Study: long hours for nurses make for poorer patient care, more mistakes
by Byron Kho
The Summer Pennsylvanian
July 29, 2004
To most, it is an accepted fact -- even common sense -- that high stress and fatigue can lead to errors in the workplace. But one study -- co-authored by a Penn associate professor -- has finally given scientific credence to this axiom as it applies to the nursing field.
In the study, an extended review of the hours, breaks and errors personally logged by 393 full-time, experienced nurses from all over the country revealed that those who worked longer hours, for whatever reason, tended to commit more errors than those who worked shorter hours. These errors run the gamut from nondescript mistakes in charting and transcription to more dangerous, possibly life-threatening errors involving medication administration.
Ann Rogers, an associate professor at the School of Nursing who co-authored the study, said she hopes that "people will start paying attention to the hours nurses work and push for changes such that nurses don't have to work such long shifts."
The results of the study come at an time when national nursing shortages have forced hospitals to institute policies that some call questionable for dealing with the gap in manpower.
These include extensive hiring of foreign nurses and "mandation" -- a policy of mandatory overtime that can extend a typical eight to 12-hour shift to 16 hours or longer.
According to Victoria Rich, chief nursing officer at the Hospital of the University of Pennsylvania, this policy is not instituted at Penn.
"We as nurse administrators respect people's time and realize they get tired," Rich said.
Mandatory overtime generally involves the unspoken assumption that one could be fired or subjected to various disciplinary procedures for refusing to stay the required number of hours.
According to data accumulated in the study, over 500 shifts included mandation or perceived coercion to work overtime. A large number also worked voluntary overtime. In total, every nurse worked overtime at least once, and on average four out of every five shifts worked. These extended hours -- approximately 40 percent of the nurses reported working more than 12-hour shifts -- were linked to the 199 errors and 213 near-errors catalogued within the two-week span of the study.
This number, already large, may be understated in actual practice.
Recent studies show that the average number of reported errors by nursing staff within large medical institutions is usually much below the actual number. Usually, only the potentially life-threatening errors are reported, which make up approximately five percent of all significant errors. Near-errors are considered non-reportable events by the Joint Commission on Accreditation of Healthcare Organizations.
Penn, unlike some organizations, utilizes an anonymous error-reporting system that allows a cataloguing and review of adverse events and near-misses for the entire hospital.
The potential ramifications for error and near-error, are tremendous,as nurses are responsible for providing most of the direct care that patients receive at a hospital. In fact, registered nurses are the largest group of health-care providers in the U.S.
A November 2003 panel from the Institute of Medicine warned of links between medical errors and working conditions in nursing "most notably the fatigue caused by these extended shifts, which are already longer than that experienced in most other fields."
Other research shows that the odds of a patient dying increase an average of seven percent for every patient added to a nurse's workload. However, the full extent of fatigue effects on patient safety is not entirely known, as the subject has not been studied much to date.
Rogers warned that things are no different in nursing than in other fields. She cited the numerous studies of resident-physicians and of industrial workers that described trends of increasing accidents as shifts grew longer.
"Nurses are just like other human beings. We get tired and make mistakes after so many hours," Rogers said.
Decreasing health care quality is worrisome to nurses and laypersons alike. A strike by nurses at the Medical College of Pennsylvania last year cited similar concerns for patient safety, as well as for their own personal well-being. Legislation has been introduced all over the nation in support of reduction of hours and banning of mandatory overtime; however, only California, Maine, New Jersey and Oregon have actually passed bills prohibiting the practice.
In 2001, similar conclusions involving doctor performance led to nationally supported limitations on work hours for residents and other medical professionals, but not nurses.
The unstated argument, advocated by the Institute of Medicine report and by other professionals, puts forth that safer patient care is more likely to result from changes in health care worker conditions. As such, preliminary initiatives have begun at HUP to push for change. Rich plans to implement a policy on nurse fatigue within the next year.
"There needs to be institutional changes," said Rogers. "Nurses shouldn't have to shoulder all the burden."