivation
Irritability
Illness
Source: www.asse.org, Professional Safety, December 2010
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Human Error, Work Environment & ImpactsHuman error
Definition Susceptible environments
Impact of cognitive fatigue
Mistakes Intentional planning related error (e.g., skill-based errors)
Dynamic work environments and standardized work processes do not ensure sufficient worker-hazard interactions
Mistakes become more common as workers’ judgment deteriorates during extended periods of work and mistakes remain undetected
Slips Unintended erroneous actions that result from mental distractions in familiar work environments
Typical work environments with one or more unusual external distractions.
Distractions have a greater effect as workers have increasing difficulty focusing on their work tasks.
Lapses Unintended erroneous actions that result from temporary memory failure
Typical work environments
Memory failures increase dramatically during periods of mental fatigueSource: www.asse.org, Professional Safety, December
2010
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Lagging Indicators of Fatigue
Effects of fatigue on performance
Reduction in quality
Reduction in productivity
Increased severity of injuries
Increased frequency of injuries
Quality of life impacts
Illnesses (i.e., GI, CAD, HTN, etc.)
Stress
Sleep complaints
Unhealthy diets
Lack of exercise
Smoking
Suicide due to overwork
Source: www.asse.org, Professional Safety, December 2010
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Practice Environment beforeMMH Fatigue Management Guidelines
16-hour shifts normal for RNs, house supervisors, pharmacists and others.
No regard or respect to the effects of fatigue on safety.
Poor results on surveys (e.g., NDNQI RN Satisfaction Survey, Culture of Patient Safety).
Other effects unrecognized that may have been contributed to poor management of fatigue.
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Getting started (2008)
Texas Nurses Association’s Practice Committee – Dr. Debora Simmons
Formed interprofessional team to review literature and create a guideline.
Guideline approved through shared governance structure (buy-in).
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Patient Care ServicesShared Accountability Structure
EmpiricalOutcomes
Share
d G
overn
ance
Model
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MMH Fatigue Management Guideline (2009)
PURPOSE: To provide a strategy that recognizes and manages the potential negative consequences of sleep deprivation and sustained work hours on patient outcomes and staff well-being.
GUIDELINE: The direct patient caregiver is responsible and accountable for individual practice and understanding the consequences of fatigue in preserving integrity and safety. Guidelines for length of hours worked, and number of hours worked in patient care assignments during a period of seven days will be followed.
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Definitions On-call
Call hours worked
Extended work period \ sustained work hours
Extended hours worked per week
Fatigue
Circadian rhythms
Off-duty
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Guidelines Except in emergency situations, direct patient caregivers
should not work in direct patient care assignments more than 12.5 consecutive hours in a 24-hour period, not more than 60 hours in a seven-day period, and not scheduled more than three consecutive 12-hour shifts. Working outside of these parameters requires Manager and/or Director approval.
Off-duty periods should be inclusive of an uninterrupted sleep cycle, a break from continuous professional responsibilities, and a period of time of not less than eight (8) hours to perform activities of daily living.
Arrangements will be made in relation to the hours worked, to provide additional time off for direct patient caregivers working a longer shift, an extra shift, or hours worked on call to accommodate an adequate off-duty recuperation period.
The number of shifts, or on-call shifts assigned during a seven day period should reflect the above guidelines as to number of sustained work hours and adequate recuperation periods.
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Guidelines (cont.)
An individual’s ability to meet an increased work demand should be taken into account.
All direct patient caregivers should uphold their ethical responsibility to patients and to themselves to arrive at work adequately rested and prepared for duty.
In extreme conditions, i.e. surge management or a disaster, staff may be asked to work additional hours, following the above guidelines for fatigue management.
Leaders have a responsibility to monitor staff fatigue, provide breaks and release staff as soon as possible.
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Other initiatives
Clinical Manager Model
Agency for Healthcare Research and Quality’s (AHRQ) TeamSTEPPS® Training
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Updated Review (2014)
Defined “direct patient caregiver” as clinical nurse, physical therapists, respiratory therapists, pharmacists, scrub tech as required.
Recommendation for all employees.
Sleep Hygiene: the promotion of regular, healthy sleep.
Added adapted Fatigue Management Model from The American Society of Safety Engineers (www.asse.org, Professional Safety, December 2010).
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Adapted Fatigue Management Model
Immediate Effects• Decreased productivity• Increase in mistakes, slips,
and lapses• Decrease in teamwork• Weariness• Physical weakness• Lack of motivation and/or
engagement• Sleepiness• Irritability• Concentration difficulties• Stress• Burnout
Countermeasures• Fatigue Management
Guidelines• Breaks• Hydration• Decrease pace• Increase teaming• Sleep hygiene
Long-Term Effects• Chronic illnesses• Insomnia• Family problems• Increased Mortality &
Morbidity
Causal FactorsShift work
Extended work shifts
Work time control
Repetitive tasksNighttime work
Individual Risk Factors
AgeLiving ConditionsCircadian rhythmsPreexisting illness
Prior work experience
Fatigue
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A Leadership Framework from Kouzes & Posner Model the way
Inspire a shared vision
Challenge the process
Enable others to act
Recognize the
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References
1. Birmingham, S.E., Dent, R.L., Ellerbe, S. (2013). Reducing the impact of RN fatigue on patient and nurse safety. Nurse Leader. 31-34.
2. Bosek, M.S. (2001) Mandatory overtime: Professional duty, harms, and justice. JONAS Healthcare Law Ethics Regulations. (4):99-102.
3. Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. American Operating Room Nurse, 87(6), 1191-1204.
4. Hallowell, M.R. (2010). Worker fatigue: Managing concerns in rapid renewal highway construction projects. Professional Safety. 18-26.
5. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: The National Academic Press.
6. Rogers, A.E., Hwang, W.T., Scott, L.D., Aiken, L.H., and Dinges, D.F. (2004) The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 23(4):202-212
7. Trinkoff, A.M., Le, R., Geiger-Brown, J., and Lipscomb, J. (2007) Work schedule, needle use, and needlestick injuries among registered nurses. Infection Control and Hospital Epidemiology. 28 (2) 156-164.
8. Wells, M.E. and Vaughn, B.V. (2012). Poor sleep challenging the health of a nation. Neurology J. 52: 233-249.
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Questions?
Contact Information:
Dr. Bob Dent
(432) 221-4566 – Office
(432) 559-2911 – Mobile
You may:
Follow me on Twitter @bobdent
Connect with me on LinkedIn
Thank you!