Nurses Breaks - Stress & Fatigue
Continuous work without any effective breaks can make any one exhausted, fatigued and stressed out. This implies to day to day work and relatively is true for nurses working long shifts with out any breaks. According to Milliken, Clements and Tillman (2007) “Often we work double shifts to meet the needs when staffing is overstretched. We are tired” (p.203). In my work experience at Intensive Care Unit (ICU), I have observed that nurses do not take adequate breaks during their duty hours. Moreover, when they want to go, staff coverage usually makes it difficult to avail their break time. This in turn makes them frustrated and stressed out and finally patient care and safety is getting compromised. For example, it was observed that when staff was relieved on breaks without proper coverage the rate of accidental extubation increased in ICU. This paper is designed to develop the understanding that why adequate breaks by nurses during shifts are important and its impact on nursing care. In addition, it will elaborate on the reasons why nurses are not taking breaks and finally the strategies or policy implications to resolve the problem in lieu to literature.
Breaks timing are very important to consider. All health institution and labor industries have their own policy statements related to timings of breaks. While going through Aga Khan University Hospital (AKUH) policy statement it has been documented that
“Shift employees will work the shift schedules established by their respective Departments. Non-shift employees will observe …at the IED and the Hospital, work hours will be from 8.30 a.m. to 5.15 p.m., with a 45 minute lunch break. In line with legal requirements, there will be a formal break of half-an-hour at the end of a continuous 5 hour work period. In case of a continuous work period of 6 hours, there will be a formal break of one hour” (Personal policies and procedures manual).
It is interesting to know that shift employees break are not mention at all. Moreover, it is mentioned that legally staff is entitled to have one hour break if working 6 hour continuously and breaks will not be accounted to wards working hours. Therefore, it can be infer from the policy that in eight hour shift atleast one hour break should be avail by the employees of institution. In connection, when comparing the above policy with international state policy Rogers, Hwang, and Scott (2004b) reported that most of the state in USA like California, Massachusetts, Oregon, New York and Washington have the policy for thirty minute breaks when staff working continuously for 6 or 7.5 hours. (Refer appendix 1). Similarly, in Europe “employees are entitled to a rest break when daily working time exceeds 6 hours” (Nurses and overtime).
Spokane (2006) reported that according to the arbitrator’s decision, the collective bargaining contract “…15minute breaks shall be provided during each four-hour work period and in order to provide quality care, nurses need occasional rest breaks to attend to personal needs. Simply drinking glass of water or quickly using the bathroom does not suffice” (p.2). Therefore, to maintain patient safety adequate breaks between shifts in very important and usually it is mentioned that every four hours some rest period should be taken. Lilley, Feyer, Kirk and Gander (2002) reported that “recent sleep, number of breaks taken during the workday, and specific job/tasks were independently associated with reporting of high fatigue levels at work” (p.53). This directly reveals the effect of fatigue with number of breaks taken at work day. According to Rogers, Hwang, Scott, Aiken, and Dinges (2004a) “…Combination of fatigue and increased work intensity may contribute to the errors” (p.209). When nurses do not take adequate breaks it results in fatigue and tiredness. This fatigue prone them to make errors and ultimately patient safety become a great concerns.
Tucker, Folkard and Macdonald (2003) also emphasized that regular breaks can help decreasing the fatigue. Fatigue can also cause the decrease in efficacy of the task being done and then it can compromise the quality. Tomei, Cinti , Cerratti and Fioravanti (2006) also supported that “fatigue plays a important role in a working context since, it may interfere with the work itself by reducing the worker's efficiency and performance” (p.417). Likewise, American nurses association (ANA) Code of Ethics Provision Six states that “The nurse participates in establishing, maintaining, and improving health care environments” (ANA, 2006a, p. 3). To accomplish this goal it is very important for nurses to exercise there right to take adequate breaks in between duty hours. In addition, Avey as cited in Spokane (2006) “Nurses must have the opportunity to take a break to refresh ourselves in order to provide the quality care that our patients deserve” (p. 2). This is also supported that taking a breaks has direct relation with quality of patient care.
