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Searching for Joy and Meaning at Work:

Supporting Staff Satisfaction and

Engagement

Ann Scott Blouin, RN, PhD, FACHE Joanne Watson, MD, MPH

Executive Vice President, Customer Relations Deputy Medical Director

The Joint Commission Torbay & South Devon

NHS Foundation Trust

5th Annual Middle East Forum on Quality and Safety in Healthcare

May 5, 2017

2

Objectives

Explore the concepts of joy and meaning within one’s professional work

Understand the issues around staff engagement, clinical leadership

behaviors, and how these directly relate to high quality clinical outcomes

Discuss specific strategies for developing joy and meaning in one’s work

3

To provide caring, competent care

When nurses feel powerless, they become disillusioned and

may leave their job or even the profession

Why Do People Choose Nursing?

4

Practicing from inner core beliefs

Understanding others from within (a sense of empathy

and connection to patients as persons)

Making a difference

Evolving as a professional nurse, willing to learn and

open to others

What Keeps Nurses in Nursing?

Adapted from Dunn, D. What Keeps Nurses in Nursing?

International Journal for Human Caring. 2012, Vol. 16, No. 3.

5

An intensely positive, vivid, and expansive emotion that

arises from an internal state or results form an external

event or situation.

What is Joy at Work?

Manion, 2003.

6

Gratitude

Intentional listening

Mindfulness with each interaction

Personal health & well-being

Willingness to help

Positivity

Personal Attributes Underlying Joy & Meaning

7

Loving your work

Being recognized

Achieving something meaningful

Feeling connected

Leads to satisfaction and engagement

What Creates Joy and Meaning?

Manion, 2003.

8

USA physicians: 60% respondents considering leaving

practice; 70% knew at least one colleague who left due to

poor morale

British physicians: 44% respondents had low or very low

morale

USA nurses: 35% felt like resigning from their current job

European surveys report nurse dissatisfaction ranging from

11% to 56%

Current State of Joy and Meaning

Sikka R, et al. BMJ Qual Saf 2015;0:1-3. doi:10.1136/bmjqs-2015-004160.

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Lack of organizational/unit support

Inability to provide quality care

Being overwhelmed with workload, exhaustion

Lack of challenge, boredom

What Prevents or Diminishes Joy & Meaning?

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What Really Is Fatigue?

Fatigue: “the body’s response to sleep loss or to

prolonged physical or mental exertion” (Am Coll

Occup Envir Med, 2012)

– Not the same as “sleepiness” which is the tendency to

fall asleep (e.g., boredom, post-prandial, night time)

Affected by both the quantity and quality of sleep

– Sufficient hours, individual variation

– Uninterrupted

– Consistency with natural day/night Circadian rhythms

Acute or chronic

11

Contributing Factors

Organization & Management

• Overtime requirements

• Inadequate staffing

• Excessive workload

• Lack of safety culture, trust

• Lack of support systems, provisions (places to rest, etc.)

Nature of the Work

• Shift work (around the clock)

• Shift rotation

• Shift length

• Patient / resident acuity, needs

• Mental and physical demands of activities

Personal

• “Moonlighting”

• Extra work, education

• Habits, choices

• Family (new baby, multiple care-giving roles)

• Sleep disorders

• Overconfidence

12

Contributing Factor: Staff Shortages

Staff Shortages

Difficulty in Recruiting &

Retaining Staff

Changing Work

Patterns (OT) & Physical demands

Impact on Quality of

Care

13

Costly and Dangerous Cycle When Workload-Staffing

Imbalance Exists

Understaffing

Increasing Overtime

FatigueStaff

Burnout

Increased Turnover

Source: Lerman et al, 2012, ACOEM Fatigue Risk Management

14

Consequences of Fatigue

Lapses in attention Inability to stay focused Memory lapses

Confusion

Irritability

Diminished reaction time Slowed or faulty information processing and judgment

Compromised problem solving

Impaired communication

Reduced motivation

Indifference and loss of empathy*

Adverse effects on worker nervous, cardiovascular, metabolic, and immune functioning **

Sources: Sentinel Event Alert 48, Dec 14, 2011; *Hughes 2004; **NIOSH 2009

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Potential Impact of Fatigue

Increased Rate of Errors

Patient Adverse Events

• Medication errors

• Charting errors

• Transcription

• Medical errors

Worker Adverse Events

• Sharps injuries

• Musculoskeletal injuries

• Decreased physical/emotional well-being

• Decreased personal safety (e.g., motor vehicle accidents)

