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The Importance of Mandatory Rest Periods in OR Environments
OPINION
The Importance of Mandatory Rest Periods in OR Environments JUDITH LIPTON GOLDBERG, RN, MSN, CNOR; PAMELA L. MARSHALKOWSKI, RN, BSN, CASC; RACHEL BATTAGLIA NISSEN, RN, MSN
A
t 2 AM, a perioperative nurse is finally driving home from work. As she drives down a dark, deserted road, she thinks about her day, which began the previous morning at 7 AM. The day started as always, with a full schedule of procedures. There was adequate staffing to cover each room and the day was uneventful. Unfortunately, the nurse had been assigned to be part of the call team, and she needed to stay for emergency surOvertime hours geries that continued to pile up all evening. worked in most After working nearly 20 hours, the nurse left industries, including work to drive home. Her feet were tired, her head health care, have hurt, and all she could think about was the few increased steadily hours she could sleep before she had to return to over the past work at 7 AM. As she pulled into her driveway, 15 years. she realized that she did not remember the last two miles that led to her home or even stopping at the traffic light before pulling into her subdivision. She had been on “autopilot” the whole way home and was lucky there was little traffic in her way. For just a moment, before turning the key to her back door, the nurse thought about her ability to function in the morning when she would return to work.
OVERTIME AND FATIGUE IN THE PERIOPERATIVE ENVIRONMENT In addition to working their regularly scheduled shifts, perioperative nurses routinely are required to be on call1
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as a means of covering unscheduled or emergency procedures after normal hours or when scheduled procedures run late. Because of the complexity of scheduling and the unpredictability of surgical procedures, many facilities have altered staffing patterns to include eight-, 10-, and 12-hour shifts, as well as on-call requirements. The US Department of Labor Occupational Safety and Health Administration states, “a normal work shift is generally considered to be a work period of no more than eight consecutive hours during the day, five days a week, with at least an eight-hour rest.”2 The number of overtime hours worked in most industries, including health care, has increased steadily over the past 15 years,3 and the perioperative environment commonly uses mandatory overtime. Mandatory overtime is defined by the Economic Policy Institute as those hours worked above the standard 40-hour week that an employer makes compulsory with the threat of job loss or other reprisals.3 Many professional nurses working in the perioperative environment have experienced fatigue and exhaustion related to overtime and on-call practices. Every day, nurses are required to stay past their scheduled shifts to accommodate overbooked procedures, emergencies, and sick calls. When fatigue sets in, whose responsibility is it to determine whether an individual is working at a safe practice level?
SAFETY ISSUES ASSOCIATED
WITH
FATIGUE
According to the American Nurses Association (ANA), nurses should be able to care for themselves and make the determination that they are too
© AORN, Inc, 2008
Opinion
tired to practice at safe levels.4 Unfortunately, having the courage to admit that one is too tired to function optimally can be difficult. According to the AORN On-Call Electronic Task Force, there are multiple reasons why perioperative nurses work more than their scheduled hours.5 These reasons range from lack of available trained staff, to nurses wanting the extra overtime pay, to surgeons refusing relief during a procedure. Because work fatigue can occur during any of these situations, it is the individual nurse’s responsibility to identify when fatigue sets in. Organizations, then, must facilitate a positive environment where nurses are comfortable expressing their exhaustion without fearing retribution. Working extended hours without proper rest affects not only workers but also families, community members, employers, and patients. The adverse effects in each of these groups are documented by research. Families can be adversely affected when parents are not available or are too tired to supervise children, help with homework, or enjoy leisure time together. In fact, those who work more than 50 hours per week report significantly higher work-family conflicts than those who work fewer hours.3 Community safety is put at risk when people who have worked extended hours drive home while drowsy, which has been compared to being legally drunk.6 Twelve-hour shifts, common in nursing, are known to increase the risks for motor vehicle crashes linked to fatigue. In one study, nurses who worked night shifts were nearly four times more likely to have difficulty staying awake while driving home compared to nurses who did not work at night.6 The employer also is adversely affected by fatigue because extended hours eventually lead to nursing burnout.7 Nurses overwhelmed and exhausted are leaving the profession or, even worse, are unable to maintain a caring, professional demeanor. Those who do stay in the profession are more likely to suffer from depression and illnesses linked to absenteeism8 or to succumb to addictive tendencies.9 The patient-related safety issues surrounding working while fatigued are well documented, and fatigue is known to affect judgement.
NOVEMBER 2008, VOL 88, NO 5
Organizations must facilitate a positive environment where nurses are comfortable expressing their exhaustion without fearing retribution.