According to Kohn, Corrigan and Donaldson (1999) “A report by the Institute of Medicine (IOM) revealed that errors in the nation’s hospitals cause between 44,000 and 98,000 deaths per year” Therefore there is a intense need for nurses to take breaks in between duty hour which in turn increase the efficacy and able to help nurses to cope effectively. D’Anna (2006) stated that “Those who rest when needed are able to combat burnout and manage workplace stress. Conversely, those who do not rest will experience physical and emotional exhaustion that leads to resentment, loss of interest and inability to function” It clearly showed that to decrease physical and emotional exhaustion one should avail the break timing. Along with physical and emotional exhaustion, nurses’ leadership qualities also got dimmed. According to IOM report (2004) “Strong evidence links prolonged work hours…rotating shifts and insufficient breaks compromised problem solving, reduced motivation, decreased energy for successful completion of required tasks” (p.12). Stress can also be increased if staffs are not taking adequate breaks and ultimately patient safety comes in danger. Milliken et al (2007) described the consequences of stress on the nurses could be “…poor decision making, lack of concentration, apathy, decreased motivation, and anxiety may impair job performance, possibly resulting in lethal threats to patient safety” (p.205).
In keeping with literature, we have seen that policy statement have given clear directions for taking breaks. In addition, many authors have talked about relation of not taking breaks with fatigue and comprised patient care. Then why this important aspect is neglected by nurses at a large. To answer this question when I have done analysis I came to the point that one of the clause in the policy statement reveals that breaks are not counted as working hours and mostly unpaid. As policy statement of AKUH states that “Breaks will not be accounted for as working hours” (Personal policies and procedures manual) and all international policies cited above also consider break timings as unpaid. Therefore, one of the reasons could be that nurses do not want to go on breaks so that they can avail the money. Where as, in our country this law is not implemented and nurses are not getting adequate breaks and even money as replacement.
Bolman and Deal (2003) defines organizations as “workplace, school or even family” (p. 41). In addition, according to them organization can be analyzed by four frames such as structural, political, symbolic and human resource. In above mentioned scenario I have applied the Bolman and Deal frame analysis. In structural analysis one can always see the policies within the structure. As earlier discussed, policies already exist for meal breaks but need to work on implementation. If we see it as political aspect, legally nurses should be paid if they are not taking breaks but it’s not the case in most of the organization. Moreover, if we see the situation in light of human resource as Bolman and Deal stated that “our most important resource is our people” (p.111). In the scenario when nurses are deprived of break and are not utilized as human being and this is affecting the care of patient, nurses’ health and retention of people could become the main problem in near future. Finally, in symbolic frame we got adjusted to our culture at work place where we even do not realize that our health and patient safety is being compromised by not taking rest breaks between our duty hours. Bolman and Deal explains symbolic perspective very beautifully that “we live in cultures in the same way that fish live in water. Just as fish are said to discover waster last, our own cultural ways are often invisible to us” (p.240).
While talking to a nurse who had two years of experience in ICU she said that we do not take breaks because we have to complete our work on time and if we take break in between then we have to stay after the shift to complete the documentation and other stuff. Rogers et al, (2004b) also supported that “Many nurses feel that taking a break will jeopardize patient care and/or make it difficult to complete their assigned tasks before the end of the shift” (p.518).
For some nurses patient care is so important that they comprised their break timings. For example I have seen in my practical experience at ICU that if nurse break time is due and patient has just passed the stool. She will prefer to clean the patient first rather going to break. According to Agreement between Oregon Nurses Association and State of Oregon including Eastern Oregon Training and Psychiatric Centers “Anecdotal data, recent collective bargaining agreements, and court cases suggest that nurses are regularly sacrificing their breaks and meal periods to provide patient care”
One might also think of the cause of not taking break is the physical environment of rooms where nurses take breaks. Faugier, Lancaster, Pickles and Dobson (2001a) reported that “Respondents in this study do not consider their working environments to be conducive to healthy eating practices” (p.33). This might be the reason of some of the nurses that they prefer not to avail break timings. If I compare this to AKUH clinical areas I can easily see that the room which is available for ICU nurses to take breaks is relatively too small as compared to need and accommodate very less people. In addition the availability of meals also plays and important role. Unfortunately ICU staff cannot go out to cafeteria and accessibility of food is a issue. Faugier et al, (2001b) highlighted that “Packed lunches or plated salads obtainable …by evening and night-shift nurses should be offered” (p.36).
