By Madhu Rajaraman
COLLEGE PARK, Md. (January 28, 2011) The demanding work schedules of registered nurses may be to blame for patient mortality, says a recent study by researchers at the University of Maryland School of Nursing and the Johns Hopkins University School of Medicine.
The study found that long work hours and insufficient time away from the job were the strongest contributors to patient deaths, said Alison Trinkoff, a professor at the nursing school. These factors can cause sleep deprivation and fatigue in nurses, who are then at a higher risk for making errors at work.
The study was published in the January/February 2011 edition of Nursing Research. It linked patient outcomes with survey responses from 633 nurses in 71 nonfederal hospitals.
Although the relationship between nurse staffing and patient mortality has previously been studied, the study of independent work schedules in relation to patient mortality has been limited, according to the study abstract.
Trinkoff's research found that patient pneumonia deaths were more likely to occur when nurses worked 12-hour shifts or longer, as opposed to shorter ones.
Abdominal aortic aneurysm was associated with a lack of time away from work, and in cases of congestive heart failure, mortality was associated with working while sick.
Acute myocardial infarctions, or heart attacks, were associated with the weekly burden of hours worked and days worked in a row.
The study is part of ongoing research funded by the National Council of State Boards of Nursing.
Jim Reiter, a spokesman for the Maryland Hospital Association, declined to comment directly on the findings of the study, because he said he had not read it. But he said medical institutions are simply doing what they can to effectively deal with the reality of staff shortages.
"Most hospitals are using whatever creative staffing strategies they can" to stay productive, he said.
He added that some hospitals do have sleep rooms and allow flexible scheduling for nurses, such as a "one day on, one day off" schedule.
"Every hospital is different," and staffs differently for the best productivity, he said.
Katie Brewer, a senior policy analyst for the American Nurses Association, agreed that sleep deprivation, a lack of breaks and forced overtime all contribute to compromised patient care, but cautions that nurses need to monitor themselves.
"Nurses have a responsibility to be mindful of working while fatigued," she said.
A previous 2010 study by Trinkoff's colleague Jeanne Geiger-Brown found that nurses working successive 12-hour shifts reported five-and-a-half hours of sleep on average in between shifts. Not only is this amount insufficient, but many do not take breaks during a 12-hour shift, Trinkoff said.
"There's not an opportunity [for breaks]," Trinkoff said, adding that even when a nurse attempts to take one, finding another nurse to replace them, even temporarily, is a challenge. "A substantial amount [of nurses] get no breaks, including for meals."
The Institute of Medicine, a nonprofit health care advisory group, has a list of recommendations from a 2003 report that is used by many hospitals as a guide to nursing and patient safety. The guide suggests that "to reduce error-producing fatigue, state regulatory bodies should prohibit nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any 24-hour period and in excess of 60 hours per 7-day period."
But these are merely suggestions, and do not require facilities to comply with them.
"Some feel that those (guidelines) don't go far enough," Trinkoff said.
In fact, almost all hospitals in the United States operate exclusively on a 12-hour shift schedule for nurses, rather than an eight-hour shift, Trinkoff said. While this does not technically violate the institute's guidelines, nurses are often put on-call during unscheduled work hours, and therefore may end up working more than the suggested maximum, she said.
"Sometimes there can be pressure to have people come back in," she said. "But it's not good for the nurses."
Brewer said nurses should be aware of their rights in the workplace, such as the right to submit an Assignment Despite Objection form if they believe that an assignment poses a threat to a patient. The form, available through union organizations such as United Healthcare Workers East, provides nurses with an opportunity to submit written documentation following a verbal request to be taken off an assignment that could potentially place a patient at risk. It places responsibility for the patient in the hands of not just the nurse, but the hospital as well.
The 12-hour shift paradigm, originally implemented during nursing shortages in the 1980s, was "initially very appealing" to those in the profession, Trinkoff said.
"The nurses themselves liked it," she said, because the dense nature of longer shifts meant more time off later. "But 12-hour shifts do not work for everyone"
According to the Department of Labor, 20 states have statutes in place establishing meal period requirements for adult private sector employees, and only nine states have statutes establishing minimum paid rest period requirements. The state of Maryland has neither.
Maryland does, however, have a mandatory overtime law prohibiting employers from forcing nurses to work more than the hours on a predetermined schedule. But "there are ways people have gotten around it," Trinkoff said.
Brewer hopes the issues of overworked nurses and patient mortality will be given more attention at the national level.
"I wish it was a national priority," she said.
But Brewer said that progress in the transportation and aviation industries indicates the possibility of greater federal involvement in regulating the nursing workforce.
"It's a concern; it affects patient care," she said. "People are getting hurt. That's not right."