Too Tired to Care: Fatigue in Nursing Has Ugly Outcomes

[Cynthiahowardrnphd]

"Nursing workload a key factor in rising patient deaths" is a headline in an online news blog and cites the work by researcher Linda Aiken. Professor Aiken has published numerous studies linking nurse workload to increased patient deaths.

More and more nurses report they get less than 6 hours sleep per night. As we head into the holiday season that number may even be less.

Do you compromise on your sleep? If you have a hard time saying no, you may head up shorting yourself on sleep just to get more done. Sleep is actually the time when your body does the repair needed to keep all other systems running well.

Did you know that sleep deprivation contributes to weight gain:

• carbohydrates are not metabolized well and your body stores fat.
• cortisol is secreted which increases hunger.
• growth hormone is decreased. Growth hormone helps regulate the ratio of fat and muscle keeping your metabolism optimal and burning fat.

Sleep doesn't always seem so important or necessary when you are artificially energized by caffeine, sugar and the adrenaline during sympathetic overdrive. Unfortunately this is short lived and the crash will come. When this happens getting quality sleep is actually more difficult making the matter worse.

One of the risks of chronic stress is adrenal fatigue. This is when your body no longer compensates with the flight or fight syndrome energizing your body to handle what is in front of you. Cortisol actually shifts from being secreted in the early part of the day, around 5-6a and is secreted at night giving people a "second wind" when they come home from work. This usually interferes with going to bed at a decent time and getting the sleep they need.

A diet high in caffeine, simple carbs and sugars, usually eaten to compensate for fatigue further leads to sleep problems due to the blood sugar instability that can happen with a diet high in sugars and low in fiber and protein.

I know that many nurses "know" that getting enough sleep is important and yet, many do not heed their own warning. I know I did not until I hit the wall. The problem is that adrenal fatigue takes a very long time to come back from and it requires a regimen of supplements, diet and meditation or other relaxation practice to reset the adrenals. I know this having had an Integrative Health Practice and specializing in adrenal fatigue with education and certification in Functional Nutrition. I have helped hundreds of people reclaim their lives after losing so much of it due to their lack of energy and interest.

This article is also about those lost moments personally and professionally. Fatigue can cost you a precious moment with your child when they want your attention but you are too tired to care. What about times with your sweetheart that is lost because you are too tired? How does this affect relationships long term? Too often nurses are too tired to care.

Living a life of constant fatigue not only compromises patient safety, it compromises the relationships and people in nurses' lives that mean the world to them - family.

The risk of fatigue to nurses is that when left unchecked, this becomes the new normal; flat, cynical and disinterested. Here are a couple of simple yet very effective suggestions to naturally energize your body.

1. Drink water, not coffee.

Water is a natural energizer. Add in cucumber, mint and lemon or strawberries and you will have a burst of flavor. This is also helpful in burning fat! The more water you drink, the more you boost metabolism. Adding in these flavors enhances the process.

Coffee dehydrates you and reduces your body's stores of magnesium. This is an important mineral. More reason to drink water and keep your coffee to 2 cups per day.

2. Eat more vegetables.

Vegetables are filled with minerals which are the spark plugs of the body's energy-generating machine. Magnesium is an important mineral that has been found to be important in the sleep cycle and also helpful in combating fatigue. It has been found to be involved in hundreds of important functions in the body.

When you eat more vegetables you are eating less of the sugars and simple carbs in fast food. Just think about how you feel after eating fast food. Are you energized or do you feel like falling asleep?

The ugly truth about fatigue is that the consequences are far-reaching. Patients, relationships and especially the nurse can be harmed when nurses are tired. Fatigue sets up low expectations for life that can be full of potential.

As you approach the New Year, make a commitment to yourself to get the sleep you need and do what you have to do to recover from 'having to get just one more thing done' syndrome.

[wellcoachRN]

Great article!

[MunoRN, RN]

There isn't actually good evidence that 12 hour shifts are more error-prone or more fatiguing overall for nurses. There is evidence however that suggests an 8 hour shift schedule can be more fatiguing and error prone. This certainly can't be applied to everyone, since there are those for whom the effect of 12 hour shifts is more harmful than the effect of the additional weekly shifts required of an 8-hour schedule, but it's certainly not a rule that can be applied generally to all nurses.

[NocturneRN]

Interesting, MunoRN. Do you happen to have a link to (or information to identify) the study or studies showing that 8 hour shifts can result in more errors? What do they attribute that to---working more days? Or three handoffs per day instead of two? Or is it something else?

[Cynthiahowardrnphd]

nurseonamotorcycle first stop trying to do all of that and sleep too... better sleep = weight loss and many other bene's. I worked nights most of my bedside years (over 10) and I consistently skimped on sleep until I crashed. At that point I almost needed 12 hours of sleep to my 12 hours of work. This is what happens to the body when you compromise - chronic fatigue is real and happens insidiously... drink more water, eat less carbs.

[LadyFree28, BSN, LPN, RN]

There isn't actually good evidence that 12 hour shifts are more error-prone or more fatiguing overall for nurses. There is evidence however that suggests an 8 hour shift schedule can be more fatiguing and error prone. This certainly can't be applied to everyone, since there are those for whom the effect of 12 hour shifts is more harmful than the effect of the additional weekly shifts required of an 8-hour schedule, but it's certainly not a rule that can be applied generally to all nurses.

This.