According to Scott et al, “[medical] residents were unable to accurately judge their level of impairment when tested after [a] heavy call condition.”6(p1802) In addition to impairing judgement, extended work hours have contributed to at least two hospital-wide epidemics of Staphylococcus aureus, which occurred in South Florida and California.8 It later was determined that high caseloads and minimal staffing led to stress and fatigue and ultimately to mistakes that contributed to the epidemics. Studies also show that accident and error rates rise dramatically when employees work more than 12 hours.3,8 According to the study by Rogers et al,8 the risk of making an error or a near error is not affected by age, hospital type, or unit type, but is strongly linked to extended work hours. Research shows that fatigued nurses make mistakes ranging from inaccurate charting to patient care-related errors.5
MANDATORY REST PERIODS The Joint Commission mandates a focus on a culture of safety and providing care for patients in a safe, effective manner.10 This includes nurses’ safety and their ability to provide care when they are not fatigued or exhausted. The safety of patients and the protection of health care workers could be addressed by enacting standardized state and federal regulations that mandate specific rest policies. Not to be construed as union activism, political activism could provide regulatory language that would protect nursing professionals. Mandatory rest periods for health care employees are uncommon and often are not clearly defined in state or federal regulations. AORN JOURNAL •
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Opinion
NOVEMBER 2008, VOL 88, NO 5
Because of patient and employee safety concerns, it is clear that nursing must not only set similar standards but also stipulate specific regulations requiring mandatory rest periods on either a state or federal level.
Although there are specific guidelines related to on-call practices stated by AORN1,11 and other specialty nursing organizations,12 many hospitals and health care facilities do not recognize the need to support their staff members with the implementation of these types of guidelines. To further complicate matters, the needs of administrators and nursing staff members are often at odds: administrators are responsible for business, keeping the hospital open and operational—which requires nurses to be at work—while nurses need to tend to themselves and ensure they are rested to perform at optimal levels. Because nurses often are pressured to work when fatigued, administrators and managers need to be able to recognize the potential for fatigue and identify when and how it occurs. According to an ANA position statement, the employer’s responsibility is to promote a work schedule that allows for “adequate rest and recuperation between scheduled work.”13 Creative scheduling and policies that allow nurses who have worked a certain number of hours (ie, as many as 12) to go home without being penalized can prevent the abuse of overtime and provide an opportunity for nurses to rest when on-call situations arise. The need for mandatory rest periods is not limited to nurses, physicians, and other health care workers. Other examples can be seen in public-related industries where fatigue and exhaustion have prompted the need for safety regulations. The aviation industry, for exam-
792 • AORN JOURNAL
ple, has clear regulations regarding mandatory rest periods for pilots and strictly enforces a mandatory rest period between scheduled flight times.14 These required rest periods fluctuate between eight and 11 hours depending on the hours worked. The Federal Motor Carrier Safety Administration also clearly defines work week regulations with mandatory rest periods of no less than 10 hours after a maximum of 11 hours worked for drivers.15 The Nuclear Regulatory Commission (NRC) has policies in place to control the number of hours that US commercial nuclear facility employees may work.16 The purpose of these policies is to prevent employees in safety positions from working while fatigued, which could affect their ability to make decisions. In an emergency, however, these rules may be waived by a plant manager or senior manager. In a June 15, 1982, policy statement,16 the NRC stated • an individual should not be permitted to work more than 16 consecutive hours; • an individual should not be permitted to work more than 16 hours in any 24-hour period, nor more than 24 hours in any 48hour period, nor more than 72 hours in any seven-day period; • a break of at least eight hours should be allowed between work periods; and • the use of overtime should be considered on an individual basis and not for the entire staff on a shift.
REGULATORY ACTION Because of patient and employee safety concerns, it is clear that nursing must not only set similar standards but also stipulate specific regulations requiring mandatory rest periods on either a state or federal level. Although the federal guidelines regarding mandatory overtime are limited, there seems to be a shift in attitude at the state level. The Connecticut Nurses Association in October 2007 approved a resolution that promotes the ethical responsibility of professional nurses to determine their individual level of fatigue before working beyond their regular hours.17 “Assuring patient safety: registered nurses’ responsibility to guard against working when
Opinion
fatigued”17 describes multiple considerations nurses and employers should take when requesting overtime hours, including advocating models that limit the number of hours nurses and nursing students can provide direct patient care or care requiring clinical judgment that affects direct patient care. In recent years, 14 states have restricted the use of mandatory overtime for nurses. Eleven have enacted legislation (ie, Connecticut, Illinois, Maryland, Minnesota, New Jersey, New Hampshire, New York, Oregon, Rhode Island, Washington, West Virginia), and three have provisions in regulations (ie, California, Missouri, Texas).18 In 2008, nine more states introduced legislation (ie, Arkansas, Arizona, Florida, New York, Ohio, Vermont, Washington, Wisconsin, West Virginia).18 Several of these states—New York, Maryland, California, and West Virginia—have made exceptions to their regulations, however, and allow mandatory overtime to be used in emergency circumstances related to public health or for surgical procedures. Although mandatory overtime sometimes must occur in the perioperative environment, limits need to be defined. For example, if there is no one to relieve a nurse during a procedure, he or she must stay to avoid patient abandonment. This example demonstrates the need for appropriate staffing levels and schedule management: procedures should not be started if there is not sufficient staff for relief shifts. Although there has been state regulatory action regarding limiting overtime, few states have specific regulations related to mandatory rest periods.18 Among states with laws banning mandatory overtime, Illinois and Maine require rest periods of at least eight hours following 12-hour shifts. In some cases, nurses employed by unionbased health care facilities may be able to work mandatory overtime regulations into their contracts. Limiting mandatory overtime can provide an added benefit to the employee and employer. The employee benefits by having adequate rest periods and so being able to perform at optimal levels, and the employer benefits by having nurses who are not suffering
NOVEMBER 2008, VOL 88, NO 5
In recent years, 14 states have restricted the use of mandatory overtime for nurses: 11 have enacted legislation and three have provisions in regulations.