In conjunction to all above reasons, the most crucial one is in adequate staffing which hinders nurses to take breaks. If staffing is too short how nurses will be able to take breaks. In most of situation where staffing is inappropriate and no adequate coverage breaks can directly have impact on patient safety? It has been reported that “Missed meal and rest breaks have a direct relationship to short staffing which can lead to unsafe patient care” (Seattle/King County Health Department). Due to inadequate staffing workload of a nurse always increased and then may lead to serious errors. According to Roger et al, (2004 a) “…nurses, who were fatigued and stressed by high patient caseloads and understaffing, made frequent mistakes and procedural errors” (p. 208). In adequate staffing which mostly leading to increase work load often make nurses very frustrated and some nurses do quit the job due to unbearable stresses related to work load. Khowaja, Merchant and Hirani (2005) reported that “…the most dissatisfying factors at work and within the work setting were identified as: high workload, stress associated with high workload” (p.32). In addition, inadeuqte staffing ratio make nurses exhausted, staffing ratios have long been described as a significant factor that affects outcomes for patients in acute care settings. Halm, Peterson, Kandels, Sabo, Blalock, Braden et al (2005) described that “A number of studiesreflect an inverse relationship between nurse-to-patient ratio and poorer patient outcomes….These ratios may also impact nurses' perception of their practice and the degree to which they suffer emotional and physical exhaustion” (p. 242). It clearly demonstrates that adequate nurse patient ratio has very significant effect on patient care.
In lieu to legal aspect it has been documented in wide literature that this is the right of employee to take adequate breaks. Fair Labor Standards Act (FLSA), of US states that “employees must be completely relieved from duty for the purpose of eating required meals” (Rogers et al, 2004b, p.518). Labor law favors the utilization of break timings effectively and reveals that it is necessary. With this connection, literature supported that nurses and workers should be paid if they are not able to avail break timings. According to Sutter Medical Center Sacramento (2008) “Companies that deny hourly employees a 30-minute meal break after five hours of work …must compensate the worker with a full hour of additional pay, according to state labor law”. In addition Rogers et al (2004b) also supported it by stating that “The number of recent union contracts delineating that hospital nurses must be paid if they miss their meal periods” (p. 517).
Ethical Obligation should be taken into consideration when taking care of patients. This notion is supported by ANA Interpretive Statement 6.3 which delineates that “the ethical responsibilities of nurse managers and administrators are to take action to curtail extended work hours and insufficient rest time between shifts” (ANA, 2006a, p. 3). It is essential responsibility of nurse to hold back if she is feeling fatigue and may risk the patient safety. Interpretive Statements from the Code of Ethics for Nurses further explained that “The ethical obligation of the individual registered nurse to monitor fatigue and to decline assignments that put patients at risk should be stressed” (ANA, 2006a, p. 7). In ethics it has been debated very vastly that individual rights should have its own importance. Ogilvie, Mill, Astle, Fanning and Opare (2007) emphasized that “Creative policy approaches are required to balance these rights and to ensure that the individual rights of health professionals do not compromise the societal right to health” (p.114).
Strategies to resolve this problem is very important to be implemented. According to D’Anna (2006) “The Hawthorne Studies, conducted from 1927 to 1932, revealed that five-minute rest breaks increase worker output, and 10-minute breaks increase it even more” This clearly shows that how important it is to give adequate breaks to nurses in between duty hours because it ultimately increase the effectivity of work they perform. There is a dire need to ponder on strategies at hospital management level in terms of adequate break timing and staffing.
