Running head: NURSE FATIGUE 1

An Evidence-Based Approach to the Reduction of Nurse Fatigue

Susan Scholar

Eastern Mennonite University

NRS 405

Nursing Research

August 27, 2013

An Evidence-Based Approach to the Reduction of Nurse Fatigue NURSE FATIGUE 2

Nursing care has evolved as a fundamentally important element in the quality, efficiency and safety of the healthcare system (Thompson, 2012). Because nurses are the healthcare providers who spend the most time at the bedside, they are in close touch with patients’ experiences and outcomes. It is no coincidence that hospitals have identified nurses as the leading providers of health care and are important in making a difference in quality of care

(Draper, Felland, Liebhaber, & Melichar, 2008).

Competence is a clear expectation of all nurses who aim to achieve the very best possible outcomes for all patients within their care (Hudacek, 2005). Many patients, however, perceive quality nursing care as involving not only competence on the part of the nurse, but also caring

(Hudacek). Caring is described in a very straightforward manner by Nelson (as cited in O’Brien,

2011) who has said that “caring is an active attitude which genuinely conveys to the other person that he or she does really matter” (p. 13). Nurses who demonstrate a caring attitude earn the trust and confidence of their patients (Bishop & Scudder as cited in O’Brien) and this is critical to the achievement of outcomes. Compassion is but one element of caring (Roach as cited in O’Brien).

Simply put, nurses are expected to be compassionate in their interactions with those under their care (Coetzee & Klopper, 2010). This is not easy, however. In general, nursing involves strenuous work and amounts to extensive pressure. Worldwide, nurses encounter demanding situations including heavy workloads, nursing shortages, lack of administrative support, and unpredictable work situations. In addition, shift work – working hours other than during the day -- increases the overall demands placed on nurses. All of these factors can influence nurses’ emotions and thus, the expression of compassion (Buchan; Van den Berg et al.;

Aiken et al.; as cited in Coetzee & Klopper). NURSE FATIGUE 3

Several factors can reduce nurses’ capacity for compassion: physical fatigue and compassion fatigue. Either or a combination of both may lead to burnout. Physical fatigue is the universally experienced lack of energy that results when a person’s rest and nutrition are inadequate to meet the demands placed on the body (Aaronson et al. as cited in Barker &

Nussbaum, 2010).

The term “compassion fatigue” was used for the first time by Joinson while studying burnout (as cited in Coetzee & Klopper, 2010). Compassion fatigue is a result of physical, emotional, and spiritual tiredness from seeing and becoming engrossed in the problems and pain of others. It results from a nurse’s constant, prolonged and intense exposure to patients’ distress

(Coetzee & Klopper). A related – but less commonly used term for CF -- was used by Figley

(1995) who called it “secondary traumatic stress disorder” (as cited in Coetzee & Klopper).

Ultimately, compassion fatigue (CF) is manifested in physical, emotional and social symptoms: lack of energy, predisposition to accidents, apathy, job dissatisfaction, lack of concern, heartlessness, and coldness towards patients (Coetzee & Klopper). Ultimately, compassion fatigue, with its physical and emotional components, may lead to the phenomenon known as burnout. Burnout, a serious problem in the profession of nursing, is the loss of interest and exhaustion from being overworked and experiencing prolonged stress (Wisniewski, 2013).

Overall, nurse fatigue has been linked to concerns about patient safety and nursing quality (Rogers et al.; Samaha et al.; Potera as cited in Fang, Qui, Xu, & You, 2013). Fatigue contributes to 70% of work-related injuries, as well as dysfunctional families and drug abuse in overworked employees (Vila as cited in Scott, Hofmeister, Rogness, & Rogers, 2010). Compared to other industrial sectors in 2010, the health care sector had the second largest number of work- place injuries and illnesses (Braun et al., 2012). NURSE FATIGUE 4

Clearly, it is vital to increase global awareness of the challenges of caring because failure to address this concern will continue to result in nurses dropping out of their jobs due to fatigue and burnout (Gordon, 2005). This concern must be addressed by nursing research. Nursing research has had and will continue to have an incredible impact on modern and future nursing practice (Tingen, Burnett, Murchison, & Zhu, 2009). Research supports better patient care.

Undoubtedly, study to address the measureable outcomes of nursing care is greatly needed to help in establishing appropriate standards for care (Shelly & Miller, 2006). As such, appreciating the role of nurses in improving quality and noting the challenges they face can help improve professional nursing practice and increase patient satisfaction (Draper et al., 2008).

