UW nursing dean, sleep research key to policy statement on nurse fatigue

There are just few things the human body truly requires to keep going. Food and water are on the list. And so is the focus of Linda Scott’s research.

“Sleep is a physiological need,” says the dean of the University of Wisconsin–Madison School of Nursing, who has spent nearly two decades studying the effects of fatigue. “If you do not get it, eventually, your body will make you sleep.”

Unfortunately, nurses — who often work long hours without many breaks — may not always be able to get the sleep they need. Scott and fellow members of the American Academy of Nursing are taking the initiative to change that in order to improve the working environment for the benefit of their colleagues and patients.

Scott co-authored a wake-up call on the subject, a position statement published in the journal Nursing Outlook recommending that nurses and employers get educated on the health and safety risks of fatigue and long hours. The position statement also encouraged health systems to work collaboratively with nurses to use research findings to design schedules and policies that promote a rested and alert workforce.

“Many healthcare organizations may not fully understand the health risks for both nurses and their patients from a tired workforce,” Academy president Karen Cox said of the organization’s statement, which warns that long, irregular and overnight shifts require careful management.

Nurses often work 12-hour shifts, according to Scott, who conducted the first national quantitative study of nurses’ work hours. Even during their half-day shifts, nurses in Scott’s studies often went without much more than 30 minutes altogether for breaks, restroom visits and meals. After a workday like that, nurses punch out and try to live some semblance of a personal life — commuting, caring for children, getting some exercise, sitting down to dinner — before getting some rest and returning to work for another 12 hours.

“We are a 24­/7 society. We think we are invulnerable to some of those types of physiologic needs, and we say, ‘I can gauge how tired I am. I can push through it. I am OK,’” Scott says. “But if you continue to do that, you develop what is called a cumulative sleep debt. You can never really get those hours back.”

Carrying sleep debt is dangerous, as it comes due as increased risk of cardiovascular disease, diabetes, a faltering immune system and even, eventually, dementia.

Indeed, insufficient sleep can have profound long-term nurse health consequences as well as short-term patient safety consequences, and Scott has studied both. Her investigations into the role of fatigue in error rates and decision regret shows both increase as workdays lengthen. A long list of notable disasters — including the space shuttle Challenger, Exxon Valdez and Chernobyl — count the fatigue of key decision-makers among contributing factors.

Tired nurses can struggle, too.

“The risk of error doubles once you’ve worked more than eight consecutive hours, and nurses who worked 12 consecutive hours or more were 3.5 times more likely to make an error,” Scott says.

Scott and the Academy believe it is critical for employers to assume some of the responsibility for ensuring a rested, and therefore safe, workforce. Nurses still must tend to their own sleep hygiene in their off-hours, but they should also have and take the opportunity to work with healthcare organizations to schedule shifts, structure worktime, and implement policies that prioritize, promote and support rest and recovery.

“This idea of partnership is an important part of the American Academy of Nursing’s policy statement and some other evidence-based strategies,” Scott says. “It is not just the individual’s responsibility. It is also the employer’s responsibility to ensure your employees are healthy and fit for duty.”

Like airline pilots and truck drivers, who have had hours-of-service rules for decades, nurses may need to diligently monitor their time since rest. Evidence also suggests employers avoid schedules that keep nurses on their feet during our sleepiest hours — 2 a.m. to 5 a.m. and 2 p.m. to 5 p.m.

“You may think you can overdo it, and play catch-up, but it is fatigue that is going to catch up to you.”

Linda Scott

Scott has tested a fatigue-countermeasure program for nurses that has proven successful in improving alertness and decision-making. The program includes education for nurses on topics on the immutable circadian rhythms that make us naturally alert and groggy, good sleep practices at home, and how to make a caffeine habit serve their schedule instead of hinder it.

Scott’s research has also shown the benefits of naps. Twenty-minute “strategic” naps add hours of alertness before more rest is necessary, says Scott, but in many environments, they are prohibited.

“The thing is, most hospitals still have human resource policies in place that if you are found sleeping on the job it is grounds for termination,” Scott says. “For our countermeasure study, we got hospitals to suspend those. But a lot of them went right back in place when we were done.”

Culture can also be a culprit. Even when some work environments do allow naps, nurses are often discouraged—either by managers or by peers—from taking them. Nurses who nap can run the risk of appearing less capable than their peers or having their dedication or efficiency questioned in their performance reviews.

Scott’s findings underscore the importance of involving nurses in collaborative initiatives to implement change.

“We have confirmed there is a significant amount of sleep debt among nurses, and the greater the sleep debt the more likely there were to be errors,” Scott says. “We have shown that fatigue countermeasures — education on sleep and sleep environment, combined with good scheduling and letting nurses nap — improves overall sleep and decreases errors. And the nurses all felt better.”

Of course, Scott says, the problem goes beyond nurses. Everyone, she says, should consider their own sleep health. Because nobody gets to cheat nature.

“It is not just nurses who are sleep-deprived. It is a societal problem,” she says. “You may think you can overdo it, and play catch-up, but it is fatigue that is going to catch up to you.”