Organi-zationalEffects

Sources: Rogers et al. 2004; Landrigan et al. 2007; Lockley et al 2007; DHHS (NIOSH) 2009

• Legal issues, injury claims

• Satisfaction

• Staff turnover

16

Alarming Statistics

Risk of error (especially medication errors) increases after 8

hours and is more significant after 12.5 hours

Employee accident rates increase after 9 hours of work and

double after 12 hours of consecutive work

3 Mile Island, Chernobyl, Exxon Valdez: accidents occurred at

night – contributing factor was sleep deprivation

17

Alarming Statistics

Extended work hours per day (>8hrs) = 37% increase in injury

rate

Extended work hours per week (>48hrs)= 23% increase in injury

rate

OT = 61% increase in injury rate

Time of day night nurses struggle to stay awake:

2 a.m. to 4 a.m. and 12 p.m. to 4 p.m.

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Recommendations for Staff

Eat balanced diet

Exercise to decrease work-dependent fatigue

Report unsafe work conditions

Recognize symptoms of own fatigue

Collaborate with other staff on taking breaks

Practice good sleep hygiene (schedule 7-8 hours of sleep)

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©2016 Advisory Board • All Rights Reserved •33975D

Source: “The AONE Nurse Executive Competencies,” AONE,

http://www.aone.org/resources/leadership%20tools/nursecomp.shtm;Nursing

Executive Center interviews and analysis.

19

20

Nobility (n.)

The state of being in one’s character, mind,

birthright, rank.

Associated with dignity, goodness and courage.

Adams, JH. The Joy of Nursing. Reclaiming Our Nobility. SteamboatSprings Publishing. 2011.

21

If one is lucky, one solitary fantasy

can totally transform one million

realities.

MAYA ANGELOU

Adams, JH. The Joy of Nursing. Reclaiming Our Nobility. SteamboatSprings Publishing. 2011.

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Maslow’s Hierarchy of Needs

Maslow, Abraham H. Oxford, England: Viking The farther reaches of human

nature.(1971). xxi 423 pp.

23

Deeply understand work environment challenges for the staff

Be an active listener and problem-solver

Develop initiatives to stimulate sense of meaning and

achievement

Use peer role models to help

Stop “fantasy thinking” about work-life balance

Money alone won’t provide joy & meaning

What Can Leaders Do to Help?

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3 Waves of Innovation in Patient Safety

Technical and procedural improvements have made surgery safer, but future innovations will

focus on reliably organizing the work of patient care.

Ghaferi AA, et al. The Next Wave of Hospital Innovation to Make

Patients Safer. Harvard Business Review. Aug. 8, 2016

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Leadership RPI

Commitment to

Zero Patient

Harm

Safety

Culture

Empowering staff to

speak up

about patient risks

Systematic data-driven

approach to solving

complex problems

High Reliability in Health Care Requires

26

Eight Recommendations for Achieving Total

Systems Safety

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Eight Recommendations for Achieving Total

Systems Safety

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ECRI Institute

New Safety Concern 2016

Failure to Embrace a

Culture of Safety

Healthcare organizations must have a culture of

safety that both spans the entire organization and

permeates each department.

Source: Top 10 Patient Safety Concerns for Healthcare

Organizations 2016. ECRI Institute Executive Brief. April 2016.

29

Why Culture Is Important

Culture

The shared values and beliefs of individuals

in a group or organization

CultureShared Values

& Beliefs

Shared Values& Beliefs Our Behaviors

Our Behaviors Outcomes

=

30

11 Tenets of a Safety Culture

Definition of a Safety Culture: Safety Culture is the sum of what an organization is and does in the

pursuit of safety. The Patient Safety Systems (PS) chapter of The Joint Commission accreditation

manuals defines safety culture as the product of individual and group beliefs, values, attitudes,

perceptions, competencies, and patters of behavior that determine the organization’s commitment to

quality and patient safety.

Source: “The essential role of leadership in developing a safety culture,”

The Joint Commission Sentinel Event Alert, Issue 57, March 1, 2017.

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11 Tenets of a Safety Culture(continued)

Source: “The essential role of leadership in developing a safety culture,”

The Joint Commission Sentinel Event Alert, Issue 57, March 1, 2017.

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Getting to Zero Harm

“The single greatest impediment to error prevention in the medical

industry is that we punish people for making mistakes.”

