Are critical care nurses too fatigued?
Critical-care nursing has evolved over time into one of the most demanding, stressful, and labor-intensive specialties in the discipline of nursing. Each week, new regulatory mandates require additional documentation and competencies, the acuity of patients admitted to critical-care units is escalating, and advances in technology continue to change regularly, requiring more frequent in-services and trainings to stay up-to-date. Two types of fatigue affect critical-care nurses: general fatigue and what is being termed “alarm fatigue.”
General fatigue
Critical-care nurses “provide the bulk of care to patients with oftentimes unstable conditions ... must be alert to subtle changes in patients’ conditions, perform accurate clinical assessments, and respond in an expedient manner,” according to the American Journal of Critical Care (Jan 2006). Scott, Rogers, Hwang and Zhang published the results of a study titled "Effects of Critical Care Nurses’ Work Hours on Vigilance and Patients’ Safety." Over a 28-day period, they surveyed over 1,000 eligible full-time nurses currently working in critical-care hospital settings, and slightly less than half (502) provided data for the study.
Results from this study showed that critical-care nurses regularly work longer than their scheduled hours, and that 10% of them worked more than 16 consecutive hours at least once during a 28-day period. Other results indicated that nurses worked longer than scheduled 86% of the time, working on average almost one hour longer than scheduled.
Additional data indicated that all except one of the 502 nurses worked some overtime in this 28-day period, with over half working overtime 10 or more times. Addressing the issue of general fatigue, further results showed that close to two thirds of the nurses reported difficulty staying awake at work at least one time, and this occurred on both day shifts and night shifts. In addition, 20% of the nurses reported that they actually fell asleep during their shift at least once in 28 days.
Over a quarter of the nurses reported making an error, and over one third reported a near error. Most of these errors and near errors were related to medication administration.
The study concluded that the probability for errors and near errors increased with longer work duration common to critical-care units. The results also indicated that longer work shifts were related to decreased levels of vigilance. However, there was no association found between an increased risk of errors and decreased vigilance.
Alarm fatigue
In the September 6, 2010 issue of Nursing Spectrum, Debra Anscombe Wood, RN, reports “a major factor in errors that affect patient care is fatigue—both alarm and physical.” Alarm fatigue occurs due to the numerous alarm bells, whistles and chirps in critical-care units. Nurses tune out these sounds that are supposed to be patient alerts, and in some instances, critical-care nurses have turned off alarms.
Linda Bell, RN,MSN, clinical practice specialist at the American Association of Critical-Care Nurses, believes an “increasing number of devices with alarms have nurses becoming more aware of the dangers of alarm fatigue.” In January, 2010, in an instance where a bedside alarm had been turned off, a cardiac patient at Massachusetts General Hospital in Boston died. Although alarms sounded on the central nursing station monitors, nurses reported to the Centers for Medicare & Medicaid Services during their investigation, that they were “experiencing alarm fatigue and a desensitization to alarms after hearing them throughout the workday.”
Since this incident the monitors have been modified, so that the alarms may not be turned off. Linda Bell believes that “you should never be able to turn an alarm off.” Jeanette Ives Erickson, RN, senior vice president for patient care and chief nurse at MGH, explains that there are a lot of false positive alarms, and they “degrade the ability of clinicians to decipher important alarms.” When the alarms are too sensitive, this can lead to apathy and contribute to nurses ignoring alarms, and developing alarm fatigue.