fatigue and therefore are less prone to committing errors. Some union-based hospitals have worked out the issue of mandatory rest periods for perioperative and postanesthesia care unit nurses with specific stipulations within their contracts.19,20 Although many non-union hospitals recognize AORN guidelines and standards for safe on-call practices,1,11 budget constraints and limited staff can make it difficult to employ those standards. Some facilities recognize the need for mandatory rest periods and have developed fair and equitable policies in conjunction with staff members. The Charlotte Hungerford Hospital in Torrington, Connecticut, for example, is a non-union hospital that recently approved a new policy for mandatory rest periods.21 This policy benefits not only the perioperative staff, but it also extends to nursing personnel hospital-wide. In recent years, US senators from several states have repeatedly proposed legislation to ban or limit mandatory overtime for nurses. The Safe Nursing and Patient Care Act of 2007 (SNPCA),22 is the most recent attempt at a federal regulation regarding mandatory overtime. This bill is intended “to provide for patient protection by limiting the number of mandatory overtime hours a nurse may be required to work.”22(p1) Although mandatory overtime is the key factor within this legislation, mandatory rest periods for nurses are not addressed. Legislators need to be made aware of the necessity for mandatory rest periods as a mechanism to ensure patient and employee safety and include this in the next version of the SNPCA. Perioperative nurses can educate legislators AORN JOURNAL •
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NOVEMBER 2008, VOL 88, NO 5
about the need for mandatory rest periods, lobby for legislation to safeguard patients, and work with facility administrators to enact policy change. Nurses can attend state lobby day activities, set up meetings to discuss the issues with senators and representatives both in their districts and those on the public health committees, write letters, make phone calls, and write editorials for local newspapers.
WORKING TOWARD SAFER CARE The dangers of fatigue in the health care setting are well documented, and are known to adversely affect both patients and employees. These dangers could be alleviated with regulations that impose mandatory rest policies for nurses. Because most nurses feel compelled to work their shifts and call schedules with little consideration for themselves or the patients that they are potentially jeopardizing, administrators and managers need to be able to recognize the potential for fatigue and identify when and how it occurs. If it is the responsibility of the nurse to identify when fatigue sets in, organizations must facilitate a positive environment where nurses are comfortable expressing their exhaustion without fear of retribution. The employers’s responsibility is to promote a work schedule that allows rest between scheduled work shifts. It is clear that the nursing profession must not only set standards but also stipulate specific regulations requiring mandatory rest periods on either a state or federal level. Legislators need to be made aware of the necessity for mandatory rest periods as a mechanism to ensure patient and employee safety. The current lack of federal and state regulations regarding mandatory rest periods requires individual hospitals and their administrators, managers, and nursing leaders to be responsible for the safety and well-being of their nursing staff members and patients. Collaborating with human resources departments to provide appropriate nursing policies regarding mandatory rest periods offers an equitable solution to preventing fatigue and unsafe nursing practices. In turn, sharing in this practice of employee safety allows each hospital to pro-
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vide an arena for the safe and quality care of their patients.
