Sleep Not Just Beauty Rest:

Sleep Not Just Beauty Rest: An Innovative Approach to Reducing Healthcare Worker Fatigue Sarah E. Buenaventura, MSN, RN, CMSRN, NE-BC, Abigail Jones, MSN, RN, CNRN, and Ann Schramm, MSN, RN, NEA-BC G worker fatigue negatively impacts quality of health issues, and drowsy driving rates.1,2,3-5 However, care, patient safety, employee satisfaction, and the there is little employee awareness or knowledge of health of employees. Worker fatigue has been shown to worker fatigue and its impact on quality and safety and increase the risk for patient care errors and employee the ability to function as a high-reliability organization. 60 rowing research identifies that healthcare injuries, smoking and alcohol abuse rates, chronic Nurse Leader

As part of the strategic plan for nursing excellence at Northwestern Memorial Hospital (NMH), a large urban academic medical center located in Chicago, Illinois, nurse leaders committed to creating a safe and healthy work environment. This initiative included examining drivers of worker fatigue and providing evidence-based information, tools, and resources to managers and employees to minimize the risks of healthcare worker fatigue. Ensuring that strategy was supported by effective structures and processes ensured the achievement of desired outcomes. ESTABLISHING THE SENSE OF URGENCY The impact of worker fatigue has been a major focus of the Patient Care Division at NMH for the past 7 years. Groundbreaking initial work led to achieving changes to organizational policy language related to sleeping during scheduled breaks, as well as the need to support team members taking uninterrupted breaks during their shifts. Embracing these foundational policies resulted in the establishment of fatigue-focused scheduling guidelines, quiet rooms, and a transportation kitty, and assessment of fatigue related to patient and employee adverse events. In March of 2010, NMH nurse leaders interest was further sparked when they attended the Illinois Organization of Nurse Leaders (IONL) annual conference. The IONL had invited Dr. Jeanne Geiger-Brown, PhD, RN (Work and Health Research Center, University of Maryland School of Nursing) to present. Her title, Is It Time to Pull the Plug on 12-Hour Shifts? was intriguing. Although our organization did not know it at the time, Geiger-Brown s presentation would have a major impact on the professional work environment, our thinking, and the everyday decision making at NMH. As expected, Dr. Geiger-Brown s presentation skillfully summarized and reinforced the growing body of evidence regarding the risks of healthcare worker fatigue to the safety of patients. In addition, the research she shared demonstrated the depth of the impact sleep deprivation and fatigue, including chronic fatigue, has on the individual healthcare worker. 1-3 The evidence demonstrates the significant impact of fatigue on physiological, psychological, and cognitive functioning, and the resulting risks to patients and healthcare workers health, safety, and satisfaction. There also are the risks to the employing organization as a result of patient adverse events, employee injuries, healthcare costs, and paid time off for employees, as well as lower team morale and engagement. 1-3 Our role as nurse leaders is to recognize and understand worker fatigue as a threat to the health, safety, and satisfaction of patients and team members, and to commit to the actions needed to mitigate the known risks. LAUNCHING THE INITIATIVE At our organization, this work began with incorporating a goal to address worker fatigue within our nursing strategic plan. Once identified by the directors of nursing as a priority initiative, it was linked to annual Northwestern Medicine and NMH nursing goals, and then further linked to nursing shared leadership committee goals. Establishing links between goals at all levels of the organization has been key to making and keeping priority initiatives, such as worker fatigue, a main thing for nursing at our organization. Addressing worker fatigue at NMH required a change in culture both for acceptance in identifying and admitting fatigue in workers and for establishing expectations of shared accountability for decreasing fatigue. Despite all of the evidence now known, there is little awareness of worker fatigue as a threat to patients and employees. Thus, a priority goal must be to increase awareness and understanding of all team members on the risks of fatigue and its mitigation. Inviting an expert, Dr. Jeanne Geiger-Brown, to campus was an important investment for our team. The Nursing Best People and Professional Excellence (NBP&PE) committee was a strong partner in inviting and hosting Dr. Geiger- Brown. This was a wonderful opportunity to have a renowned nurse researcher visit NMH to share her research findings on healthcare worker fatigue and to educate on strategies to mitigate the risks (e.g., offer sleep hygiene tips). The committee s input was important in planning our time with Dr. Geiger-Brown to ensure that both patient care leaders and caregivers were exposed to her expertise. Prior to her visit, the 3-part Journal of Nursing Administration series 1-3 was distributed to optimize interactions. Both presentations and small-group discussions were