ANA emphasized on “a work schedule that provides for adequate rest and recuperation between scheduled work” (ANA, 2006a, p. 1). Rogers et al (2004b) discussed some strategies that mangers have the responsibility to make “formal schedule” which is necessary to follow for all staff to take breaks. Milliken et al (2007) emphasized on simple strategies “For example, cover the unit for 3 to 5 minutes while encouraging a seemingly stressed employee to simply take a "stretch break” (p 208). It has been reported that this simple strategies could also increase the efficiency of staff and decrease stress conditions.
In connection to strategies for adequate staffing it has been reported that “Seven studies found that higher RN-to-patient ratios reduced length of hospital stay and ICU length of stay” (Amaravadi et al, Cho et al., Lassnigg et al., Lichtig et al., Needleman et al., Pronovost et al., Schultz et al., as cited in Thungjaroenkul, Cummings, Embleton, 2007, p.262). Adequate staffing is a very crucial issue now a day in health care setting. The focus of it should be on the effective patient’s outcome and to fulfill the requirements of health care. Thungjaroenkul et al (2007) stated that “Decisions about nurse staffing levels should be based on sound evidence to ensure that appropriate numbers of skilled nursing staff are available to achieve safety standards and optimum patient outcomes”(p. 265)
In addition, Barbara as cited in Spokane (2006) stated that “This decision sends a clear message to employers that they must provide for adequate staffing in order to ensure that nurses are able to take the rest breaks” (p.2). Moreover their should be adequate coverage present at time of break so that staff can be relieved completely from work area and not thinking about safety of their patients. This has been supported by Rogers et al (2004b) that it is necessary to “Provide sufficient staff so that nurses do not feel they are neglecting or endangering their patients by taking a break” (p. 517)
“ANA and State Nurses Associations are promoting legislation to hold hospitals accountable for the development and implementation of valid and reliable nurse staffing plans” (Nurse Staffing Plans and Ratios). This gives us the clear idea that hospital management need to work towards providing adequate staffing and its part of legislative process. If a hospital able to fulfill the requirement of adequate staffing then coverage issue will resolve it self and other benefits to staff will be added. Khowaja et al (2005) also give emphasis on “…reducing workload by adequate nurse–patient ratios according to international standards” (p. 32).
ANA has also discussed the importance of strategies to be implemented at school of nursing level which includes addressing the issues of skipping meals and its impact on patient, staff and others. Moreover, it is recommended by ANA to add “…curricula information on the impact of hours worked, rotating shifts, and neglecting to take meal and rest breaks on patient safety and harm to self and peers” (ANA, 2006b, p. 5). To resolve nurses shortage one of the strategy mentioned by Aiken (2007) is “Expanding nursing school capacity to accommodate qualified native applicants and implementing evidence-based initiatives to improve nurse retention and productivity could prevent future nurse shortages(p.1299).This gives us an idea that nurses have become adjusted and not taking adequate breaks but then it implies to many consequences. “The negative consequences are not limited to physical health, e.g. fatigue, headache, sleeplessness. Disruptions and stressed dynamics with the social and family life are also reported” (Nurse and over time). The impact of these stressors has many negative consequences on physical life of person them selves, patient as well as family (Nurse and over time) (Refer Appendix 2). To over come this problem morning tea break has made a significant positive impact on the nurses work outcomes (Lee, 2001). According to Washington State's Nursing Association it has been reported that “Strictly limiting the use of mandatory overtime and ensuring real meal/rest breaks are important steps toward improving patient safety and nurse retention” (Seattle/King county health department)
In addition, findings from a landmark study, The Working Hours of Hospital Staff Nurses and Patient Safety clearly demonstrates that “the hours a registered nurse worked were related to the errors and near misses made by that registered nurse in patient care” (Roger et al, 2004a , p. 210). Health care setting is facing the back lock of staffing at each level form physician to nurses. Talati and Pappas (2006) talks in context of physician that “Pakistan cannot meet its needs for health care given the current levels of production” (p.55). Here we need to work more intensely on production of health care personnel’s but with the goal of effective patient care and staff retention. According to Roger et al (2004 b) “Staffing levels so low that nurses feel they must work nonstop to meet the needs of their patients may also contribute to burnout and nurses leaving the profession” (p. 517).
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