REFERENCES 1. AORN position statement: Safe work/on-call practices. In: Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:409-412. http://www.aorn.org/PracticeResources/AORN PositionStatements/Position_SafeWorkOnCallPrac tices. Accessed August 11, 2008. 2. Extended/unusual work shifts. US Department of Labor Occupational Safety and Health Administration. http://www.osha.gov/SLTC/emergency preparedness/guides/extended.html. September 2, 2004. Accessed August 11, 2008. 3. Golden L, Jorgensen H. Economic Policy Institute (EPI) Briefing Paper: Time after time—mandatory overtime in the US economy. http://www.epi.org /content.cfm/briefingpapers_bp120. January 2002. Accessed August 11, 2008. 4. Nurse fatigue. American Nurses Association. http:// www.nursingworld.org/MainMenuCategories/The PracticeofProfessionalNursing/workplace/Workforce /NurseFatigue.aspx. Accessed September 22, 2008. 5. Kenyon TA, Gluesing RE, White KY, Dunkel WL, Burlingame BL. On call: alert or unsafe? A report of the AORN on-call electronic task force. AORN J. 2007;86(4):630-639. 6. Scott LD, Hwang WT, Rogers AE, Nysse T, Dean GE, Dinges DF. The relationship between nurse work schedules, sleep duration, and drowsy driving. Sleep. 2007;30(12):1801-1807. 7. Garrett C. The effect of nurse staffing patterns on medical errors and nurse burnout. AORN J. 2008; 87(6):1191-204. 8. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202-212. 9. Dunn D. Substance abuse among nurses— defining the issue. AORN J. 2005;82(4):573-596. 10. Studies cite persistent threat to patient safety, hospital work environment and present improvement options. Joint Commission Resources. http://www.jcrinc.com/27660/JCRnews/27930. November 1, 2007. Accessed August 11, 2008. 11. AORN guidance statement: Safe on-call practices in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:240-242. 12. Association of PeriAnesthesia Nurses. A position statement on On call/work schedule. In: The Standards of Perianesthesia Nursing Practice. Cherry Hill, New Jersey: ASPAN, Inc; 2006:104-105. 13. ANA position statement: assuring patient safety: the employers’ role in promoting healthy nursing work hours for registered nurses in all roles and settings. Effective December 8, 2006. http:// www.nursingworld.org/MainMenuCategories/
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HealthcareandPolicyIssues/ANAPositionStatements /workplac/EmployersRole.aspx. Accessed August 11, 2008. 14. Federal Aviation Administration. Civil Aviation Regulations [State] Part 8—Operations, Vol 2.5. http://www.faa.gov/safety/programs_initiatives /oversight/iasa/model_aviation/media/PART08 .doc. April 2007. Accessed August 11, 2008. 15. Hours-of-service regulations. Federal Motor Carrier Safety Administration. http://www.fmcsa .dot.gov/rules-regulations/topics/hos/HOS-2005 .htm. Effective date: October 5, 2005. Accessed August 11, 2008. 16. Nuclear power plant staff working hours (generic letter No. 82-12). June 15, 1982. Nuclear Regulatory Commission. http://www.nrc.gov/reading-rm/doc -collections/gen-comm/gen-letters/1982/gl82012 .html. Accessed September 22, 2008. 17. Connecticut Nurses’ Association members approve resolutions at annual meeting. Connecticut Nursing News. 2007;80(4):1-3. http://www.ctnurses .org/associations/1710/CNN%20December%202 007%20final.pdf. Accessed August 11, 2008. 18. American Nurses Association. In: ANA State Government Relations. http://www.nursingworld .org/mainmenucategories/anapoliticalpower/state /statelegislativeagenda/mandatoryovertime.aspx. Published 2005. Accessed September 22, 2008. 19. Contract between the University of Connecticut Health Center and University Health Professionals Local 3837 AFT/AFT-CT/AFL-CIO. Farmington, CT: University of Connecticut Health Center; 2006. http://employ.uchc.edu/information/pdfs/barg aining/UHPContract2006_2010(Complete).pdf. Accessed August 11, 2008. 20. UW/SEIU 1199 Contract. Article 7: Hours of
Work and Overtime. University of Washington Labor Relations. http://www.washington.edu/ad min/hr/laborrel/contracts/1199/contract/a07.html. Effective July 1, 2007 to June 30, 2009. Accessed August 11, 2008. 21. Rest time for employees on call scheduled to work the next day [policy and procedure manual]. Torrington, CT: The Charlotte Hungerford Hospital; April 4, 2007. Rev January 24, 2008. 22. American Nurses Association. Safe Nursing and Patient Care Act of 2007 (HR 2122). http://rnaction .org/politicalpower/mandatory_overtime_house. Accessed August 11, 2008.
CLINICAL
FARMINGTON
JUDITH LIPTON GOLDBERG RN, MSN, CNOR DIRECTOR, CENTRAL PROCESSING DEPARTMENT THE WILLIAM W. BACKUS HOSPITAL NORWICH, CT
PAMELA L. MARSHALKOWSKI RN, BSN, CASC NURSE MANAGER SURGERY CENTER, UNIVERSITY OF CONNECTICUT HEALTH CENTER, JOHN DEMPSEY HOSPITAL FARMINGTON, CT RACHEL BATTAGLIA NISSEN RN, MSN STAFF NURSE CHARLOTTE HUNGERFORD HOSPITAL TORRINGTON, CT
Be a “Congress Voices” Journalist ave you always wanted to see your name in print but were uncertain where to start? Here’s your chance! Congress News, a daily publication written by AORN staff editors at Congress, is published on site and provides news and information to attendees. This year, Congress News will continue its feature section, “Congress Voices”, as an online supplement to the daily print version. “Congress Voices” will be written by selected
H
AORN members who are attending Congress and are willing to share stories about their 2009 Congress experiences. AORN members who are attending Congress in Chicago, Illinois, are eligible to apply. Current Board members, candidates, AORN staff, and exhibitors are not eligible. Applications must be received by Wednesday, February 11, 2008. For application instructions, please contact [email protected].
