Nurse Fatigue: The Human Factor

Alabama Nurse,  Sep-Nov 2005  by Tabone, Stephanie

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The National Transportation Safety Board (NTSB) study of flight crew incidents between 1978 and 1990 found that 50% of airline captains for which data existed had been awake for more the 12 hours prior to their accidents. This led to the conclusion that fatigue is the probable cause of a large portion of air accidents due to impaired judgment and decision making, and flight handling abilities.

So if a pilot who's been awake for the prior 12 hours (and perhaps, not even piloting the plane) can't necessarily land the aircraft successfully even with the benefit of an instrument panel of data, and a crew, albeit fatigued, telling him he's missed the correct instrument readings, why would nurses who are fatigued think they could continue to provide safe patient care? In many cases, we nurses have to make critical, split second judgments in patient care without the benefit of instrument panels and supportive crew members.

The NTSB recommended that scheduling policies be amended to not only limit scheduled flight times but also provide time for "adequate restorative rest." Restorative rest varies but NTSB recommends that it include at least 8 hours of continuous sleep before reassignment to flight. The NTSB says that age should be taken into consideration because as persons age, they are more susceptible to sleep disturbance and this should be considered in the calculating of recovery time. OK, you nurses with an average age of 46 years, are you getting adequate restorative rest with your 12-plus hour shifts?

PREDICTABILITY OF FATIGUE

Now, let's get more specific. What are the laboratory findings regarding sleep deficiency with a loss of as little as 2 hours of sleep in a night?

* decrease in alertness

* worsened mood

* decreased performance including:

degraded judgment,

degraded situation awareness,

degraded decision making,

decrease in memory,

slowed reaction time,

lack of concentration,

fixation

Of interest to nurses, conditions that contribute to the above problems include how long one has been awake and how long one has been at a particular task. The symptoms of fatigue according to the laboratory studies begin with errors of omission, progress to errors of commission, and finally result in micro sleep (periods of sleep lasting for seconds or minutes).

Let's recap. Our nurse studies and medical studies are not yet definitive on the subject of fatigue and errors. But, every study we have to date implies that we nurses are not different from any other humans who are subject to the effects of fatigue. Those effects are predictable. We even advise our patients to get adequate rest for maximum performance.

So, what are we waiting for? We knew for a decade that studies would prove that nurses were essential at the patient bedside and contributed to the quality of patient care. We now have definitive studies that prove we were right. We should predict, based upon current data, that repeated studies that include larger numbers of nurses and doctors will give us results on error related fatigue that is similar to results we already have in other safety related industries. We just haven't studied it yet.