Despite available data regarding the negative effects of nurse fatigue in general along with compassion fatigue specifically, my workplace does not have any initiatives designed to reduce nurse fatigue. The challenges faced as a result of long hours of work (eight versus 12 hourly shifts), overtime (more than 40 hours of work per week), and shift-work (evening, night, rotating shifts) are significant when it comes to safe nursing. In addition, the lack of breaks during work, heavy workload, and denied vacation requests contribute to burnout. The costs incurred by burnout because of staff illness/injury, medical errors, and nurse turnover cannot be ignored. Therefore, engaging in countermeasures to reduce nurse fatigue and burnout is of paramount importance in my workplace.

For my evidence-based practice project, I will explore an evidence-based approach to reducing nurse fatigue. I hope to do a poster presentation in my hospital to raise awareness of the problem. I will also collaborate with my nurse manager and others to devise interventions that may enhance nurse job satisfaction and retention with an ultimate goal of improving patient satisfaction and outcomes. NURSE FATIGUE 5

The Relationship Between Shift Work and Nurse Fatigue

One of the aspects of fatigue addressed in the research addresses its relationship to shift work. Accordingly, Yuan et al (2011) published an observational study in Taiwan to determine whether nurses working on day shift would function in the same way as those working non-day shifts. These researchers used a convenience sample of 107 registered nurses who worked in surgical and intensive care units. The participants worked eight hours a day with a maximum of

40 hours a week. The sample comprised of nurses 27 who worked during the day while 80 worked non-day shifts.

This quantitative study by Yuan et al. (2011) found a statistically significant difference in fatigue between the nurses working in shifts and those working during the day (p < 0.05). Nurses who worked shifts were more drowsy and fatigued than those who worked during the day (p <

0.1). This study also found that non-day shift nurses had more difficulty focusing than day nurses

(p < 0.05).

This level IIB study (Newhouse, Dearholt, Poe, Pugh & White, 2005) by Yuan et al.

(2011) was quite well conducted and appears credible. The data collection and analysis procedures appear to have been valid. A limitation, however, was the use of a convenience sample from one hospital. Furthermore, this research was conducted in Taiwan. It is difficult to know for sure if cultural differences may hinder generalizability of the results to my work place.

Therefore, the findings of this study (Yuan et al., 2011) may be generalized with some caution to the Children’s Hospital where I work.

This research by Yuan et al., 2011) is further supported by findings of a quantitative study by Barker and Nussbaum (2010) who found that mental, physical, and total fatigue differed according to work schedule, shift length and overtime. The Fatigue-Related Symptoms NURSE FATIGUE 6

Questionnaire (F-RSQ) instrument (Yoshitake as cited in Barker & Nussbaum, 2010) was completed by nurses who worked various shifts.

Findings of this study showed that physical fatigue differed with work schedule. Nurses who worked regular night shift and rotating shifts were less mentally tired than those who worked regular evening shift (a statistically significant finding with a p < 0.001). Regular night shift nurses had statistically significantly lower F-RSQ scores than regular evening and rotating days/evening shift nurses (p = 0.002). In addition, the same instrument (FRSQ) showed that physical fatigue differed with shift length. Staff who worked less than 10 hours per day had less physical fatigue than those who worked more than 10 hours per day (p < 0.001).

The researchers in this study also used The Swedish Occupational Fatigue Inventory

(SOFI) Physical Discomfort Dimension (Ahsberg et al. as cited in Barker & Nussbaum, 2010) and found a significant difference between the physical fatigue of nurses who worked overtime

(over 60 hours a week) and those who worked less or equal to 40 hours a week (p < 0.0039).

These studies by Yuan et al. (2011) and Barker and Nussbaum (2010) suggest that shift work, long hours and overtime are associated with high fatigue levels. Generalizing these findings to my workplace in the Children’s Hospital may improve nurse performance. Shift work, long hours of work and overtime should be considered when delegating work assignments.

Emphasis on taking breaks during work may be important to counter fatigue during work.

The Relationship Between Shift Schedule and Nurse Safety

Equally important as the finding that shift-work contributes to increased fatigue is the finding that shift work also contributes to poor nurse safety. Accordingly, a cross-sectional, descriptive study conducted in the Philippines by De Castro et al. (2010) set out to determine whether shift work along with overtime were linked with nurses’ work-related accidents and NURSE FATIGUE 7 sickness. The study used a random nationwide sample of 655 registered nurses who had attended the Philippines Nurses Association National Convention. There was a 69% response rate.