AORN JOURNAL •
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The Importance of Mandatory Rest Periods in OR Environments JUDITH LIPTON GOLDBERG, RN, MSN, CNOR; PAMELA L. MARSHALKOWSKI, RN, BSN, CASC; RACHEL BATTAGLIA NISSEN, RN, MSN
A
t 2 AM, a perioperative nurse is finally driving home from work. As she drives down a dark, deserted road, she thinks about her day, which began the previous morning at 7 AM. The day started as always, with a full schedule of procedures. There was adequate staffing to cover each room and the day was uneventful. Unfortunately, the nurse had been assigned to be part of the call team, and she needed to stay for emergency surOvertime hours geries that continued to pile up all evening. worked in most After working nearly 20 hours, the nurse left industries, including work to drive home. Her feet were tired, her head health care, have hurt, and all she could think about was the few increased steadily hours she could sleep before she had to return to over the past work at 7 AM. As she pulled into her driveway, 15 years. she realized that she did not remember the last two miles that led to her home or even stopping at the traffic light before pulling into her subdivision. She had been on “autopilot” the whole way home and was lucky there was little traffic in her way. For just a moment, before turning the key to her back door, the nurse thought about her ability to function in the morning when she would return to work.
OVERTIME AND FATIGUE IN THE PERIOPERATIVE ENVIRONMENT In addition to working their regularly scheduled shifts, perioperative nurses routinely are required to be on call1
790 • AORN JOURNAL • NOVEMBER 2008, VOL 88, NO 5
as a means of covering unscheduled or emergency procedures after normal hours or when scheduled procedures run late. Because of the complexity of scheduling and the unpredictability of surgical procedures, many facilities have altered staffing patterns to include eight-, 10-, and 12-hour shifts, as well as on-call requirements. The US Department of Labor Occupational Safety and Health Administration states, “a normal work shift is generally considered to be a work period of no more than eight consecutive hours during the day, five days a week, with at least an eight-hour rest.”2 The number of overtime hours worked in most industries, including health care, has increased steadily over the past 15 years,3 and the perioperative environment commonly uses mandatory overtime. Mandatory overtime is defined by the Economic Policy Institute as those hours worked above the standard 40-hour week that an employer makes compulsory with the threat of job loss or other reprisals.3 Many professional nurses working in the perioperative environment have experienced fatigue and exhaustion related to overtime and on-call practices. Every day, nurses are required to stay past their scheduled shifts to accommodate overbooked procedures, emergencies, and sick calls. When fatigue sets in, whose responsibility is it to determine whether an individual is working at a safe practice level?
SAFETY ISSUES ASSOCIATED
WITH
FATIGUE
According to the American Nurses Association (ANA), nurses should be able to care for themselves and make the determination that they are too
© AORN, Inc, 2008
Opinion
tired to practice at safe levels.4 Unfortunately, having the courage to admit that one is too tired to function optimally can be difficult. According to the AORN On-Call Electronic Task Force, there are multiple reasons why perioperative nurses work more than their scheduled hours.5 These reasons range from lack of available trained staff, to nurses wanting the extra overtime pay, to surgeons refusing relief during a procedure. Because work fatigue can occur during any of these situations, it is the individual nurse’s responsibility to identify when fatigue sets in. Organizations, then, must facilitate a positive environment where nurses are comfortable expressing their exhaustion without fearing retribution. Working extended hours without proper rest affects not only workers but also families, community members, employers, and patients. The adverse effects in each of these groups are documented by research. Families can be adversely affected when parents are not available or are too tired to supervise children, help with homework, or enjoy leisure time together. In fact, those who work more than 50 hours per week report significantly higher work-family conflicts than those who work fewer hours.3 Community safety is put at risk when people who have worked extended hours drive home while drowsy, which has been compared to being legally drunk.6 Twelve-hour shifts, common in nursing, are known to increase the risks for motor vehicle crashes linked to fatigue. In one study, nurses who worked night shifts were nearly four times more likely to have difficulty staying awake while driving home compared to nurses who did not work at night.6 The employer also is adversely affected by fatigue because extended hours eventually lead to nursing burnout.7 Nurses overwhelmed and exhausted are leaving the profession or, even worse, are unable to maintain a caring, professional demeanor. Those who do stay in the profession are more likely to suffer from depression and illnesses linked to absenteeism8 or to succumb to addictive tendencies.9 The patient-related safety issues surrounding working while fatigued are well documented, and fatigue is known to affect judgement.
NOVEMBER 2008, VOL 88, NO 5
Organizations must facilitate a positive environment where nurses are comfortable expressing their exhaustion without fearing retribution.
