Multiple Jobs Add to Nurse Fatigue

Nurses seeking higher incomes are working multiple jobs, which leads to fatigue and puts patient safety at risk. Should state nursing boards step in?

The author of a study linking nurses' decision regret with fatigue has called 12-hour shifts "one of the worst things we ever did."

I wrote about that study recently and it touched a raw nerve; I received email and comments from lots of readers. They not only agreed that 12-hour shifts are a bad idea, but also pointed out a number of nuances about the matter that working nurses know very well:

• Hand-hygiene compliance declines throughout a shift;
• Medication errors are linked with fatigue;
• Nurses have noticed that patient requests fall through the cracks during 12-hour shifts;
• 12-hour shifts might contribute to a lack of continuity in patient care; and
• Nurses "stack" working days so that they work 6 days in a row and can have a week off ("I would not want to be the patient of that nurse doing the 6th shift," one reader wrote).

And more than one reader pointed out the issue of nurses working multiple jobs. This is an interesting problem because it undermines efforts from hospitals and sometimes even states to reduce nurse fatigue.

For instance, Robert Wood Johnson Foundation research shows that even though state mandates are helping to curb mandatory nurse overtime, "regulations targeting hospital compliance overlook regulating nurses themselves, who can choose to increase their work hours (and fatigue) by working multiple jobs."

An 'Ethical Responsibility' to Consider Fatigue
An ANA position statement says that "Registered nurses should consider the impact that multiple jobs have on their level of fatigue and ability to practice safely" and that "all registered nurses have an ethical responsibility to carefully consider their level of fatigue [PDF] when deciding whether to accept any assignment extending beyond their regularly scheduled work day or week." (ANA is revising its position statement on nurse fatigue; the public comment period is open until February 10).

ANA spokesperson Adam Sachs tells me via email that: [The] "ANA does not know of any laws or regulations prohibiting nurses from working second jobs. We have heard anecdotes about employers requiring employees to fill out a form to notify them prior to taking a second job. There also may be organizations that prohibit nurses from taking second jobs by contract, but we can't verify that."

One nurse leader who's had experience with nurses working multiple jobs is Kathryn Hughes MSN, RN, program coordinator, nursing administration at University Medical Center in Las Vegas. She tells me via email that as a clinical manager, she often sees nurses who have multiple jobs, such as ones who have two full-time jobs; work per diem at several different locations; work full-time at one job and per diem elsewhere; or work as both a full-time nurse and a nursing instructor.

She says that these nurses are totally honest about having two jobs, and that the hospital has no policy governing what its staff does in their off-time.

The Root of Fatigue: Money
Yet Hughes recalls experiences that should make any nurse leader question their employees who work more than one job. She says she's seen everything from nurses who act surly toward patients to ones who fail to double-check medication labels. She even had a nurse who arrived to work a 12-hour day shift immediately after working a 12-hour night shift at another facility.

"I sent her home," Hughes says. "I would rather [work] short staffed than with a dangerously fatigued nurse."

So why do nurses tax themselves this way, especially when evidence shows that fatigue impairs function and decision-making?

"The most common reason is money," Hughes says. "We have single parents, persons trying to fund children's college tuition, persons trying to fund their own college tuition, persons who have not set back money for retirement and now are nearing retirement and trying to get money put aside"

Hughes believes that it's in the best interest of patient care for there to be some sort of formal limits on how many hours a nurse can work per week, one that takes into account the fact that some nurses might work multiple jobs.

"Hospitals cannot govern what people do when they are off, but I would imagine the board of nursing can," she says. "I would like to see all 50 [state] boards of nursing band together and limit nurses working hours. I would like to see limits of x hours/24 hour period and x/hours per week. Nurses could keep logs of their time worked much like truckers log books of how many hours on the road."

But perhaps the real, underlying issue here is why nurses feel they need to work more than one job to begin with.

"[I]t is essential for health care organizations to pay adequate salaries to nurses," Sachs says, "so they don't feel compelled to get a second job to support themselves and/or a family, since nursing is very demanding work physically, mentally, and emotionally."