I find working 8 hours MORE tiring than 12 hour shifts.

I lost weight working rotating 12s; when I went back to day 8 hours 5 days in a row, I gained weight back and am 20 lbs overweight.

I am a flexibly nocturnal person; I also enjoyed 12s due to the scheduling that I had days off between shifts, which allowed me to eat healthy, get exercise, etc. working many more days straight does not have the perfect scheduling for me.

If five days were scheduled differently, then perhaps fatigue wouldn't be an issue; but I don't always see that, at least in the facilities that I was employed in.

My new job has two 12s and two 8s; will see what happens with this schedule-though I suspect as long as the schedule allows for adequate days off, my health and rest will be in my favor.

[MunoRN, RN]

Interesting, MunoRN. Do you happen to have a link to (or information to identify) the study or studies showing that 8 hour shifts can result in more errors? What do they attribute that to---working more days? Or three handoffs per day instead of two? Or is it something else?

One of the few studies specific to nursing that shows a difference in errors between the two shift lengths comes from Ann Roger's 2004 and 2006 studies, although the difference is incorrectly interpreted. What seems to be the most popular statistic on the topic comes from Roger's 2006 study which claimed that 12 hour shifts had 2-3 times the risk of errors or near errors, which the study bases on the number of self-reported errors/near errors per shift. When comparing the risk of errors you would of course need to standardize the risk of errors to make the number of errors for each shift time comparable, in other words you need to look at the number of errors per an equal opportunity for error. One way to standardize this would be to look at the number of errors per hour worked. What the Rogers study did was to compare the number of errors per shift, which of course is a different amount of time, and therefore represents a different quantity of opportunities for errors. For example, if there are 250 opportunities for errors in a 24 hour period, using "per shift" as the measurement for 12 hour shifts would represent number of errors per 125 opportunities, while the "per shift" measurement for 8 hour shifts would represent the number of errors per 83 opportunities for errors.

The data from the 2006 study was further manipulated beyond the units of measurement by using the known effect of excess-of-shift (EOS) on errors. EOS, which essentially represents and over-saturated workload, has a known correlation to factors that contribute to errors in both 8 hour and 12 hour shifts. The data that the study used to claim the higher risk in 12-hour shifts was obtained by comparing 8 hour shifts with those that had EOS excluded, to 12 hour shifts with EOS shift included. Even so, when you convert the "per shift" measurement to the correct "per hour" measurement, the risk is nearly identical.

The 2004 study included the data for both 8-hour and 12-hour shifts without EOS, when converted to a per-hour measurement the risk of errors/near errors in the 12-hour shifts was about half that of 8-hour shifts.

The majority of studies specific to nursing don't show any significant difference between the two shift lengths and only show a significant increase with shifts that exceed 13.5 hours. There are much larger scale studies available for a broader variety of occupations, there is for instance a NIOSH meta-analysis that is pretty thorough and better defines the importance of looking at the effects of the additional working days/nights required of an 8-hour schedule rather than just looking at a single shift as many nursing studies do. In particular, they look at the consecutive-shift-phenomenon, where the risk of errors increase with each additional consecutive shift, particularly for those who work night shift where the opportunity for recovery from fatigue (nights off) just isn't sufficient to adequately manage fatigue in the long term, resulting in a continuously building level of fatigue. Basically, they found that while the risk of errors increases near the end of a 12-hour shift, that increased risk is actually not only offset but exceeded by the increased risk in the additional shifts required of an 8-hour schedule.

Most nursing studies focus on measuring the factors that we believe contributes to fatigue, errors, and injuries. The studies that show a significant difference when taking into account the additional shifts required in an 8-hour schedule actually show an increase in the factors that contribute to errors/injuries, attributed to increased sleep deficit, compressed workload, lack of opportunity for more effective nighttime sleep, etc.

There are a few studies the difference in sleep durations from Ann Rogers. There is also the Stone et al 2006 study that showed significantly decreased overall fatigue for those working a shorter work week 12-hour schedule. Johnson et al 2008 and Smith et al 2008 also showed similar results.

And then there's the issue of the increased risk of cancer, MI, stroke, and diabetes from working night shift, which has been shown to be associated with number of night shifts worked, not the length of shift, which suggests 8-hour schedules are more likely to cause these chronic conditions.

[MunoRN, RN]

This.

I find working 8 hours MORE tiring than 12 hour shifts.

I lost weight working rotating 12s; when I went back to day 8 hours 5 days in a row, I gained weight back and am 20 lbs overweight.

I am a flexibly nocturnal person; I also enjoyed 12s due to the scheduling that I had days off between shifts, which allowed me to eat healthy, get exercise, etc. working many more days straight does not have the perfect scheduling for me.

If five days were scheduled differently, then perhaps fatigue wouldn't be an issue; but I don't always see that, at least in the facilities that I was employed in.

My new job has two 12s and two 8s; will see what happens with this schedule-though I suspect as long as the schedule allows for adequate days off, my health and rest will be in my favor.

One problem is that working full time 8's typically doesn't make it possible to work only 5 days in a row. With every-other-weekend scheduling, in order to have your two sets of two days off be both consecutive days off (two days off in a row), which is a must for night shift workers, your longer stretch that includes your weekend off will have to be at least 7 days/night in a row. And then after 7 night shifts in a row you only get two nights off, which typically isn't sufficient time to recover from 7 straight night shifts.