According to Scott et al, “[medical] residents were unable to accurately judge their level of impairment when tested after [a] heavy call condition.”6(p1802) In addition to impairing judgement, extended work hours have contributed to at least two hospital-wide epidemics of Staphylococcus aureus, which occurred in South Florida and California.8 It later was determined that high caseloads and minimal staffing led to stress and fatigue and ultimately to mistakes that contributed to the epidemics. Studies also show that accident and error rates rise dramatically when employees work more than 12 hours.3,8 According to the study by Rogers et al,8 the risk of making an error or a near error is not affected by age, hospital type, or unit type, but is strongly linked to extended work hours. Research shows that fatigued nurses make mistakes ranging from inaccurate charting to patient care-related errors.5
MANDATORY REST PERIODS The Joint Commission mandates a focus on a culture of safety and providing care for patients in a safe, effective manner.10 This includes nurses’ safety and their ability to provide care when they are not fatigued or exhausted. The safety of patients and the protection of health care workers could be addressed by enacting standardized state and federal regulations that mandate specific rest policies. Not to be construed as union activism, political activism could provide regulatory language that would protect nursing professionals. Mandatory rest periods for health care employees are uncommon and often are not clearly defined in state or federal regulations. AORN JOURNAL •
791
Opinion
NOVEMBER 2008, VOL 88, NO 5
Because of patient and employee safety concerns, it is clear that nursing must not only set similar standards but also stipulate specific regulations requiring mandatory rest periods on either a state or federal level.
Although there are specific guidelines related to on-call practices stated by AORN1,11 and other specialty nursing organizations,12 many hospitals and health care facilities do not recognize the need to support their staff members with the implementation of these types of guidelines. To further complicate matters, the needs of administrators and nursing staff members are often at odds: administrators are responsible for business, keeping the hospital open and operational—which requires nurses to be at work—while nurses need to tend to themselves and ensure they are rested to perform at optimal levels. Because nurses often are pressured to work when fatigued, administrators and managers need to be able to recognize the potential for fatigue and identify when and how it occurs. According to an ANA position statement, the employer’s responsibility is to promote a work schedule that allows for “adequate rest and recuperation between scheduled work.”13 Creative scheduling and policies that allow nurses who have worked a certain number of hours (ie, as many as 12) to go home without being penalized can prevent the abuse of overtime and provide an opportunity for nurses to rest when on-call situations arise. The need for mandatory rest periods is not limited to nurses, physicians, and other health care workers. Other examples can be seen in public-related industries where fatigue and exhaustion have prompted the need for safety regulations. The aviation industry, for exam-
792 • AORN JOURNAL
ple, has clear regulations regarding mandatory rest periods for pilots and strictly enforces a mandatory rest period between scheduled flight times.14 These required rest periods fluctuate between eight and 11 hours depending on the hours worked. The Federal Motor Carrier Safety Administration also clearly defines work week regulations with mandatory rest periods of no less than 10 hours after a maximum of 11 hours worked for drivers.15 The Nuclear Regulatory Commission (NRC) has policies in place to control the number of hours that US commercial nuclear facility employees may work.16 The purpose of these policies is to prevent employees in safety positions from working while fatigued, which could affect their ability to make decisions. In an emergency, however, these rules may be waived by a plant manager or senior manager. In a June 15, 1982, policy statement,16 the NRC stated • an individual should not be permitted to work more than 16 consecutive hours; • an individual should not be permitted to work more than 16 hours in any 24-hour period, nor more than 24 hours in any 48hour period, nor more than 72 hours in any seven-day period; • a break of at least eight hours should be allowed between work periods; and • the use of overtime should be considered on an individual basis and not for the entire staff on a shift.
REGULATORY ACTION Because of patient and employee safety concerns, it is clear that nursing must not only set similar standards but also stipulate specific regulations requiring mandatory rest periods on either a state or federal level. Although the federal guidelines regarding mandatory overtime are limited, there seems to be a shift in attitude at the state level. The Connecticut Nurses Association in October 2007 approved a resolution that promotes the ethical responsibility of professional nurses to determine their individual level of fatigue before working beyond their regular hours.17 “Assuring patient safety: registered nurses’ responsibility to guard against working when
Opinion
fatigued”17 describes multiple considerations nurses and employers should take when requesting overtime hours, including advocating models that limit the number of hours nurses and nursing students can provide direct patient care or care requiring clinical judgment that affects direct patient care. In recent years, 14 states have restricted the use of mandatory overtime for nurses. Eleven have enacted legislation (ie, Connecticut, Illinois, Maryland, Minnesota, New Jersey, New Hampshire, New York, Oregon, Rhode Island, Washington, West Virginia), and three have provisions in regulations (ie, California, Missouri, Texas).18 In 2008, nine more states introduced legislation (ie, Arkansas, Arizona, Florida, New York, Ohio, Vermont, Washington, Wisconsin, West Virginia).18 Several of these states—New York, Maryland, California, and West Virginia—have made exceptions to their regulations, however, and allow mandatory overtime to be used in emergency circumstances related to public health or for surgical procedures. Although mandatory overtime sometimes must occur in the perioperative environment, limits need to be defined. For example, if there is no one to relieve a nurse during a procedure, he or she must stay to avoid patient abandonment. This example demonstrates the need for appropriate staffing levels and schedule management: procedures should not be started if there is not sufficient staff for relief shifts. Although there has been state regulatory action regarding limiting overtime, few states have specific regulations related to mandatory rest periods.18 Among states with laws banning mandatory overtime, Illinois and Maine require rest periods of at least eight hours following 12-hour shifts. In some cases, nurses employed by unionbased health care facilities may be able to work mandatory overtime regulations into their contracts. Limiting mandatory overtime can provide an added benefit to the employee and employer. The employee benefits by having adequate rest periods and so being able to perform at optimal levels, and the employer benefits by having nurses who are not suffering
NOVEMBER 2008, VOL 88, NO 5
In recent years, 14 states have restricted the use of mandatory overtime for nurses: 11 have enacted legislation and three have provisions in regulations.
