There has been a spate of news articles in the last few months about nurse protests and threats of strikes. A frayed work environment lies at the heart of many of these confrontations, with a workforce that feels it is stretched too thin. Nurses are speaking up about overwork and short staffing and the effect they feel it has on patient care.
Nurses at a Veterans Administration hospital in Augusta, GA, last week planned a protest claiming 16-hour workdays that they said threatened patient care. Facing a budget deficit of several million dollars, the VA nurses association said the hospital was forced to slow hiring and extend nurses workdays.
The Washington State Nurses Association successfully sued two healthcare organizations over missed rest breaks. The rulings affirmed the employers' responsibility to provide uninterrupted rest breaks.
These incidents, and others, are surprising during a weak economy, when jobs are scarce—particularly for new grads—and employers in all professions find many people are simply grateful to have a job.
The complaints are even more surprising given the culture of nursing. Rarely having time for rest and meal breaks is part of the nursing folklore. New graduate initiation practically stipulates that a requirement of successful floor nurses is a gargantuan bladder.
This culture is entrenched. A 2004 study published in the Journal of Nursing Administration revealed that hospital staff nurses were completely free of patient care responsibilities during a break or meal period less than half the shifts they worked. In 10% of their shifts, nurses reported having no opportunity to sit down for a break or meal period. The rest of the time, nurses said they had time for a break, but no one was available to take over patient care.
The study found that nurses reported having only 25.7 minutes break during their entire shift. Nurses working the longest hours were least likely to receive appropriate breaks (e.g., 10 minutes every 2 hours and a 30-minute meal period free of patient care responsibilities).
Research demonstrates that overworked, tired nurses make more errors. They are more likely to make a medication error and they are less able to think critically. They may fail to catch the subtleties in a patient's case that indicate a serious problem, leading, eventually, to failure to rescue (which CMS is now tracking, incidentally).
This skewed culture can also be evidence of a deeper problem of horizontal hostility, also known as bullying, lateral violence, or nurses "eating their young." It manifests itself in a culture where nurses complain about having to watch someone's patients while they take a quick break. Or gossiping about so-and-so being a "bad nurse" because he leaves his patients to get lunch.
Instead of being viewed as a rite of passage, or a part of nursing, it should be required that nurses take breaks. Senior leadership should pay attention to whether nurses take breaks for the sake of staff and patient health.
Here are three tips leadership can implement:
1. Promote taking a break as the right thing to do for patient safety. The Washington State case found it was the hospital's responsibility to ensure nurses were receiving breaks, not the individual nurses. Leaders must step in. Ask nurse managers to pay attention to this issue and check whether staff are getting breaks. Support nurse managers to make the culture change when needed.
2. Educate nurses on the importance of breaks: Host a lunch and learn seminar on the importance of rest and the danger that fatigued nurses pose to patients. Provide strategies for busy units on how to ensure nurses are able to take breaks.
3. Implement fatigue countermeasures: It can be as simple as talking about breaks to change the culture of martyrdom too many nurses feel they must work under. Small investments can pay big dividends, particularly if you bring extra help. Consider having per diem or float pool nurses who work during meal periods. I've written before about creative scheduling for older nurses and those who want non-traditional hours. You'd be surprised at the number of people who would love to work two hours rather than a full shift. A hospital in California developed an SOS?save our staff—program to do just this. They have nurses who work 3- to 4-hours to cover lunch breaks. If a unit is stretched thin that day, they can ask the SOS nurses whether they want to stay longer.
Another option is to bring in nursing students. The hospital pays students to answer call bells or check dressings. It gives the students experience on the unit, which they want, and removes some of the burden from the RNs.
When budgets are stretched thin, it may appear the wrong time to focus on this issue. A little extra effort, however, can pay dividends in staff satisfaction and patient safety. And it just might stop those nurses ending up on the local evening news.
Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits www.StrategiesForNurseManagers.com and manages The Leaders' Lounge blog for nurse managers. Email her at rhendren@hcpro.com.