held with leaders and at nursing grand rounds for both day and night shift teams. Utilizing different forums allowed Dr. Geiger-Brown, not only to formally present her information and data, but also to focus with smaller groups on the barriers and challenges to making needed changes. Overall, Dr. Geiger-Brown s visit contributed to organizational leaders and teams now being able to recognize and understand fatigue as a threat to the health, safety, and satisfaction of patients and employees, as well as the mitigation of known risks. Education and awareness efforts were also continued throughout the year at every opportunity, including booths at our annual professional nursing fair and the inclusion of key fatigue messages into our new-hire orientation program. THE WORK PLAN Education and awareness supported the development of a formalized work plan to advance our worker fatigue goal. The work plan defined the focus and key concepts of an accountability model that would communicate, align, and monitor expectations and included: Guiding principles Goals Outcomes owners Process owners Responsible committees and individuals Tactics and key steps Completion dates Having a plan that is clear, specific, and supports accountability and timeliness ensures that the focus on priorities is maintained and that desired outcomes are achieved. In our setting, we achieved 6 outcomes with the project. www.nurseleader.com Nurse Leader 61

OUTCOME #1: REVISED RULES OF PERSONAL CONDUCT/SLEEP POLICY The Joint Commission recently published a monograph titled Improving Patient and Worker Safety, 6 written to stimulate a greater awareness of the potential synergies between patient and worker health and safety activities. One of the suggested interventions is to develop policies that support periodic rest and regular meal breaks by providing uninterrupted coverage of all responsibilities. The NBP&PE committee reviewed the organizational rules for personal conduct that includes our sleep policy. Before revision, the policy did not permit employees to sleep during scheduled shifts. The committee revised the policy to support encouraging caregivers to take a break and rest in non-patient care areas, including planned napping. (A quiet room is also now available.) The policy now reads: Sleeping, preparing to sleep or being in a sleep-like position in patient care and/or public hospital space at any time is prohibited. However, an employee with authorization from a person in charge may rest or sleep while on break in a designated non-patient care, nonpublic hospital space during non-working periods. OUTCOME #2: DEVELOPMENT OF A TAKE-A- BREAK INITIATIVE AND EDUCATION One of the charges for the NBP&PE committee was to look at best practices for supporting a healthy work environment. A literature review on healthcare worker fatigue, conducted in fiscal year 2008, outlined the importance of taking breaks in both minimizing fatigue and preventing errors. In 1 research study (Rogers et al., 4 2004) of 393 nurses (with a response rate of 40%), respondents reported having a break or meal period free of patient care responsibilities on less than half of the shifts worked. The study found that a longer duration of break times offers some protection against reported errors. This study provides some of the first systematic data to support anecdotal reports that staff nurses are routinely skipping breaks and meal periods to provide patient care. A literature review conducted by Witkowski and Dickson 5 (2010) revealed that hospital staff nurses are often working longer hours with no breaks or meal periods. Federal law does not require employers to provide work or meal breaks. Fewer than half of states have laws requiring work or meal breaks. Evidence supports the importance of taking breaks. Time away equals improved safety and quality outcomes, decreased risk of errors, decreased fatigue, increased employee morale, increased job satisfaction, and increased retention. The NBP&PE committee conducted a survey of clinical coordinators (CCs) (primary charge nurses) in all patient care areas in September of 2008, asking them to rate how often they believed care providers in their areas were able to consistently take 30-minute, uninterrupted breaks. The emergency department, intensive care units, surgical services, radiology, and professional services (GI lab) indicated that nurses were taking breaks 95% of the time or more. The areas with low percentages were the other inpatient units. In response to the survey results, several cost-neutral strategies were implemented including: 62 Nurse Leader NBP&PE committee members acted as coaches for inconsistent areas. The NBP&PE committee chair and facilitator rounded on units to identify barriers, communicate best practices, and share strategies. The organization established standards and systems to ensure breaks in a formal, documented system (i.e., buddy system, assigned patient care teams, take-abreak nurse). The NBP&PE committee chair and facilitator presented to the managers/directors at the chief nurse executive council and at the department shared leadership committees (unit levels). Take-a-break lunch bags were given as Nurses Week gifts. Articles about reducing healthcare worker fatigue were written in enursing Now (an internal electronic news bulletin for nurses). To obtain further understanding and build awareness, an online survey was created and sent to all clinical nurses in September of 2009 and again in August of 2010. Nurses were asked how often they were able to receive a 30-minute, uninterrupted break. The results revealed that we had not yet reached our goal. The strategies implemented in 2009 had not been sustained. During the same time period nationally (between March 30, 2008, through April 13, 2010), the American Nurses Association also created an online poll asking the question, How often were you able to take your full meal break? 