This quantitative study by De Castro et al. (2010) found that working a non-day shift was significantly associated with work-related accidents (odds ratio [OR] =1.54; 95% CI) and sickness (OR =1.48; 95% CI). The results suggested that an employee working a shift had greater risk of getting injured at work and falling sick than one who worked a regular day shift.

Working overtime was also significantly linked to work-related accidents (OR=1.22), sicknesses

(OR = 1.19) and work absence (OR = 1.25).

According to Newhouse et al. (2005) this study by De Castro et al. (2009) yielded level

IIB evidence. The results seem reasonable. The sample size seemed large (N=655) and the response rate (69%) was quite good. There was, however, a limitation to this study. The research was done in The Philippines which may influence the generalizability of the findings to my practice due to cultural, policies, practice, and environmental differences.

Despite this limitation, the study was essentially well conducted and showed that shift work may adversely affect nurses’ well-being. I believe that the findings are generalizable to my work setting with caution. Fatigue relating to nurse and patient safety is costly to a facility.

Implementing ways to reduce fatigue during shift work is critical to reducing injury.

Nurse Performance: Nursing Care and Compassion Satisfaction Related to Burnout

Nurse performance and the quality of nursing care are obvious topics of interest in any study of the relationship between shift work and safety. In 2010, a quantitative, correlational study by Burtson and Stichler examined the link between compassion satisfaction (CS), job contentment, stress, burnout and compassion fatigue (CF) as they related to the caring capacity of the nurses. CS refers to fulfillment resulting from providing care (Stamm as cited in Burtson NURSE FATIGUE 8

& Stitchler). The researchers used a convenience sample from a single hospital. It was comprised of 126 nurses working in medical-surgical units, emergency departments and critical care units.

The results of this study by Burtson and Stichler (2010) revealed a significant negative correlation between nurse caring and burnout (p < 0.01). On the other hand, a multiple regression analysis showed that compassion satisfaction correlated highly with nurse caring (p ≤ 0.001). Job satisfaction led to compassion satisfaction which resulted in the nurse caring attitude. Findings also suggested that compassion satisfaction was a result of nurse contentment leading to high quality bedside care. On the other hand, burnout negatively impacted nurse caring.

This research by Burtson and Stichler (2010) was well conducted and yielded level IIB evidence according to Newhouse et al. (2005). There were, however, some limitations in this rather well-conducted study. The sample was small and one of convenience (N=126) and there was a very low response rate of 28%. It is reasonable to ask if the nurses failed to respond because they were simply too burned out. It is, therefore, difficult to draw firm conclusions based on such a small sample from a single hospital.

Although there were limitations, the findings of this study by Burtson and Stichler (2010) seem reasonable and shed light on the phenomenon. The research seems credible and there seems no risk in applying the findings. The results are, thus, generalizable with caution to my work place. Certainly, the administration at my facility could reduce nurse stress and burnout so as to promote better nursing care through job satisfaction. In turn, this could improve patient satisfaction.

Regarding the effects of burnout as they relate to patient outcomes, a cross-sectional online survey study carried out in the U.S.A. by Barker and Nussbaum (2010) explored nurse- perceived fatigue levels. It also examined the relationships between nurse fatigue and NURSE FATIGUE 9 performance across varied work settings. These researchers used a convenience sample of 745 registered nurses working in hospitals, community or public health settings, ambulatory care, nursing homes and extended-care facilities. The sample was recruited via professional nursing organizations and publications to recruit participants for this quantitative study.

The Barker and Nussbaum (2010) research concluded that mental, physical and total fatigue was negatively correlated with performance (p< 0.01). Scores on the Nurse Performance

Instrument (Schwirian as cited in Barker & Nussbaum, 2010) showed that performance varied according to levels of mental fatigue (p < 0.001) and physical fatigue (p < 0.001 to p < 0.05).

Mental fatigue showed a greater negative correlation with performance than did physical fatigue and total fatigue (p < 0.001).

This Level IIB (Newhouse et al., 2005) by Barker and Nussbaum (2010) study was reasonably well conducted and results seem valid. However, the study used the “Survey

Monkey” method. The method’s reliability and validity has not been established. Even with these limitations, though, the results of this study by Barker and Nussbaum (2010) seem credible and are generalizable with caution to my work setting. Using these findings may be helpful in dealing with nurse fatigue caused by nurse staff shortage and heavy workload at my workplace, which may improve nurse performance.