fatigue and therefore are less prone to committing errors. Some union-based hospitals have worked out the issue of mandatory rest periods for perioperative and postanesthesia care unit nurses with specific stipulations within their contracts.19,20 Although many non-union hospitals recognize AORN guidelines and standards for safe on-call practices,1,11 budget constraints and limited staff can make it difficult to employ those standards. Some facilities recognize the need for mandatory rest periods and have developed fair and equitable policies in conjunction with staff members. The Charlotte Hungerford Hospital in Torrington, Connecticut, for example, is a non-union hospital that recently approved a new policy for mandatory rest periods.21 This policy benefits not only the perioperative staff, but it also extends to nursing personnel hospital-wide. In recent years, US senators from several states have repeatedly proposed legislation to ban or limit mandatory overtime for nurses. The Safe Nursing and Patient Care Act of 2007 (SNPCA),22 is the most recent attempt at a federal regulation regarding mandatory overtime. This bill is intended “to provide for patient protection by limiting the number of mandatory overtime hours a nurse may be required to work.”22(p1) Although mandatory overtime is the key factor within this legislation, mandatory rest periods for nurses are not addressed. Legislators need to be made aware of the necessity for mandatory rest periods as a mechanism to ensure patient and employee safety and include this in the next version of the SNPCA. Perioperative nurses can educate legislators AORN JOURNAL •
793
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about the need for mandatory rest periods, lobby for legislation to safeguard patients, and work with facility administrators to enact policy change. Nurses can attend state lobby day activities, set up meetings to discuss the issues with senators and representatives both in their districts and those on the public health committees, write letters, make phone calls, and write editorials for local newspapers.
WORKING TOWARD SAFER CARE The dangers of fatigue in the health care setting are well documented, and are known to adversely affect both patients and employees. These dangers could be alleviated with regulations that impose mandatory rest policies for nurses. Because most nurses feel compelled to work their shifts and call schedules with little consideration for themselves or the patients that they are potentially jeopardizing, administrators and managers need to be able to recognize the potential for fatigue and identify when and how it occurs. If it is the responsibility of the nurse to identify when fatigue sets in, organizations must facilitate a positive environment where nurses are comfortable expressing their exhaustion without fear of retribution. The employers’s responsibility is to promote a work schedule that allows rest between scheduled work shifts. It is clear that the nursing profession must not only set standards but also stipulate specific regulations requiring mandatory rest periods on either a state or federal level. Legislators need to be made aware of the necessity for mandatory rest periods as a mechanism to ensure patient and employee safety. The current lack of federal and state regulations regarding mandatory rest periods requires individual hospitals and their administrators, managers, and nursing leaders to be responsible for the safety and well-being of their nursing staff members and patients. Collaborating with human resources departments to provide appropriate nursing policies regarding mandatory rest periods offers an equitable solution to preventing fatigue and unsafe nursing practices. In turn, sharing in this practice of employee safety allows each hospital to pro-
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vide an arena for the safe and quality care of their patients.