7 Out of 16,000 nurses who responded, 35% reported that that they have the opportunity to take a break. To further promote individual take-a-break accountability, we increased director and manager involvement in setting expectations and monitoring compliance. Starting in January of 2011, we began monitoring daily caregiver breaks. Caregivers were asked to document daily breaks on unit assignment sheets. Bundling these interventions together allowed our organization to reach 100% compliance in all patient care areas. OUTCOME #3: MODIFICATION OF STAFF SCHEDULING GUIDELINES The Joint Commission s Improving Patient and Worker Safety monograph 6 also recommends establishing a means of assessing for organizational employee worker fatigue. This includes the assessment of off-shift hours and consecutive shifts worked, and a review of staffing policies to confirm they address extended work shifts and hours. Such an assessment was conducted at our organization by the Manager Forum (a group of high-performing managers) who began with a review of the literature of recommended scheduling practices to reduce healthcare worker fatigue. All clinical managers were asked to evaluate current scheduling practices by reviewing the prior 6-week schedule. The assessment also included review of a pay period snapshot of extended work hours obtained from the online timecard system. How often were caregivers working? How many consecutive shifts in a row were they working? How long were they working? Were they working both day and night shifts?

We were excited with the results. We realized that most employees (more than 95%) were working fewer than 3 consecutive 12-hour shifts in a row, as recommended by the research. New scheduling guidelines presented below were then drafted based on the Institute of Medicine recommendations. 8 They were approved by the NBP&PE committee, managers, directors, and the chief nurse executive. Revised Scheduling Guidelines Maximum number of consecutive scheduled 12-hour shifts should not exceed 3. Minimum number of hours off after 3 consecutive day shifts is 24; night shift is 48. Do not pre-schedule any 16-hour shifts. The maximum number of hours an employee is allowed to work in 1 week (Sunday through Saturday) is 60 hours. Working with our online scheduling vendor, information technology solutions were built in to support the new guidelines. For example, an employee is unable to pre-schedule to work 16 hours in 1 day or more than 60 hours in 1 week. Adhering to the scheduling guidelines has required changes in historical unit practices. For example, to avoid employees working extended hours, managers need to schedule team meetings during employees regularly scheduled hours. This may include a manager coming in early or on nights. Managers also are encouraged to optimize electronic communication. Team huddles have been implemented every 4 hours, not only to improve handoffs, improve patient safety, and improve communication among team members, but also to help assess how team members are doing with the distribution of work and assigned tasks. How can the workload be redistributed among the team to ensure all members take a break and get out of work on time? OUTCOME #4: ASSESSMENT OF THE IMPACT OF FATIGUE ON EMPLOYEE INJURIES AND PATIENT INCIDENT REPORTS Another aspect of assessing for organizational employee fatigue is to understand the impact of fatigue on employee and patient incidents. At our organization, incident reports are completed for all employee injuries and patient adverse events. A better understanding of worker fatigue resulted in changes to the incident report forms, allowing us to better assess and trend the impact of fatigue on employees and patients. Questions were added to the forms regarding fatigue. How many hours into the shift had been worked prior to the incident? How many shifts had been previously worked that week? All reports are shared with the appropriate manager, director, occupational health, employee safety, and/or risk management. Members of this team then provide individual coaching, education, and resources to reinforce safe work practices. The identification and communication of trends has then been helpful in identifying opportunities for further organizational messaging, policy, and practice changes. This interdisciplinary approach parallels the Joint Commission s November 2012 recommendations. 6 OUTCOME #5: DESIGNATION OF QUIET ROOMS Once a new policy was created that encouraged planned napping, we recognized that a designated napping space was needed. Having a quiet room is also another recommendation from the Joint Commission s 2012 Improving Patient and Worker Safety monograph. 