- Lucian Leape MD, member of the Quality of Health Care in America Committee

at the Institute of Medicine and adjunct professor of the Harvard School of Public Health

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A Psychologically Safe Culture:

Interlocking Elements

Learning

culture

Just

culture

Reporting

culture

Source: James Reason

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Essential Elements:

Culture of “Mindfulness” for Psychological

Safety

An atmosphere of trust in which errors and “near misses” are valuable

lessons

A “just” response to human errors, differentiating intentional from

unintentional

A system that provides for easy, de-identified reporting of unexpected

events and errors, and that gives feedback and learning to those who

report

A learning system that not only shares feedback, but uses the learning to

redesign the operations and challenge the assumptions that underlie the

system itself

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Safety Culture Maturation

Trust and intimidating

behavior are not assessed

Emphasis is on blame;

inequitable application of

discipline

Root cause analysis is

limited to adverse events

Limited or no efforts to

assess system defenses

against quality failures and

remedy weaknesses

No measures of safety

culture exist

Beginning Approaching

High levels of (measured) trust exist in

all clinical areas

All staff recognize/act on personal

accountability; equitable disciplinary

procedures

System defenses proactively

assessed; weaknesses proactively

repaired

Close calls/unsafe conditions routinely

reported with early problem resolution

Safety culture measures results

routinely reported to the board; system

improvement initiatives under way

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What Behaviors Are Intimidating?

Wide range: from hanging up the phone instead of answering a

question to verbal abuse (cursing, yelling) or physical abuse

Most common?

Refusal to answer questions or to return phone calls or pages;

condescending tone or language; impatience with questions

Have we improved?

37

Culture Change is Difficult

AHRQ Safety Culture Survey

1. Staff feel mistakes are held

against them (% YES)

2. When event is reported, it feels

like the person is being written up,

not the problem (% YES)

3. Staff worry mistakes are kept in

their personnel files (% YES)

2007 (n=382) 2012 (n=1128)

2007 2012

50

54

65

50

57

65

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https://www.jointcommission.org/issues/article.aspx?Article=rFhOFvmOhideyaeaXWHwd

F7iIsdGP%2bTcEobEhA7d2RU%3d accessed via internet June 24, 2016

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Some Barriers To Safety Culture

Blaming

Denial

Silence

Temporary fixes

Trade-offs

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Sometimes the silence gets

so loud, the only thing left

to do is hope your heart is

strong enough to beat it out

Author: Rachel Wolchin

Culture of Silence

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Drive out fear and create trust

- W. Edward Deming41

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TrustCredibility Reliability Authenticity

Self-Interest

“The Trust Equation”

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Trust

ReportImprove

Adapted from Reason J., and Hobbs A. 2003. Managing Maintenance Error: A

Practical Guide. Burlington, VT: Ashgate.

Safety Culture

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What gets rewarded gets repeated

“Recognition”

It’s not a natural skill . . .

It must be taught!

“65% of Americans reported that they received no recognition

for good work in the past year …”

Source: Rath T, Clifton D. How Full Is Your Bucket, 2004.

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Safety Culture

Principles and Traits

Principle Trait

Everyone is personally - Personal Accountability

responsible for safety

Leaders demonstrate a - Leadership safety values

commitment to safety

Trust permeates the - Effective safety communications

organization - Respectful work environment

- Environment for raising concerns

Decision-making reflects - Decision-making

safety first

Adapted from: Traits of a Healthy Nuclear Safety Culture. INPO 12–012, April 2013.

Copyright © 2012, 2013 by the Institute of Nuclear Power Operations

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Safety Culture

Principles and Traits(continued)

Principle Trait

Health care technology is - Work processes automated

recognized as special and

unique

A questioning attitude is - Questioning attitude applauded

cultivated

Organizational learning is - Continuous learning

embraced - Problem identification & resolution

Patient Safety undergoes - Continuous learning and fixes

constant evaluation - Problem identification

Adapted from: Traits of a Healthy Nuclear Safety Culture. INPO 12–012, April 2013.

Copyright © 2012, 2013 by the Institute of Nuclear Power Operations

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What Do Healthcare Staff Need for

Psychological Safety?

Respect and engagement

Freedom from harm

– physical

– psychological

Meaningful work

Opportunities to learn

and develop

Source: Lucian Leape Institute Roundtable, National Patient Safety Foundation 2013.

http://www.patientcarelink.org/uploadDocs/1/Through-Eyes-of-the-Workforce_online.pdf

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4949

© 2015 Press Ganey Associates, Inc.