REFERENCES 1. AORN position statement: Safe work/on-call practices. In: Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:409-412. http://www.aorn.org/PracticeResources/AORN PositionStatements/Position_SafeWorkOnCallPrac tices. Accessed August 11, 2008. 2. Extended/unusual work shifts. US Department of Labor Occupational Safety and Health Administration. http://www.osha.gov/SLTC/emergency preparedness/guides/extended.html. September 2, 2004. Accessed August 11, 2008. 3. Golden L, Jorgensen H. Economic Policy Institute (EPI) Briefing Paper: Time after time—mandatory overtime in the US economy. http://www.epi.org /content.cfm/briefingpapers_bp120. January 2002. Accessed August 11, 2008. 4. Nurse fatigue. American Nurses Association. http:// www.nursingworld.org/MainMenuCategories/The PracticeofProfessionalNursing/workplace/Workforce /NurseFatigue.aspx. Accessed September 22, 2008. 5. Kenyon TA, Gluesing RE, White KY, Dunkel WL, Burlingame BL. On call: alert or unsafe? A report of the AORN on-call electronic task force. AORN J. 2007;86(4):630-639. 6. Scott LD, Hwang WT, Rogers AE, Nysse T, Dean GE, Dinges DF. The relationship between nurse work schedules, sleep duration, and drowsy driving. Sleep. 2007;30(12):1801-1807. 7. Garrett C. The effect of nurse staffing patterns on medical errors and nurse burnout. AORN J. 2008; 87(6):1191-204. 8. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202-212. 9. Dunn D. Substance abuse among nurses— defining the issue. AORN J. 2005;82(4):573-596. 10. Studies cite persistent threat to patient safety, hospital work environment and present improvement options. Joint Commission Resources. http://www.jcrinc.com/27660/JCRnews/27930. November 1, 2007. Accessed August 11, 2008. 11. AORN guidance statement: Safe on-call practices in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:240-242. 12. Association of PeriAnesthesia Nurses. A position statement on On call/work schedule. In: The Standards of Perianesthesia Nursing Practice. Cherry Hill, New Jersey: ASPAN, Inc; 2006:104-105. 13. ANA position statement: assuring patient safety: the employers’ role in promoting healthy nursing work hours for registered nurses in all roles and settings. Effective December 8, 2006. http:// www.nursingworld.org/MainMenuCategories/
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HealthcareandPolicyIssues/ANAPositionStatements /workplac/EmployersRole.aspx. Accessed August 11, 2008. 14. Federal Aviation Administration. Civil Aviation Regulations [State] Part 8—Operations, Vol 2.5. http://www.faa.gov/safety/programs_initiatives /oversight/iasa/model_aviation/media/PART08 .doc. April 2007. Accessed August 11, 2008. 15. Hours-of-service regulations. Federal Motor Carrier Safety Administration. http://www.fmcsa .dot.gov/rules-regulations/topics/hos/HOS-2005 .htm. Effective date: October 5, 2005. Accessed August 11, 2008. 16. Nuclear power plant staff working hours (generic letter No. 82-12). June 15, 1982. Nuclear Regulatory Commission. http://www.nrc.gov/reading-rm/doc -collections/gen-comm/gen-letters/1982/gl82012 .html. Accessed September 22, 2008. 17. Connecticut Nurses’ Association members approve resolutions at annual meeting. Connecticut Nursing News. 2007;80(4):1-3. http://www.ctnurses .org/associations/1710/CNN%20December%202 007%20final.pdf. Accessed August 11, 2008. 18. American Nurses Association. In: ANA State Government Relations. http://www.nursingworld .org/mainmenucategories/anapoliticalpower/state /statelegislativeagenda/mandatoryovertime.aspx. Published 2005. Accessed September 22, 2008. 19. Contract between the University of Connecticut Health Center and University Health Professionals Local 3837 AFT/AFT-CT/AFL-CIO. Farmington, CT: University of Connecticut Health Center; 2006. http://employ.uchc.edu/information/pdfs/barg aining/UHPContract2006_2010(Complete).pdf. Accessed August 11, 2008. 20. UW/SEIU 1199 Contract. Article 7: Hours of
Work and Overtime. University of Washington Labor Relations. http://www.washington.edu/ad min/hr/laborrel/contracts/1199/contract/a07.html. Effective July 1, 2007 to June 30, 2009. Accessed August 11, 2008. 21. Rest time for employees on call scheduled to work the next day [policy and procedure manual]. Torrington, CT: The Charlotte Hungerford Hospital; April 4, 2007. Rev January 24, 2008. 22. American Nurses Association. Safe Nursing and Patient Care Act of 2007 (HR 2122). http://rnaction .org/politicalpower/mandatory_overtime_house. Accessed August 11, 2008.
CLINICAL
FARMINGTON
JUDITH LIPTON GOLDBERG RN, MSN, CNOR DIRECTOR, CENTRAL PROCESSING DEPARTMENT THE WILLIAM W. BACKUS HOSPITAL NORWICH, CT
PAMELA L. MARSHALKOWSKI RN, BSN, CASC NURSE MANAGER SURGERY CENTER, UNIVERSITY OF CONNECTICUT HEALTH CENTER, JOHN DEMPSEY HOSPITAL FARMINGTON, CT RACHEL BATTAGLIA NISSEN RN, MSN STAFF NURSE CHARLOTTE HUNGERFORD HOSPITAL TORRINGTON, CT
Be a “Congress Voices” Journalist ave you always wanted to see your name in print but were uncertain where to start? Here’s your chance! Congress News, a daily publication written by AORN staff editors at Congress, is published on site and provides news and information to attendees. This year, Congress News will continue its feature section, “Congress Voices”, as an online supplement to the daily print version. “Congress Voices” will be written by selected
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AORN members who are attending Congress and are willing to share stories about their 2009 Congress experiences. AORN members who are attending Congress in Chicago, Illinois, are eligible to apply. Current Board members, candidates, AORN staff, and exhibitors are not eligible. Applications must be received by Wednesday, February 11, 2008. For application instructions, please contact [email protected].
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