Turnover and Nurse Retention Related to Burnout

Besides the concerns of burnout and patient satisfaction, nurses’ job satisfaction is paramount for staff retention. In 2009, Bogaert, Meulemans, Clarke, Vermeyen and Van De

Heyning published structural equation model research that was conducted in Belgium. This study was designed to explore associations between the work setting, burnout, job outcomes and the NURSE FATIGUE 10 quality of care. The researchers used a sample of 401 staff nurses from 31medical, surgical and intensive care units in two hospitals.

Findings of this study suggested that work environments with high levels of nurse burnout were significantly related to job outcomes (p < 0.05). Specifically, the results showed that job outcomes were directly predicted by the depersonalization and personal accomplishments aspects of burnout (p < 0.01). Lack of administrative support resulted in feelings of distrust, job inefficiency, and fatigue (p < 0.05). This led to job dissatisfaction, a decreased quality of care, and turnover intentions (p < 0.05).

The findings of this research by Bogaert et al. (2009) yielded level IIB evidence

(Newhouse et al., 2005). The research was well done and seems trustworthy. Nevertheless, there were limitations to this well-conducted study. Only two hospitals were used in this study, thereby limiting the generalizability of the findings. Clearly, a replication of the Bogaert et al.’s study in more hospitals involved in more challenging varied settings may increase my confidence in the results.

Although there were limitations, I believe that the findings of this study by Bogaert et al.

(2009) are generalizable with caution to my work setting. The study was conducted in Belgium which is a somewhat similar nursing culture to my facility. My observation in the Children’s

Hospital is that some nurses leave because of extreme workloads and exhaustion. The findings of this study support my observation in that they suggest that burnout contributes to nurses’ intentions to leave work and a reduction of fatigue could improve nurse retention.

Similar to the above study, a correlational, descriptive study done in Canada’s Atlantic

Provinces by Leiter and Maslach (2009) examined the role of burnout in determining nurses’ intentions to quit and find other jobs. This quantitative study used a sample (N=667) comprised NURSE FATIGUE 11 of staff nurses (n=601), nurse managers (n=29), and 37 who worked in other fields. Participants were registered nurses, licensed practical nurses, clinical nurse specialists, clinical nurse educators, and nurse practitioners, and others from unspecified fields. The study was carried out in four selected hospitals. The participants worked in tertiary hospitals, regional hospitals, and community hospitals while others failed to specify their type of facility.

The main conclusions of this study suggested that heavy workload was significantly correlated with burnout (p < 0.001). Consequently, burnout eventually led to staff planning to leave their employment (p < 0.001). An exploratory analysis of participants who showed early signs of distrust or exhaustion indicated that irreconcilabilities in job situations (as evidenced by a lack of staff recognition or reward) were significantly correlated with turnover intentions (p <

0.01).

The findings of this level IIB study (Newhouse et al., 2005) suggest that work environment alone does not predict turnover but with fatigue as a mediator, work environment predicts staff intentions to quit work. In this study, one peculiar limitation was the lack of a homogeneous sample which may influence the generalizability of the findings. Nurse practitioners and nurse managers have different workloads from staff nurses; therefore, involving all groups may have skewed the results.

The study by Leiter and Maslach (2009) was well conducted and seems believable. This research was done in Canada where the hospital work environments are very similar to those in this country. Therefore, despite limitations, these findings are generalizable with caution to my work setting. In my work place, staff retention is a requirement for Magnet® status certification.

Clearly there is a need for administrative and employee awareness of the effects and costs of fatigue on job satisfaction and retention. NURSE FATIGUE 12

Interventions/Motivational Factors to the Reduction of Burnout

As a result of the negative effects of nurse burnout on patient and nurse outcomes, fatigue countermeasures are gaining attention so as to enhance nurse and patient satisfaction. An exploratory study done in the U.S.A. by Scott, Hofmeister, Rogness, and Rogers (2010) explained the experiences of registered nurses and their managers. The experiences were examined after implementation of a Fatigue Countermeasures Program for Nurses (FCMPN).

The FCMPN was designed using the National Aeronautics and Space Administration (NASA) and Sleep Alertness and Fatigue Education in Residency (SAFER) program curriculum.

The study used a sample of 54 which was comprised of 46 full time staff nurses (SN) and eight nurse managers (NM) from three hospitals. The participants worked in medical and surgical areas. The FCMPN was applied at both the unit, and personal levels. SNs were educated about fatigue management and sleeping habits. The participating facilities were to staff the units adequately to allow for breaks; they were to encourage nurses to take breaks, and also allowed nurses to nap at work.