Compassionate Connected Care ™ for the CareGiver

An approach to reduce CareGiver suffering…

We should acknowledge the complexity and gravity of the work provided by caregivers

It is the responsibility of management to provide support in the form of material, human, and emotional resources

Teamwork is a vital component for success

Empathy and trust must be fostered and modeled

Caregivers' perception of a positive work/life balance reduces compassion fatigue

Communication at all levels is foundational

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Elements of Psychological Safety in Teams

Trust teammates to support and help each other

Respectful communications

Assume good intentions – no “hidden agendas”

Believe everyone’s goals are aligned

Able to challenge others’ ideas in positive manner

Hold each individual accountable for own actions

Open to learning from mistakes

Fear is absent

51

Role of Hospital Leaders in Building a Culture of

Psychological Safety

Motivate care teams to uphold a fair and just safety culture

Provide a transparent environment in which patient safety

events are honestly reported

Model professional behavior

Remove intimidating behavior that might inhibit a culture of

safety

Provide the resources and training necessary to take on

improvement initiatives

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Where to Start: A Simple Test

Can your staff answer yes to the following three questions?

1. Am I treated with dignity and respect everyday by everyone I work with?

2. Do I have the knowledge, skills, and tools to do my job?

3. Am I recognized and thanked for my contributions?

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Triple Aim: Better Care. Better Health. Lower Cost.

Triple Aim

Consider Quadruple Aim: Meaningful Work

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Quadruple Aim

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Pre-Condition: Joy and Meaning

Respect and engagement

Freedom from harm

– physical

– psychological

Meaningful work

Opportunities to learn

and develop

Source: Lucian Leape Institute Roundtable, National Patient Safety Foundation 2013.

http://www.patientcarelink.org/uploadDocs/1/Through-Eyes-of-the-Workforce_online.pdf

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Strategy 1: Develop and embody shared core values of mutual respect and

civility; transparency and truth telling; safety of all workers and patients; and

alignment and accountability from the boardroom through the front lines

Strategy 2: Adopt the explicit aim to eliminate harm to the workforce and to

patients

Strategy 3: Commit to creating a high-reliability organization (HRO) and

demonstrate the discipline to achieve highly reliable performance. This will

require adopting evidence-based management skills for reliability

What Are the Seven Things

That an Organization Must Do?

“Through the Eyes of the Workforce: Creating Joy, Meaning and Safer

Health Care.” Lucian Leape Institute, National Patient Safety Foundation,

2013; pp. 27-29

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Strategy 4: Create a learning and improvement system

Strategy 5: Establish data capture, database, and performance metrics for

accountability and improvement

Strategy 6: Recognize and celebrate the work and accomplishments of

the workforce, regularly and with high visibility

Strategy 7: Support industry-wide research to design and conduct studies

that will explore issues and conditions in health care that are harming our

workforce and our patients

What Are the Seven Things

That an Organization Must Do?

“Through the Eyes of the Workforce: Creating Joy, Meaning and Safer

Health Care.” Lucian Leape Institute, National Patient Safety Foundation,

2013; pp. 27-29

58

References

Adams, JH. The Joy of Nursing. Reclaiming Our Nobility. SteamboatSprings Publishing. 2011.

Albaugh, JA. Resolving the Nursing Shortage: Finding Passion and Joy in Nursing. Urologic Nursing. February 2005, Vol. 25, No. 1.

American Nurses Association. Shiftwork Sleep Disorder: The Role of the Nurse Understanding the Consequences of SWSD For Your and

Your Patients. Toolkit Online, accessed 1/2/13.

Blouin AS, McDonagh KJ. Framework for patient safety, part 1: culture as an imperative. Journal of Nursing Administration. 2011 Oct

1;41(10):397-400.

Blouin AS, McDonagh KJ. A framework for patient safety, part 2: resilience, the next frontier. Journal of Nursing Administration. 2011 Nov

1;41(11):450-2.

Caruso, CC, Hitchcock, EM. Strategies for Nurses to Prevent Sleep Related Injuries and Errors. Rehabilitation Nursing 2010 Sept./Oct.;

35(5):192-197.

Consensus Statement of the Health Enhancement Research Organization, American College of Occupational and Environmental Cancer

Action Network, American Diabetes Association, and American Heart Association. Guidance for a Reasonably Designed, Employer-

Sponsored Wellness Program Using Outcomes-Based Incentives. Journal of Occupational & Environmental Medicine. 54(7):889-896, July

2012.

Dunn, D. What Keeps Nurses in Nursing? International Journal for Human Caring. 2012, Vol. 16, No. 3.

