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'Decision Regret' in Nurses Linked to Fatigue

 |  By Alexandra Wilson Pecci  
   January 14, 2014

Calling twelve-hours shifts "one of the worst things we ever did," the author of a study on inadequate sleep among nurses is calling for leaders to encourage strategic napping and shorter shifts.

My four-year-old daughter recently spent six nights in the hospital after surgery, and I was thrilled when her favorite nurse took care of her two days in a row. This nurse worked the day shift: 7:00 AM to 7:00 PM. She was there when my daughter was getting ready for bed one night, and again when she was waking up the next morning.

"You're back!" I said to her. "Did you sleep?"

She laughed, and said yes, she had slept. But how long had she slept? I know she has two young daughters of her own, and lives outside the city where the hospital is. I also know that even though their shifts ended at 7:00 PM, the nurses didn't really leave until around 7:30.

Factor in the evening commute, eating dinner, putting the kids to bed, winding down, getting the kids ready for school the next day, and the morning commute, how much time could there really be left for sleep?

I felt torn. As a mother, I was thrilled that this wonderful nurse was there to care for my daughter again. In fact, a part of me wished she could be there 24/7! But as a nursing writer, I'm all too aware of the issues that can arise when nurses don't get enough sleep.

That's why I was especially intrigued when I read last week about a study in the January issue of the American Journal of Critical Care that links nurse fatigue with "decision regret," which is defined as "a negative cognitive emotion that occurs when the actual outcome differs from the desired or expected outcome."

How Much Sleep is Enough?
The study's lead author, Linda D. Scott, PhD, RN, NEA-BC, FAAN, Associate Dean for Academic Affairs at the University of Illinois at Chicago College of Nursing, says sleeping four or five hours per night simply isn't enough.

"We still require eight hours of sleep within a 24-hour period in order to be effective the next day. [Otherwise,] it's very difficult for you to make good decisions," Scott says, adding that losing even one or two hours of sleep each night is enough to impair function. In fact, other research has shown that "20-25 hours of wakefulness produced performance decrements equivalent to those observed at a blood alcohol concentration of 0.10%."

Scott surveyed 605 nurses, and 29% of them reported having experienced decision regret. Nurses with decision regret reported "more fatigue, more daytime sleepiness, less inter-shift recovery, and worse sleep quality than did nurses without decision regret."

Scott says nurse leaders spend a lot of time thinking about the kinds of people who they hire to staff their unit, and this is, of course, critically important. A study I wrote about just last week associated lower odds of patient death with more years of nursing experience. But it's also important to think about how nurses work.

"It's not just about having the right mix of people, but really truly thinking about the other human factors that really affect the service and care," Scott says. "It's not just about the numbers, but it's about having a healthy environment with healthy employees. And how can we make that happen?"

Encourage Naps
Scott says nurse and hospital leaders should prioritize sleep and incorporate fatigue countermeasures into the workplace on an organization-wide level. Scott says HR policies where people can be fired if they take a nap are counterproductive. Instead, nurses should be encouraged to take real breaks—and turn off their phones!—and maybe even take 15-minute naps in designated quiet rooms.

Nurses who nap "would be so much more alert for the rest of their shift than having someone just continue to go through the motions," Scott says. Such "strategic naps" could really help nurses feel more alert.

"This would be an important thing for health leaders to consider. Even though space is a premium, it's an opportunity to make an investment in your staff," Scott says of creating sleep spaces. "Completely relieved breaks should be mandatory, and anything we can do to break up consecutive awake hours should be strongly encouraged."

She also says nurse leaders should consider natural circadian rhythms when scheduling. For instance, shifts that start 3:00 am, when the body naturally wants to be asleep, set nurses up to be fatigued. Twelve-hour shifts and not leaving enough rest time between shifts can also contribute to fatigue.

Reconsider 12-Hour Shifts
"Twelve-hours shifts is probably one of the worst things we ever did," she says. "It's thinking about doing things differently. [Nurse leaders should be] partnering with the staff instead of punishing them for taking breaks or covering for each other."

Scott acknowledges that cultural factors can stand in the way of taking breaks or naps. She says nurses often say they "don't get fatigued, or they just keep going or they force themselves to stay awake. That's almost physiologically impossible to do."

And although many nurses say they like working successive 12-hour shifts, and having long stretches of time off, Scott says picking up extra shifts on days off is common.

She also says nurses sometimes believe that "no one else can take care of my patients the way that I can take care of them;" they're reluctant to "hand over the accountability to someone else."

Finally, nurses often feel guilty when they take breaks (although she notes that smokers manage to find the time for multiple cigarette breaks).

Despite the cultural and organizational hurdles, Scott feels strongly that nurses and nurse leaders can't just carry on doing things the way they've always done them.

"When I've done presentations before I will have nurse leaders say—especially related to 12-hour shifts—that they don't want to make a change because they're afraid they'll lose their staff," Scott says.

"They may be afraid of that outcome, but there are other outcomes that are even more concerning and more serious. Our patients can't afford that. We can't afford that. Patients, employees, and employers all deserve better. We can do better."


Alexandra Wilson Pecci is an editor for HealthLeaders.

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