The researchers performed a content analysis of data from this qualitative study.

Identified themes were recorded which showed that staff nurses identified awareness, rest, and adjustment to the way of life as benefits of the FCMPN. Staff nurses, however, also identified work culture, heavy workload, and emotional distress as challenges encountered while implementing FCMPN. Nurse managers identified simplicity in the program’s use, employee- employer cooperation, and involvement in research as benefits of the FCMPN. In addition, NMs identified lack of support, nursing principles, conflict in staffing levels and hospital policies as hindrances to the plan. NURSE FATIGUE 13

This Scott et al. (2010) study yielded a level IIIB evidence according to Newhouse et al.

(2005) rating scale. The study was well conducted although it was limited by the small convenience sample size (N=54). Also, application of the FCMPN at the personal level may have resulted in skewed results as individual lifestyles are different in spite of the awareness classes provided. Even though there were limitations, this study by Scott et al. was well conducted and I believe that the findings are transferable to my work setting. Staff nurses in my workplace have no nurse replacement so they can comfortably take breaks; indeed, they often miss out on breaks completely due to patients’ needs. Clearly, staff awareness is principal to minimizing fatigue for bedside nurses.

In a like study, Burtson and Stichler (2010) experienced similar findings to Scott et al.

(2010) regarding interventions or mediating factors needed to facilitate compassionate care and eventual patient satisfaction. The Burtson and Stickler (2010) research correlated compassion satisfaction and nurse caring (p< 0.001). Also, the study found a significant correlation between job satisfaction (nurse satisfaction) and nurse caring (p < 0.05). Nurturing compassion satisfaction and social interaction opportunities enhanced nurse caring. Burtson and Stichler also suggested that interventions aimed at boosting compassion and nurse satisfaction through social involvement may improve nurse caring while strengthening nursing work and eventual job satisfaction.

These studies by Scott et al. (2010) and Burtson and Stichler (2010) suggest that rest, fatigue awareness, social interactions, and managerial support are positive interventions to the reduction of fatigue. Using findings from these studies in my facility may result in a more healthy morale. In the long term, fatigue countermeasures will not only boost nurses’ satisfaction NURSE FATIGUE 14 but will improve quality of care for the patients. As a result, the hospital may experience higher staff retention thus saving the institution money and increasing community reputation.

Conclusion

Overall, this review of seven research reports offers the latest evidence about nurse fatigue and measures that can be used to reduce the problem. Evidence shows that:

 Nurse fatigue varies with shift work in that nurses who work evening and night shifts are

drowsier and have a decreased focus and lower functioning capacity compared to regular day

shift nurses (Yuan et al, 2011).

 Nurse fatigue (mental, physical, acute, and chronic) varies with shift work, shift length, and

overtime (Barker & Nussbaum, 2010).

 Mental, physical and total fatigue negatively affects performance which varies with fatigue

levels (Barker & Nussbaum 2010).

 Non-day shift and overtime is associated with work-related accidents, sickness and absence

from work (DeCastro et al., 2010).

 Implementation of the Fatigue Countermeasures Program for Nurses (FCMPN) showed that

awareness of fatigue, taking rest breaks, adjusting lifestyle, and employer-employee

cooperation enhanced reduction of fatigue (Scott et al., 2010)

 Work culture, heavy workload, emotional distress and lack of administrative

support hindered effectiveness of the FCMPN (Scott et al., 2010).

 Work environment with high levels of nurse burnout are linked to negative job

outcomes like job turnover (Bogaert et al, 2009).

 Heavy workload is related to burnout and eventually contributes to nurses’ intent

to leave their positions ( Leiter & Maslach, 2009). NURSE FATIGUE 15

 Burnout negatively affects nurse caring (Burtson & Stitchler, 2010).

 Compassion satisfaction results in nurturing nurse caring attitude (Burtson &

Stichler, 2010).

 Job satisfaction promotes compassion satisfaction, thus improving a nurse’s

capacity for caring (Burtson & Stitchler, 2010).

 Compassion satisfaction and nurse satisfaction with social interactions promote

nurse caring (Burtson & Stitchler, 2010).

 Social interaction by team members enhances compassion satisfaction

(satisfaction derived from caring) which leads to nurse satisfaction (job satisfaction) which in

the end promotes compassion or nurse caring attitude (Burtson & Stitchler, 2010). NURSE FATIGUE 16

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