6 The need to define and design a space for napping was brought to the NBP&PE committee. Committee members brainstormed ideas regarding what this space should be, including not only what it should look like, but how it should sound, feel, and smell. A quiet room workgroup began the creation of the room in partnership with our facilities team. The room, previously used as a multipurpose break room, was closed down for renovation, following a broad communication to users. All furniture and electronics were removed. Walls, ceiling, and carpet were cleaned, followed by the painting of 1 wall a calming blue. Recliners and a couch were repurposed from other departments, and the room transformation was completed with lighting, artwork, and a decorative dried flower arrangement. Having the recliners on wheels allows them to be moved around to create individualized spaces for relaxing and re-energizing. The room, secured from the public, is open to all care team members with only a few rules. No food No talking Music only with ear phones The availability of this respite space and the message of support and concern to our employees have been positively received. Two other quiet rooms have since been created to accommodate employees in other hospital pavilions. OUTCOME #6: CREATION OF A TRANSPORTATION KITTY Dr. Geiger-Brown shared with us evidence of the dangers of drowsy driving after long shifts. As we thought about this, we realized we did not have any resources to help care providers if they felt too fatigued to safely drive home. In response, a transportation kitty was created with donated funds to support safe transportation home. Resources, with guidelines for their use, include public transportation passes and cab vouchers. All employees are encouraged to nap if too tired to drive, but if napping is not an option, then the resources from the kitty can be accessed. During business hours, the kitty can be accessed by the employee s manager and on the off shifts by a hospital administrator. A log is used to track the use of the kitty to ensure no one is over utilizing the resource; that the manager can follow up with the employee to ensure he/she got home safely; and to reinforce key fatigue mitigation messages. CONCLUSION Broad engagement of nursing shared leadership and collaborative partnerships resulted in a high level of team awareness and sensitivity to the risks of worker fatigue. The strategic focus on reducing these risks, supported by a strong structure and process, resulted in multiple organizational changes and outcomes including: policy change to www.nurseleader.com Nurse Leader 63

support planned napping; evidence-based scheduling guidelines; take-a-break standards; availability of quiet rooms for team breaks; a transportation kitty for those too fatigued to drive home; and worker fatigue as a component of the evaluation of employee and patient adverse events. As leaders, our role is to recognize and understand, and to commit to the actions needed to keep our employees and patients safe. Sharing the success of 1 organization s initiative supports the need for a universal and collaborative focus on healthcare worker fatigue as a threat to the health, safety, and satisfaction of patients and employees. NL References 1. Geiger-Brown J, Trinikoff A. Is it time to pull the plug on 12-hour shifts? Part 1. The evidence. J Nurs Adm. 2010;40:100-102. 2. Geiger-Brown J, Trinikoff A. Is it time to pull the plug on 12-hour shifts? Part 3. Harm reduction strategies if keeping 12-hour shifts. J Nurs Adm. 2010;40:157-159. 3. Montgomery K, Geiger-Brown J. Is it time to pull the plug on 12-hour shifts? Part 2. Barriers to change and executive leadership strategies. J Nurs Adm. 2010;40:147-149. 4. Rogers AE, Hwang W, Scott LD. The effect of work breaks on staff nurse performance. J Nurs Adm. 2004;34:512-519. 5. Witkowski A, Dickson V. Hospital staff nurses work hours, meal periods, and rest breaks. AAOHN J. 2010;58:489-497. 6. The Joint Commission. Improving patient and worker safety: opportunities for synergy, collaboration and innovation. Oakbrook Terrace, IL: The Joint Commission; 2012. http://www.jointcommission.org/assets/1/18/tjc- ImprovingPatientAndWorkerSafety-Monograph.pdf. Accessed December 23, 2013. 7. American Nurses Association. Safe Staffing Saves Lives. http://www.safestaffing saveslives.org/whatisanadoing/pollresults/default.aspx. Accessed December 23, 2013. 8. Institute of Medicine. Keeping patients safe: Transforming the environment for nurses. (Report recommendations); 2004. http://iom.edu/reports/2003/ Keeping-Patients-Safe-Transforming-the-Work-Environment-of-Nurses.aspx. Accessed December 23, 2013. Sarah E. Buenaventura, MSN, RN, CMSRN, NE-BC, is an operations manager in Patient Care, General Medicine, at Northwestern Memorial Hospital in Chicago, Illinois. She can be reached at slowell@nmh.org. Abigail Jones, MSN, RN, CNRN, is strategic sourcing manager at Northwestern Memorial Healthcare in Chicago, Illinois. Ann Schramm, MSN, RN, NEA-BC, is the former director, Women s Health, at Northwestern Memorial Hospital in Chicago, Illinois. 1541-4612/2014/ $ See front matter Copyright 2014 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2013.11.002 64 Nurse Leader