Ellis, JR. Quality of Care, Nurses’ Work Schedule, and Fatigue. Washington State Nurses Association White Paper, 2008.

Horstman, S. When Nurses Bond With Their Patients. The New York Times. September 13, 2013.

https://well.blogs.nytimes.com/2013/09/13/when-nurses-bond-with-their-patients/?_r=0

Hughes RG, Rogers, AE: Are you tired? Sleep deprivation compromises nurses’ health – and jeopardizes patients. American Journal ofNursing, March 2004;104(3)

59

References(continued)

Institute of Medicine: Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press,2004.

Joint Commission Resources. Strategies for Addressing Health Care Worker Fatigue. Oak Brook IL. 2008

Landrigan CP, et al: Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal ofMedicine, October 28, 2004;351:1838-1848

Landrigan C.P., et al.: Effective implementation of work hour limits and systemic improvements. Jt Comm J Qual Patient Saf. 33(suppl.):19–

29, Nov. 2007.

Lerman SE, Eskin E, Flower DJ, George EC, Gerson B, Hartenbaum N, Hursh SR, Moore-Ede M, ACOEM Presidential Task Force on

Fatigue Risk Management: Fatigue Risk Management in the Workplace Journal of Occupational & Environmental Medicine. 54(2):231-258,

Feb 2012.

Lockley SW, et al: Effect of reducing interns’ weekly work hours on sleep and attentional failures. NEJM October 28, 2004;351:1829-1837

Lockley SW, et al: Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf

November 2007;33(11)7-18, http://www.jointcommission.org/JQPS_11_07/

Lorenz, SG. 12-Hour Shifts: An Ethical Dilemma for One Nurse Executive. JONA 2008: 38(6)297-301.

McVay S, Kautz DD. Finding Joy, Gratitude, and Meaning in Routine PACU Tasks. Journal of PeriAnesthesia Nursing, Vol. 30, No. 2

(April), 2015: pp 160-163.

Middaugh DJ. Can There Really Be Joy at Work? MedSurg Nursing, Vol. 23, No. 2, March-April 2014.

NIOSH [2009]. State of the Sector | Health care and Social Assistance: Identification of Research Opportunities for the Next Decade of

NORA, Cincinnati, OH: US DHHS, Public Health Service, DHHS (NIOSH) Publication Number 2009-139

[http://www.cdc.gov/niosh/docs/2009-139/]

NPSF Lucian Leape Institute. Through the Eyes of the Workforce – Creating Joy, Meaning, and Safer Health Care. 2013.

60

References(continued)

Olds, DM, Clarke, SP. The Effect of Work Hours on Adverse Events and Errors in Health Care. J Safety Res 2010 April; 41(2);153-162.

Reason, J. Human Errors: Models and Management. BMJ 2000; 320:768-770.

Rogers AE, et al: The working hours of hospital staff nurses and patient safety. Health Affairs, 2004; 23(4):202-212

Rothschild JM, et al: Risks of complications by attending physicians after performing nighttime procedures. JAMA October 14,

2009;302:1565-1572

Scott, LD, Arslanian-Engoren, C, Engoren, M. “Association of Sleep and Fatigue With Decision Regret Among Critical Care Nurses.” AJCC

2014 January; 23(1):13-23.

Sikka R, et al. BMJ Qual Saf 2015;0:1-3. doi:10.1136/bmjqs-2015-004160.

Stimpfed, AW, Sloane, DM, Aiken, LH. The Longer the Shifts for Hospital Nurses, the Higher the Levels of Burnout and Patient

Dissatisfaction. Health Affairs 2012 November; 31(11):2501-2509.

The Joint Commission. Improving Patient and Worker Safety: Opportunities for Synergy, Conversation and Innovation. Oakbrook Terrace,

IL: The Joint Commission, November 2012.

The Joint Commission. Sentinel Event Alert. Health care worker fatigue and patient safety. Issue 48, Dec.14, 2011

http://www.jointcommission.org/assets/1/18/SEA_48.pdf

The Joint Commission. Strategies for Addressing Health Care Worker Fatigue. 2008. The Joint Commission: Oakbrook Terrace, IL.

Volpp, KG, et al. Effect of Protected Sleep Period on Hours Slept During Extended Overnight In-Hospital Duty Hours Among Medical Interns.

JAMA 2012; 308(21):2208-2217.

Wojciechowski M. Blog, Health & Wellness, May 9, 2016. http://dailynurse.com/why-i-love-being-a-nurse/. Accessed 1/31/2017.